Prognostic value of serial SCAI staging in microaxial flow-pump-treated cardiogenic shock: impact of early hemodynamic trajectory on 30-day survival

Background The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification provides a standardized framework for risk stratification in cardiogenic shock, integrating clinical presentation, biochemical markers, and hemodynamic parameters across five stages (A–E). While its prognostic value at baseline has been demonstrated, data on the dynamic evolution of SCAI stages under temporary mechanical circulatory support remain limited. Purpose To evaluate the prognostic performance of serial SCAI stage assessment at 0 h, 24 h, 48 h, and 72 h in patients with cardiogenic shock treated with microaxial flow pump (mAFP) support, and to determine the impact of early changes in SCAI stage on 30-day mortality. Methods We analyzed a prospective registry of a tertiary care center including 608 consecutive patients with cardiogenic shock receiving mAFP support. In 390 of those patients SCAI stage was determined at implantation (0 h) and after 24 h, 48 h, and 72 h. In addition, the SCAI subitems “physical examination,” “biochemical parameters,” and “hemodynamic” were documented at each time point. Mortality was assessed using Kaplan–Meier survival analysis, and differences between SCAI stages were compared using the log-rank test. Discriminatory performance of SCAI stages was evaluated across time points, and hazard ratios (HR) for mortality were calculated for temporal changes in SCAI stage. Results Median age was 67 years (IQR 59–76) and 72% were male. A cardio-pulmonary resuscitation before mAFP was performed in 47.8%, and initial serum lactate was 5.2 mmol/l (IQR 2.7-10.0 mmol/l). At baseline (0 h), patients were distributed across SCAI stages A–E, with the majority in advanced stages D and E (Tab. 1). Thirty-day mortality increased stepwise with higher SCAI stages at all time points. Discrimination for 30-day mortality was modest at 0 h but improved substantially at 24 h, 48 h, and 72 h. Only patients classified as SCAI stage A or B at 0 h showed a misclassification signal with respect to 30-day mortality (Fig. 1). These findings were consistently reflected in the individual SCAI subitems. A worsening of SCAI stage within the first 24 h was associated with a markedly increased risk of 30-day mortality (HR [95% CI] 3.9 [2.5-6.0]; p<0.001). Similar associations were observed for deterioration between 24–48 h (HR [95% CI] 2.7 [1.7-4.4]; p<0.001) and 48–72 h (HR [95% CI] 2.5 [1.1-5.6]; p=0.031). Conclusion In patients with cardiogenic shock treated with a mAFP support, serial assessment of SCAI stage provides robust discrimination of 30-day mortality, particularly beyond the initial 24 hours. Early worsening within the first 24 hours identifies a subgroup at very high risk of death. Dynamic SCAI staging may therefore serve as a clinically practical tool for ongoing risk stratification and therapeutic decision-making in patients receiving temporary mechanical circulatory support.