Criteria for Defining Stages of Cardiogenic Shock Severity

Navin K. Kapur; Manreet Kanwar; Shashank S. Sinha; Katherine L. Thayer; A. Reshad Garan; Jaime Hernandez-Montfort; Yijing Zhang; Borui Li; Paulina Baca; Fatou Dieng; Neil M. Harwani; Jacob Abraham; Gavin Hickey; Sandeep Nathan; Detlef Wencker; Shelley Hall; Andrew Schwartzman; Wissam Khalife; Song Li; Claudius Mahr; Ju H. Kim; Esther Vorovich; Evan H. Whitehead; Vanessa Blumer; Daniel Burkhoff

doi:10.1016/j.jacc.2022.04.049

Criteria for Defining Stages of Cardiogenic Shock Severity

Navin K. Kapur^*, Manreet Kanwar, Shashank S. Sinha, Katherine L. Thayer, A. Reshad Garan, Jaime Hernandez-Montfort, Yijing Zhang, Borui Li, Paulina Baca, Fatou Dieng, Neil M. Harwani, Jacob Abraham, Gavin Hickey, Sandeep Nathan, Detlef Wencker, Shelley Hall, Andrew Schwartzman, Wissam Khalife, Song Li, Claudius MahrJu H. Kim, Esther Vorovich, Evan H. Whitehead, Vanessa Blumer, Daniel Burkhoff

^*Corresponding author for this work

Medicine, Cardiology Division

Research output: Contribution to journal › Article › peer-review

139 Scopus citations

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.

Original language	English (US)
Pages (from-to)	185-198
Number of pages	14
Journal	Journal of the American College of Cardiology
Volume	80
Issue number	3
DOIs	https://doi.org/10.1016/j.jacc.2022.04.049
State	Published - Jul 19 2022

Funding

This work was supported by National Institutes of Health RO1 grants (to Dr Kapur) (R01HL139785-01; R01HL159089-01) and institutional grants from Abiomed Inc, Boston Scientific Inc, Abbott Laboratories, Getinge Inc, and LivaNova Inc to Tufts Medical Center. The sponsors had no input on collection, analysis, and interpretation of the data, nor in the preparation, review, or approval of the manuscript. Dr Kapur has received consulting honoraria and institutional grant support from Abbott Laboratories, Abiomed Inc, Boston Scientific, Medtronic, LivaNova, Getinge, and Zoll. Dr Kanwar has served on the advisory board for Abiomed Inc. Dr Sinha has served as a consultant for Abiomed Inc. Dr Garan has served as a consultant for NuPulseCV; has served on the scientific advisory board for Abiomed; and is a recipient of research support from Verantos and Abbott. Dr Hernandez-Montfort has served as a consultant for Abiomed Inc. Dr Abraham has served as a consultant for Abbott Laboratories and Abiomed Inc. Dr Nathan has received consulting honoraria from Abiomed, Getinge, and CSI. Dr Hall has served as a consultant to Abiomed, Abbott, and Medtronic. Dr Mahr has served as a consultant to Abbott, Abiomed, and Syncaria. Dr Burkhoff has received an unrestricted, educational grant from Abiomed Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. One of the key goals of introducing the SCAI classifications was to enhance clinical communication and expedite decision-making by standardizing definitions of shock severity. The descriptors of shock staging include key parameters derived from physical examination, biochemical markers, and hemodynamics.13 However, for these classifications to be reproducibly and consistently assignable at bedside requires specific threshold values for the parameters used to define hypotension and hypoperfusion. Moreover, there is increasing use of multidrug and device-based strategies, which needs to be taken into account during staging. The criteria we now propose accounts for many of these variables, including treatment intensity (vasoactive agents, inotropes, and AMCS devices), OHCA, and specific cutoff values for noninvasive hemodynamics (SBP) and laboratory data (lactate, ALT, and pH) to classify patients into individual stages. These parameters were chosen for ease of access at bedside, and were based on prior publications and further supported by data from the CSWG registry. 17-22 This approach allows clinicians to risk-stratify CS patients into SCAI stages using consistent, uniform definitions of hypotension and hypoperfusion.

