“War on Shock” Redux: A Decade of Progress, Promise, and Potential

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J INVASIVE CARDIOL 2026. doi:10.25270/jic/26.00001. Epub January 7, 2026.

“Coming together is a beginning, keeping together is progress, and working together is success.”

-Henry Ford¹

Ten years ago, an initial call to action for a “combat” approach to cardiogenic shock (CS)—inspired by prior decades’ success in tactical combat casualty care—catalyzed a transformation in emergency cardiovascular care with the advent of multidisciplinary and multispecialty shock protocols, teams, centers, and networks.^2-5 What started in 2016 as a single-institution quality improvement initiative to elevate CS processes of care and increase survivorship has developed by 2026 into a nationally recognized, guideline-concordant, and reproducible new care paradigm.^5,6 As with other complex, resource-intensive, and rapidly-fatal medical conditions, standardized and protocolized team-based care for CS has streamlined, expedited, and improved care delivery to optimize short-term patient survival and longer term outcomes.

Our CS initiative began with the assembly of a small but diverse task force of clinical and administrative stakeholders across multiple disciplines to assess the then-current state of affairs, establish priorities of effort, and assign roles and responsibilities.³ Initial work focused on increasing awareness and early recognition of CS both inside and outside the hospital, shortening delays to CS evaluation and management, expediting rapid collaborative decision making, reducing barriers to access to lifesaving interventions, and minimizing undesired heterogeneities of care—both within and between hospitals and health systems—in the mid-Atlantic region (encompassing the District of Columbia, Virginia, Maryland, and West Virginia).⁷ CS identification and management algorithms and protocols, team composition, and activation and communication processes were developed, serially refined over time, and shared broadly.

This formerly local, and now regional, experience demonstrates that CS protocols and teams are feasible, sustainable, and furthermore scalable to shock centers and shock networks. Over time, the referral and transfer network has grown to over 60 centers spanning greater than 6000 square miles.⁷ Along the way, in-hospital patient survival increased from less than 50% in 2016 to greater than 70% by 2018—where it has remained through the beginning of 2026. In parallel, other centers in other regions established their own individualized teams and programs—with similarly favorable patient outcomes—validating the reproducibility of this protocol, team, center, and network model.⁶

The growth of the CS program also highlights the critically important duty and responsibility of larger (and typically urban) CS centers, which possess a full complement of around-the-clock medical and surgical specialties to partner with, support, and elevate smaller and/or less well-resourced (and often more rural) facilities as part of both formal and informal patient-centered networks of care. Extreme geographic differences in access to health care as well as significant variabilities of care and outcomes by provider, hospital, zip code, time of day, or day of week are unwanted, unwarranted, and unacceptable; in 2026, where a patient lives should not determine if they live.

The “war on shock” continues, and the next phase may be an increased commitment to local, regional, and national collaboration focused on innovative integrated networks of local and regional CS triage, care, and transfer, all working toward an aspirational goal of zero “preventable” death from CS.^2,8 Only time will tell what further progress the next 10 years may bring to communities, states, and the nation.

Alexander G. Truesdell, MD^1,2; Megan Terek, MD²; Ramesh Singh, MD²; Michelle Ferri, NP²; Shashank S. Sinha, MD, MSc²

From ¹Virginia Heart, Fall Church, Virginia; ²Inova Schar Heart and Vascular, Falls Church, Virginia.

Disclosures: Dr Truesdell reports consulting/speaking fees/honoraria from Abiomed, Chiesi, Getinge, Shockwave, and Zoll. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Alexander G. Truesdell, MD, Virginia Heart/Inova Schar Heart and Vascular, 2901 Telestar Court, Falls Church, VA 22042, USA. Email: atruesdell@truesdellmedical.com; X: @agtruesdell