The 2026 European Clinical Consensus Statement proposes a pathophysiology-based definition of cardiogenic shock centred on three essential diagnostic pillars: cardiac dysfunction, haemodynamic abnormality, and end-organ hypoperfusion at rest.
How is cardiogenic shock defined?
Cardiogenic shock is characterised by end-organ hypoperfusion at rest caused primarily by a haemodynamic abnormality resulting from underlying cardiac dysfunction that is commensurate with the shock state.
Cardiac dysfunction + haemodynamic abnormality + end-organ hypoperfusion at rest = cardiogenic shock. All three pillars must be present.
Pillar 1: End-organ hypoperfusion at rest
Hypoperfusion is central to the diagnosis. The consensus recommends a multiparametric assessment, rather than relying on lactate or any other single measurement. The proposed criteria require at least one clinical sign plus at least one metabolic or objective marker. The principal bedside windows of perfusion are the skin, brain and kidneys.
| Clinical window | Evidence of hypoperfusion |
|---|---|
| Skin | Cold or clammy skin, mottling grade ≥2, capillary refill time >3 seconds |
| Brain | New altered mental state or agitation |
| Kidneys | Oliguria <0.5 mL/kg/h |
Metabolic and objective evidence
Important markers include:
- Lactate >2 mmol/L
- Low central or mixed venous O₂ saturation, typically <55%
- Base excess ≤−2
- Creatinine >1.5× baseline or an increase ≥0.3 mg/dL
- Transaminases >2× normal
- Spontaneous hypoglycaemia unrelated to glucose-lowering therapy
- ΔPvaCO₂ >6 mmHg or 0.8 kPa
- ΔPvaCO₂:ΔCavO₂ ratio >1.4 mmHg·dL/mL O₂
Why lactate alone is not sufficient
The diagnosis requires clinical evidence that tissue perfusion is impaired together with objective or metabolic evidence. No single measurement should establish hypoperfusion in isolation.
Pillar 2: Haemodynamic abnormality
The patient should meet at least two of the following three criteria.
| Haemodynamic criterion | Required evidence |
|---|---|
| Hypotension or vasoactive support | SBP <90 mmHg and/or MAP <65 mmHg for >30 minutes, or blood pressure maintained at or above these levels with vasoactive drugs |
| Raised filling pressures | Clinical, imaging or invasive evidence—for example elevated JVP, pulmonary oedema, CVP >12 mmHg or PAWP >18 mmHg |
| Low cardiac index | Cardiac index <2.2 L/min/m² without vasoactive drugs, assessed by echocardiography or pulmonary artery catheterisation |
Hypotension is not mandatory
A patient may have cardiogenic shock despite an SBP ≥90 mmHg if the other haemodynamic criteria and evidence of hypoperfusion are present. The framework therefore recognises normotensive cardiogenic shock.
Elevated filling pressures are also not obligatory, allowing recognition of euvolaemic cardiogenic shock.
Pillar 3: Cardiac dysfunction
The underlying cardiac abnormality must be severe enough to explain the haemodynamic compromise and shock state. The proposed qualifying abnormalities include:
- Severe LV dysfunction
- Severe RV dysfunction
- Severe biventricular dysfunction
- Severe valvular disease
- Mechanical complications
- Recurrent or persistent ventricular arrhythmias
Is reduced LVEF enough?
No. Reduced LVEF alone does not establish cardiogenic shock. The cardiac abnormality must be commensurate with the shock state and capable of explaining the haemodynamic disturbance and resulting hypoperfusion.
Assessment should consider the overall cardiac phenotype—including LV and RV function, forward flow, filling pressures, valvular pathology and mechanical complications—rather than relying on LVEF alone. Obstructive causes of shock, such as cardiac tamponade, should be excluded.
How should the three pillars be put together?
The proposed definition follows a pathophysiological sequence: cardiac dysfunction → haemodynamic abnormality → end-organ hypoperfusion at rest.
All three together establish cardiogenic shock. They do not have to become apparent at exactly the same moment. Clinical findings, laboratory abnormalities, echocardiography and invasive haemodynamics can be integrated as the patient’s condition evolves.
Clinical takeaway
The 2026 European definition moves cardiogenic shock away from a diagnosis based primarily on hypotension. True cardiogenic shock requires a cardiac cause, haemodynamic compromise and demonstrable end-organ hypoperfusion at rest.
Full reference
Lim HS, Tycinska A, Delmas C, et al. Criteria for the diagnosis of cardiogenic shock—European perspective: A Clinical Consensus Statement of the Association for Acute CardioVascular Care, the Heart Failure Association, and the European Association of Percutaneous Cardiovascular Interventions of the ESC. European Heart Journal: Acute Cardiovascular Care. 2026;15(8):634–648. doi:10.1093/ehjacc/zuag100.