PAC use in cardiogenic shock associated with lower mortality but higher sepsis risk in meta-analysis

INTRODUCTION: The role of pulmonary artery catheterization (PAC) in cardiogenic shock (CS) remains debated: prior intensive care unit trials showed no benefit, but contemporary observational registries suggest improved outcomes. However, the overall evidence remains fragmented, with inconsistent phenotypic and outcome reporting. Our objective was to assess the association between PAC use and clinical outcomes in CS. METHODS: We systematically searched MEDLINE, Cochrane, and Scopus (2015-2025) for observational and registry studies in adult CS. Outcomes included in-hospital/30-day mortality, mechanical circulatory support (MCS), and sepsis. Pooled odds ratios (OR) and hazard ratios were estimated using random-effects models. Subgroup, meta-regression, and trial sequential analysis were performed. RESULTS: Fourteen observational studies (n = 789,553; 271,305 deaths) were included. Overall mortality averaged 34%. PAC use was associated with lower mortality (OR 0.70, 95% confidence interval [CI] 0.63-0.78; P < 0.001) with consistent benefit across CS phenotypes, although substantial heterogeneity was present (I² > 90%). Time-to-event analyses (7 studies, n = 5,142) confirmed a 32% relative hazard ratio (0.68, 95% CI 0.60-0.77; I² = 34%). PAC use was also linked to higher MCS initiation (OR 2.76, 95% CI 1.82-4.20; P < 0.001), with evidence of publication bias (Egger P = 0.0057) and an adjusted OR 3.98 after trim-and-fill. In addition, PAC was associated with increased sepsis risk (OR 1.83, 95% CI 1.42-2.35; I² = 61%). CONCLUSIONS: PAC use was consistently associated with improved survival across CS, and higher MCS use was associated with increased sepsis risk. Our findings support systematic PAC use as a therapeutic enabler in CS and should inform protocols and future randomized clinical trials design.