Keywords

acute myocardial infarction
cardiogenic shock
heart failure
hemodynamics

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

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Cite this

Kapur, N. K., Kanwar, M., Sinha, S. S., Thayer, K. L., Garan, A. R., Hernandez-Montfort, J., Zhang, Y., Li, B., Baca, P., Dieng, F., Harwani, N. M., Abraham, J., Hickey, G., Nathan, S., Wencker, D., Hall, S., Schwartzman, A., Khalife, W., Li, S., ... Burkhoff, D. (2022). Criteria for Defining Stages of Cardiogenic Shock Severity. Journal of the American College of Cardiology, 80(3), 185-198. https://doi.org/10.1016/j.jacc.2022.04.049

@article{c0c754a9be3c459693c95254d50eae47,

title = "Criteria for Defining Stages of Cardiogenic Shock Severity",

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.",

keywords = "acute myocardial infarction, cardiogenic shock, heart failure, hemodynamics",

author = "Kapur, {Navin K.} and Manreet Kanwar and Sinha, {Shashank S.} and Thayer, {Katherine L.} and Garan, {A. Reshad} and Jaime Hernandez-Montfort and Yijing Zhang and Borui Li and Paulina Baca and Fatou Dieng and Harwani, {Neil M.} and Jacob Abraham and Gavin Hickey and Sandeep Nathan and Detlef Wencker and Shelley Hall and Andrew Schwartzman and Wissam Khalife and Song Li and Claudius Mahr and Kim, {Ju H.} and Esther Vorovich and Whitehead, {Evan H.} and Vanessa Blumer and Daniel Burkhoff",

note = "Publisher Copyright: {\textcopyright} 2022",

year = "2022",

month = jul,

day = "19",

doi = "10.1016/j.jacc.2022.04.049",

language = "English (US)",

volume = "80",

pages = "185--198",

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Kapur, NK, Kanwar, M, Sinha, SS, Thayer, KL, Garan, AR, Hernandez-Montfort, J, Zhang, Y, Li, B, Baca, P, Dieng, F, Harwani, NM, Abraham, J, Hickey, G, Nathan, S, Wencker, D, Hall, S, Schwartzman, A, Khalife, W, Li, S, Mahr, C, Kim, JH, Vorovich, E, Whitehead, EH, Blumer, V & Burkhoff, D 2022, 'Criteria for Defining Stages of Cardiogenic Shock Severity', Journal of the American College of Cardiology, vol. 80, no. 3, pp. 185-198. https://doi.org/10.1016/j.jacc.2022.04.049

TY - JOUR

T1 - Criteria for Defining Stages of Cardiogenic Shock Severity

AU - Kapur, Navin K.

AU - Kanwar, Manreet

AU - Sinha, Shashank S.

AU - Thayer, Katherine L.

AU - Garan, A. Reshad

AU - Hernandez-Montfort, Jaime

AU - Zhang, Yijing

AU - Li, Borui

AU - Baca, Paulina

AU - Dieng, Fatou

AU - Harwani, Neil M.

AU - Abraham, Jacob

AU - Hickey, Gavin

AU - Nathan, Sandeep

AU - Wencker, Detlef

AU - Hall, Shelley

AU - Schwartzman, Andrew

AU - Khalife, Wissam

AU - Li, Song

AU - Mahr, Claudius

AU - Kim, Ju H.

AU - Vorovich, Esther

AU - Whitehead, Evan H.

AU - Blumer, Vanessa

AU - Burkhoff, Daniel

PY - 2022/7/19

Y1 - 2022/7/19

N2 - 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.

AB - 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.

KW - acute myocardial infarction

KW - cardiogenic shock

KW - heart failure

KW - hemodynamics

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SN - 0735-1097

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JO - Journal of the American College of Cardiology

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ER -

Criteria for Defining Stages of Cardiogenic Shock Severity

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