July 1, 2022Journal of the American College of Cardiology
Criteria for Defining Stages of Cardiogenic Shock Severity
Navin K. KapurManreet KanwarShashank S. SinhaKatherine ThayerA.R. GaranJaime Hernández-MontfortYijing ZhangBorui LiPaulina BacaFatou DiengNeil HarwaniJacob AbrahamGavin HickeySandeep NathanDetlef WenckerShelley HallAndrew SchwartzmanWissam KhalifeSong LiClaudius MahrJu H. KimEsther VorovichEvan H. WhiteheadVanessa BlumerDaniel Burkhoff
Why the study?
The Society for Cardiovascular Angiography and Interventions (SCAI) staging system for cardiogenic shock severity lacks uniform criteria defining each stage.
Do formal clinical and laboratory criteria for defining SCAI stages predict in-hospital mortality in patients with cardiogenic shock?
Structured PICO
Do formal clinical and laboratory criteria for defining SCAI stages predict in-hospital mortality in patients with cardiogenic shock?
P
Population
3,455 patients with cardiogenic shock (52% caused by heart failure, 32% by myocardial infarction) enrolled in the CS Working Group registry across 17 hospitals between 2016 and 2021.
I
Intervention
Novel formal criteria for defining Society for Cardiovascular Angiography and Interventions (SCAI) stages using systolic blood pressure, lactate level, alanine transaminase level, and systemic pH.
O
Outcome
In-hospital mortalityhard clinical
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Studies continue to validate the SCAI SHOCK Stage classification as a tool to help clinicians and researchers better understand cardiogenic shock and offer guidance on treatment pathways to improve survival. The updated expert consensus will underscore the benefit of the classification system across a broad patient spectrum and provides meaningful changes that we believe will enhance both clinical care and future research.”
“The SCAI classification system is very quickly being used to fill in knowledge gaps about cardiogenic shock that will one day help us improve clinical outcomes for patients.”
SSSrihari S. NaiduDirector, Cardiac Catheterization Laboratory, Westchester Medical Center
“The new updated definition is easier to use, with tables that have eliminated relatively unnecessary variables and highlighted the more commonly present ones in each shock stage, a more useful cardiac arrest modifier, and a three-axis model that places the shock stages in context of other variables that need to be considered for the patient in front of you.”
Implication
Defining SCAI cardiogenic shock stages using objective parameters (systolic blood pressure, lactate, ALT, and pH) provides a standardized method that significantly predicts in-hospital mortality.
Abstract
BACKGROUND Risk-stratifying patients with cardiogenic shock (CS) is a major unmet need. The recently proposed Society for Cardiovascular Angiography and Interventions (SCAI) staging system for CS severity lacks uniform criteria defining each stage. OBJECTIVES The purpose of this study was to test parameters that define SCAI stages and explore their utility as predictors of in-hospital mortality in CS. METHODS The CS Working Group registry includes patients from 17 hospitals enrolled between 2016 and 2021 and was used to define clinical profiles for CS. We selected parameters of hypotension and hypoperfusion and treatment intensity, confirmed their association with mortality, then defined formal criteria for each stage and tested the association between both baseline and maximum Stage and mortality. RESULTS Of 3,455 patients, CS was caused by heart failure (52%) or myocardial infarction (32%). Mortality was 35% for the total cohort and higher among patients with myocardial infarction, out-of-hospital cardiac arrest, and treatment with increasing numbers of drugs and devices. Systolic blood pressure, lactate level, alanine transaminase level, and systemic pH were significantly associated with mortality and used to define each stage. Using these criteria, baseline and maximum stages were significantly associated with mortality (n = 1,890). Lower baseline stage was associated with a higher incidence of stage escalation and a shorter duration of time to reach maximum stage. CONCLUSIONS We report a novel approach to define SCAI stages and identify a significant association between baseline and maximum stage and mortality. This approach may improve clinical application of the staging system and provides new insight into the trajectory of hospitalized CS patients. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483).
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Cite This Study
Kapur et al. (2022) studied this question.