Navigating the Initial Hours of Cardiogenic Shock with Dr. Rebecca Mathew

How do you diagnose cardiogenic shock quickly and accurately at the bedside? What should your first therapeutic move be? And how do you know if your resuscitation is working?In this episode of SoCCC Pre-Rounds, Dr. Simon Parlow sits down with Dr. Rebecca Mathew, Director of the Cardiac ICU at the University of Ottawa Heart Institute and co-principal investigator of the CAPITAL Research Group. Together, they break down a clear, real-world approach to diagnosing, stabilizing, and treating cardiogenic shock from the moment the patient arrives.Drawing from frontline CICU experience and landmark trials such as CAPITAL DOREMI, Dr. Mathew discusses why history and physical exam still drive the diagnosis, how to approach congestion and perfusion, when inotropes actually help, and how to integrate invasive hemodynamics when available. The episode offers practical, bedside-ready guidance for clinicians managing shock in any setting.Key TakeawaysCardiogenic shock is best diagnosed through history, exam, and perfusion assessment, not lactate or invasive data alone.SCAI is the most practical framework, but Stage D should be assigned only after a failed therapeutic trial.Use inotropes only if hypoperfusion persists after decongestion; dobutamine quickly shows responsiveness.Swan-Ganz catheters help when available, but most shock worldwide is managed without invasive hemodynamics.Avoid early prognostication in the first 24–48 hours to prevent harmful self-fulfilling assumptions.In This Episode[00:00] Introduction [01:06] Importance of initial medical management in cardiogenic shock[02:53] Defining cardiogenic shock and SCAI classification[05:27] Phenotypes and subtypes of cardiogenic shock[07:23] Caveats in SCAI classification[07:49] Bedside diagnosis and risk stratification[09:53] Physical exam: hyperperfusion and congestion[11:54] Initial management approach: decongestion and inotropes[14:17] Therapeutic targets and monitoring response[15:24] Inotrope selection and individualized therapy[16:55] Ongoing research and future directions[17:55] Therapeutic targets: clinical and biochemical markers[19:47] Mean arterial pressure (MAP) targets[21:01] Prognostic factors and risk scoresNotable Quotes[03:21] “I think in its most basic sense, I think of cardiogenic shock as a clinical syndrome of clinical and biochemical hyper perfusion that’s due to a primary cardiac disorder.” — Dr. Rebecca [15:48] “People often ask me what inotrope I reach for, and despite having done the DoReMi trial and proving there’s no difference, I am anecdotally a big believer in dobutamine.” - Dr. Rebecca [22:10] “Once you’re in the throes of shock, I think we just need to focus on the tsunami in front of us and manage that.”[23:26] “The most exciting thing about cardiac critical care and managing cardiogenic shock is you are basically seeing physiology in real time." — Dr. RebeccaDr. Rebecca MathewDr. Rebecca Mathew is a critical care cardiologist and Director of the Cardiac ICU at the University of Ottawa Heart Institute. She leads major cardiogenic shock research programs, including the CAPITAL DOREMI trial published in the New England Journal of Medicine and the ongoing CAPI2 trial focused on early inotrope strategies. Her work spans clinical care, trial leadership, and translational shock physiology.Resources and LinksBecome a member of the Community: https://www.soccc.org/subscribeDr. Rebecca Mathewhttps://www.ottawaheart.ca/profile/mathew-rebeccaDr. Simon Parlowhttps://www.ottawaheart.ca/profile/parlow-simonhttps://www.soccc.org/Supported By:This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.DisclaimerThis podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.