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This article introduces the SCAI SHOCK Classification, a new and intuitive way to define and assess the severity of shock in cardiac patients. It provides a simple, bedside tool for rapid assessment and allows for frequent reassessment and reclassification. The classification has the potential to improve communication between healthcare providers, facilitate multidisciplinary care within hospitals, and aid in prognostic assessment. The article also discusses the potential of the SCAI SHOCK Classification to guide appropriate and timely escalation of care, including transfer to fully equipped centers.
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Definition of Shock: Is More Clarity Needed?Introducing the SCAI SHOCK Classification Srihari S. Naidu, MD, FACC, FAHA, FSCAI Director, Cardiac Catheterization Laboratory Director, Hypertrophic Cardiomyopathy Center of Excellence Westchester Medical Center, Valhalla, New York Professor of Medicine, New York Medical College On Behalf of the SCAI SHOCK Clinical Expert Consensus Document Writing Group
I have nothing to disclose. Disclosures:
Intersection of Key Considerationsin the Diagnosis and Management of CS It all starts here What are our support options? (pressors, MCS) Where is the problem? (Rate-limiting step in normalization of CO/CI) Is this actually CS and how bad is bad?
Problem with “One Size Fits All” IABP SHOCK II Trial SBP < 90 for 30 mins Pressors to SBP > 90 Pulm Congestion Signs of Hypoperfusion (Lactate > 2, Alt MS or Urine Output < 30 /hour) IMPRESS Trial SBP < 90 for 30 mins Pressors to SBP > 90 All pts intubated 90% cardiac arrest 20 minutes to ROSC 70-80% hypothermia Signs of Hypoperfusion (Lactate > 7-8, ph 7.1-7.2)
An Updated Lexicon:SCAI SHOCK Stages • SCAI Clinical Expert Consensus Statement on Defining the Spectrum of Cardiogenic Shock • Simultaneous Publication at SCAI 2019 Meeting • Endorsed by AHA, ACC, STS and SCCM
Goals of a New SHOCK Definition • Simple and intuitive without the need for calculation • Adds needed granularity in the severity of shock • Suitable for rapid assessment at the bedside • Allows for frequent reassessment and reclassification • Can be applied to retrospective datasets or prior trials to re-examine outcomes, and future trials to better define the included population • Provide new lexicon for communication between providers, including facilitating multidisciplinary communication within a hospital and between hospitals (hub and spoke model) • Prognostic discriminatory potential for morbidity and mortality • Easy to remember nomenclature (model INTERMACS)
Risk Modifier for Cardiac Arrest • Any cardiac arrest however brief (Defib or CPR) • SCAI SHOCK B(A) = A patient with relative hypotension or tachycardia withouthypoperfusion who suffers a witnessed VF successfully defibrillated and remains without signs of hypoperfusion • If signs of hypoperfusion develop after the arrest, this patient would be SCAI SHOCK C(A), and in need of initial efforts to improve perfusion; if those efforts do not work, the patient is now SCAI SHOCK D(A)
Where do we go from here? • Present, publish and spread the word to the wider cardiovascular and critical care communities • Validate the classification by evaluating its prognostic power and ease-of-use in databases • Drive earlier recognition of shock and the more precise stage, to guide appropriate and timely escalation of care including transfer to centers more fully equipped • Utilize the stages to better define prospectively the value of MCS/ECMO and other therapies
THANK YOU! • SCAI leadership including publication committee • SCAI publication and marketing staff • Colleagues on the writing group, especially co-Chair David Baran, Cindy Grines and Tim Henry • Endorsing societies (AHA, ACC, STS and SCCM) • Wider cardiovascular community
