Creating a Team-Based, Education-Centric Program To Manage Cardiogenic Shock: UPMC Heart and Vascular Institute’s Multiyear, Multidisciplinary Approach to Improve Mortality and Long-Term Patient Outcomes – Part 2
April 24, 2026
Featured in this three-part article series are:
- Gavin Hickey, MD, medical director, Cardiogenic Shock Program, medical director, VAD and Transplant Program, UPMC Heart and Vascular Institute Cardiogenic Shock Program
- Nicole Kunz, RN, nurse manager, Artificial Heart and Cardiogenic Shock Program, UPMC Heart and Vascular Institute
- Amanda Hopwood-Brophy, PA-C, APP surgical supervisor, VAD and Transplant Program, UPMC Heart and Vascular Institute
Historically: 40 to 50% mortality. That ought to communicate precisely the gravitational force of cardiogenic shock on individuals that develop the syndrome. Not quite as all-consuming of what gets close to it as is a cosmic supermassive black hole, but much too high for any clinician, team, or hospital to accept as a given.
Within the UPMC Heart and Vascular Institute Cardiogenic Shock Program, current mortality is now closer to 25% following systemwide changes in how cardiogenic shock is recognized and cared for. This shift did not result from a single device or protocol, but from a coordinated, education-driven model built and refined over multiple years that treats cardiogenic shock as a time-dependent, progressive syndrome that mandates an early, coordinated, aggressive multidisciplinary response if patients are to survive.
This article builds on the initial overview of the UPMC Cardiogenic Shock Program by examining why traditional approaches to cardiogenic shock were insufficient and how early program infrastructure developed.
Why Traditional Models of Managing Cardiogenic Shock Were Suboptimal
Historically in the field of cardiovascular medicine, cardiogenic shock was conceptualized as a single end-stage event. Patients were often labeled “in shock” only after hypotension, elevated lactate levels, and organ dysfunction were noticeable. At this point, treatment options can be limited. Clinical discussions therefore would focus on hemodynamic collapse and device selection after end-organ failure had already developed, rather than on where a patient was in the disease process or how rapidly they were deteriorating.
“One of the most challenging things about cardiogenic shock is how quickly a patient can move through stages, sometimes within minutes, and you do not always know in advance who will deteriorate fast. That uncertainty makes early recognition and appropriate tiering critical to managing the condition,” Ms. Hopwood-Brophy says.
The absence of a shared framework in the field meant that cardiogenic shock was not approached as a progressive syndrome. Without a consistent way to describe severity or trajectory, escalation of patient care would frequently be delayed and treatment decisions varied widely across teams and institutions, even within the same hospital or system. This was not a UPMC specific issue but a global one for all of cardiovascular medicine.
At the UPMC Heart and Vascular Institute, these limitations were encountered repeatedly. Patients were often transferred from referring hospitals only after multiorgan dysfunction had developed, and teams were asked to make urgent decisions about advanced therapies without a clear way to describe disease severity or predict trajectory. These experiences exposed a fundamental truth: cardiogenic shock could not be managed effectively without first being defined and recognized in the same way by everyone involved in the patient’s care.
“We kept having the same conversations too late. By the time we were talking about devices, the patient already had kidney failure, liver dysfunction, rising lactate. Everything was already far advanced,” Dr. Hickey says. “We did not have a consistent way to define cardiogenic shock, recognize it early, or communicate how sick someone really was across teams and hospitals. Without a shared language and a shared understanding of the continuum, no pathway or technology could function the way it was intended to.”
Early Clinical Work at UPMC (2017–2018)
The recognition that cardiogenic shock was being treated too late did not begin with a formal staging system or a systemwide program. It emerged from years of clinical discomfort with the same pattern repeating with patients rapidly decompensating, escalation conversations occurring after multiorgan failure had already developed, and advanced therapies being deployed when the physiological window for meaningful recovery had likely closed.
The first response to this discomfort was not a full-blown cardiogenic shock team or program, but a series of targeted clinical initiatives. In 2017, interventional cardiology evaluated and implemented the Detroit cardiogenic shock initiative, which emphasized percutaneous coronary intervention (PCI) Impella placement as a strategy to prevent shock rather than rescue patients after collapse. This work represented a shift in thinking: cardiogenic shock could be anticipated and mitigated, not just reacted to.
In 2018, these efforts expanded into the first systemwide cardiogenic shock meeting led by interventional cardiology. An Impella order set was developed to standardize device use, and point-of-care testing for plasma-free hemoglobin was adopted to support safer management. Best practices for Impella access were established, and heart failure services were formally engaged. These steps did not yet constitute a program, but they created the first shared infrastructure for approaching cardiogenic shock.
At this stage, care remained largely siloed and dependent on individual expertise. Nevertheless, the groundwork was being laid shared protocols, early physiologic monitoring, and interdisciplinary collaboration were beginning to replace ad hoc decision-making.
