SCAI classification, the importance of its dynamic reclassification in the first 24 hours and the impact of risk modifiers in cardiogenic shock admissions

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Abstract Introduction The Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification has been proposed as a simple, easily applied framework to stratify mortality risk across the spectrum of cardiogenic shock (CS) severity. This categorization has been recently refined (2022) to incorporate the continuum dynamic trajectory of the disease, as well as other risk modifiers. The aims of this study were: 1) to validate the SCAI classification at admission in a cohort of patients admitted to the cardiac intensive care unit (CICU) due to CS; 2) evaluate the prognostic impact of SCAI stage variation during the first 24h of admission; 3) evaluate the prognostic impact of other risk modifiers. Methods We retrospectively analyzed patients consecutively admitted to the CICU with established CS (SCAI C and above) from all causes, from January 2017 to November 2022. SCAI staging was assessed at diagnosis and after 24 hours. The primary outcome was 30-day mortality. Results A total of 208 patients (66±16 years, 67% male) were included. Overall, 53% had an acute myocardial infarction, 34% were admitted due to decompensation of chronic heart failure, and 29.1% had a cardiac arrest. The proportion of patients in SCAI stage C to E at the time of diagnosis was 69% (n=143), 25% (n=52), and 6% (n=13), respectively. 30-day mortality increased across SCAI categories (p<0.001 – figure 1.1). After the first 24 hours, 34 (%) of patients improved SCAI category, 113 (%) remained in the same class, and 45 (%) worsened, with a 30-day mortality of 18%, 34%, and 62%, respectively (p<0.001 – figure 1.2). Risk modifiers also carried prognostic significance (figure 1.3). 30-day mortality was significantly higher in patients with acute myocardial infarction vs. other etiologies (52% vs. 32%; p=0.002), acute CS vs. acute-on-chronic CS (47% vs. 33%; p=0.034), and cardiac arrest (56% vs. 37%; p=0.005). Conclusion Early changes in SCAI classification reflect the dynamic nature of CS patients while retaining significant prognostic discrimination. 24h SCAI re-staging together with risk modifiers may be valuable in readjusting therapeutic strategies aiming at shock reversal.