From Internal Tension to an Early Shock Team
As this early work progressed, it became clear that the problem was not just a technical one. Even with new devices and emerging best practices, recognition of cardiogenic shock remained inconsistent and escalation remained delayed. Patients continued to arrive from referring hospitals after organ failure had already developed, and teams were still being asked to make urgent decisions without a clear way to describe disease severity or predict trajectory.
In response, a small, informal shock team began to take shape. This early group, consisting of five or six providers represented a first attempt to coordinate patient care across disciplines. The team was notified when a case cropped up, they aligned around emerging concepts of early cardiogenic shock and tested more proactive escalation strategies. While these efforts improved communication and planning in the small team, the overall approach also revealed a fundamental limitation: a handful of specialists could not change systemwide behavior on their own.
The experience highlighted the big problem in the field. Cardiogenic shock is not only a clinical problem; it is a systems problem. Without shared definitions, standardized triggers, and aligned pathways, recognition and escalation will continue to depend on where a patient presented and who happened to be on call.
Formalizing the Continuum (2019)
Between April and July 2019, the publication of cardiogenic shock outcomes from the University of Utah and Inova Health System, alongside the introduction of the Society for Cardiovascular Angiography and Interventions (SCAI) cardiogenic shock staging system, provided the first formal frameworks for understanding what cardiogenic shock really is and how it might best be approached. The staging system described cardiogenic shock as a spectrum of severity rather than a single diagnosis and linked clinical findings, laboratory markers, hemodynamics, and the need for pharmacologic or mechanical support to discrete stages.
“When SCAI put forward a staged definition of cardiogenic shock in 2019, it made the point that the condition is a continuum — A through E— rather than a yes-or-no diagnosis. That reframing was a major inflection point for the field and for our system in terms of developing a cohesive approach to patient care,” Dr. Hickey says.
The introduction of the SCAI staging criteria did not initiate the transformation that the UPMC Heart and Vascular Institute was already starting to make around the care of patients in cardiogenic shock, but it did accelerate it. The SCAI staging system gave structure and shared language around what actually is cardiogenic shock, allowing clinicians to describe where a patient was on the continuum and how rapidly they were progressing.
“Once there was a shared way to describe cardiogenic shock, conversations changed. Teams could align more quickly around where a patient was in the progression and what needed to happen next,” Ms. Kunz says.
At the same time, internal processes were changing. Team development accelerated, and immediate send-transfer prioritization was established for patients meeting high-risk criteria. In July 2019, STAT MedEvac became involved in the process and program that was being built, text alerts were adopted, and QuickLaunch was implemented to reduce delays in mobilization. By August 2019, the fully formed cardiogenic shock program at UPMC went live, and cardiac catheterization lab attendings began taking first call for cardiogenic shock cases.
Cardiogenic shock could now be recognized, staged, and escalated using a shared language and a defined pathway no matter where the patient was at in the broader UPMC system or where they might be coming from if being transported from another care setting.
“We used to think that if we identified cardiogenic shock within a day, we were doing well. What the data now show is that the window is much smaller. We are really talking about the first six hours, and ideally the first 90 minutes, to identify these patients and activate a shock team so that intervention can actually change their trajectory. This is the equivalent of a STEMI. Time matters in exactly the same way,” Dr. Hickey says.
Transforming a Concept into an Action Plan: REACT Model
The conceptual shift toward earlier recognition of cardiogenic shock requires a corresponding operational framework. At UPMC and the UPMC Heart and Vascular Institute, this became the REACT model, an executable translation of a staged, time-dependent view of cardiogenic shock.
The REACT framework created by the cardiogenic shock team leaders created a clear sequence of actions for clinicians and care teams. REACT means: Recognize; Establish; Activate; Convene; Transfer.
Recognition comes when a patient’s ejection fraction is less than 35% or they have an acute myocardial infarction with systolic blood pressure less than 90 and clinical values indicating end organ dysfunction, primarily kidney and liver function impairment, and a lactate level more than 2.0. Establishing access for invasive monitoring follows, with a preference for pulmonary artery catheter–guided assessment. Activation of the Cardiogenic Shock team is next achieved through a single Medcall alert.
The multidisciplinary shock team then convenes to align on patient severity, trajectory, and next steps. Finally, a decision is made to either call for the patient to be managed locally if possible or have them transferred to another center if higher level of care advanced intervention is justified. The process ensures that patients receive the appropriate level of care at the appropriate time.
This framework operationalizes education. It converts shared definitions into shared behavior and embeds cardiogenic shock recognition and reaction by clinical teams into everyday workflow.
“The goal was to make the response to cardiogenic shock predictable. Instead of each team approaching these patients differently, there was now a defined sequence that helped guide decisions in real time,” Ms. Kunz says.
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