Unified Definition of Cardiogenic Shock by Srihari S. Naidu, MD

Best New Concepts in Interventional Cardiology: A Unified Definition of Cardiogenic Shock Introducing the SCAI SHOCK Classification Srihari S. Naidu, MD, FACC, FAHA, FSCAI Srihari S. Naidu, MD, FACC, FAHA, FSCAI Director, Cardiac Catheterization Laboratory Director, Cardiac Catheterization Laboratory Director, Hypertrophic Cardiomyopathy Center of Excellence Director, Hypertrophic Cardiomyopathy Center of Excellence Westchester Medical Center, Valhalla, New York Westchester Medical Center, Valhalla, New York Professor of Medicine, New York Medical College Professor of Medicine, New York Medical College On Behalf of the SCAI SHOCK Clinical Expert Consensus Document Writing Group On Behalf of the SCAI SHOCK Clinical Expert Consensus Document Writing Group

Intersection of Key Considerations in the Diagnosis and Management of CS It all starts here It all starts here Where is the Where is the problem? problem? (rate (rate- -limiting step limiting step in normalization in normalization of CO/CI of CO/CI What are our What are our support options? support options? (pressors, MCS) (pressors, MCS) Is this actually CS Is this actually CS and how bad is and how bad is bad? bad?

Is This CS and How Bad is Bad?

Simple/Traditional Definition of CS Persistent SBP < 90 mm Hg not responsive to fluid administration alone Secondary to cardiac dysfunction Associated with signs of hypoperfusion or a CI < 2.2 L/min/m2 and a PCWP > 15 mmg Hg

Problem with One Size Fits All IABP SHOCK II Trial IABP SHOCK II Trial SBP < 90 for 30 SBP < 90 for 30 mins Pressors Pressors to SBP > 90 to SBP > 90 Pulm Pulm Congestion Congestion Signs of Signs of Hypoperfusion Hypoperfusion (Lactate > 2, Alt MS or (Lactate > 2, Alt MS or Urine Output < 30 /hour) Urine Output < 30 /hour) mins IMPRESS Trial IMPRESS Trial SBP < 90 for 30 SBP < 90 for 30 mins Pressors Pressors to SBP > 90 to SBP > 90 All pts intubated All pts intubated 90% cardiac arrest 90% cardiac arrest 20 minutes to ROSC 20 minutes to ROSC 70 70- -80% hypothermia 80% hypothermia Signs of Signs of Hypoperfusion Hypoperfusion (Lactate > 7 (Lactate > 7- -8, mins 8, ph ph 7.1 7.1- -7.2) 7.2)

An Updated Lexicon: SCAI SHOCK Stages SCAI Clinical Expert Consensus Statement on SCAI Clinical Expert Consensus Statement on Defining the Spectrum of Cardiogenic Shock Defining the Spectrum of Cardiogenic Shock Simultaneous Publication at SCAI 2019 Meeting Simultaneous Publication at SCAI 2019 Meeting Endorsed by AHA, ACC, STS and SCCM Endorsed by AHA, ACC, STS and SCCM Interv Interv Cardiology Cardiology Heart Heart Failure / Failure / Tx Critical C / Critical C / Cardiology Cardiology Emerg Emerg Medicine Medicine Critical Care Critical Care Nursing Nursing Cardiac Cardiac Surgery Surgery Tx Naidu Naidu S S Baran Baran D D Hollenberg Hollenberg S S Ornato Ornato J J Stelling Stelling K K Pagani Pagani F* F* O Neill W O Neill W Hall S Hall S Van Van Diepen Diepen S S Grines Grines C C Henry Henry T T Thiele H Thiele H Kapur Kapur N N Burkhoff Burkhoff D D Bailey S Bailey S

Goals of a New SHOCK Definition 1. 1. Simple and intuitive without the need for calculation Simple and intuitive without the need for calculation 2. 2. Adds needed granularity in the severity of shock Adds needed granularity in the severity of shock 3. 3. Suitable for rapid assessment at the bedside Suitable for rapid assessment at the bedside 4. 4. Allows for frequent reassessment and reclassification Allows for frequent reassessment and reclassification 5. 5. Can be applied to retrospective datasets or prior trials to re Can be applied to retrospective datasets or prior trials to re- - examine outcomes, and future trials to better define the examine outcomes, and future trials to better define the included population included population 6. 6. Provide new lexicon for communication between providers, Provide new lexicon for communication between providers, including facilitating multidisciplinary communication within a including facilitating multidisciplinary communication within a hospital and between hospitals (hub and spoke model) hospital and between hospitals (hub and spoke model) 7. 7. Prognostic discriminatory potential for morbidity and mortality Prognostic discriminatory potential for morbidity and mortality 8. 8. Easy to remember nomenclature (model INTERMACS) Easy to remember nomenclature (model INTERMACS)

Risk Modifier for Cardiac Arrest Any cardiac arrest however brief ( Any cardiac arrest however brief (Defib Defib or CPR) or CPR) SCAI SHOCK B(A) SCAI SHOCK B(A) = A patient with relative hypotension or = A patient with relative hypotension or tachycardia tachycardia without without hypoperfusion hypoperfusion who suffers a witnessed VF successfully defibrillated and remains without signs of successfully defibrillated and remains without signs of hypoperfusion hypoperfusion If signs of If signs of hypoperfusion hypoperfusion develop after the arrest, this patient develop after the arrest, this patient would be would be SCAI SHOCK C(A) SCAI SHOCK C(A), and in need of , and in need of initial improve perfusion; if those efforts do not work, the patient is improve perfusion; if those efforts do not work, the patient is now now SCAI SHOCK D(A) SCAI SHOCK D(A) who suffers a witnessed VF initial efforts to efforts to

Where do we go from here? 1. 1. Present, publish and spread the word to the wider Present, publish and spread the word to the wider cardiovascular and critical care communities cardiovascular and critical care communities 2. 2. Validate the classification by evaluating its Validate the classification by evaluating its prognostic power and ease prognostic power and ease- -of of- -use in databases 3. 3. Drive earlier recognition of shock and the more Drive earlier recognition of shock and the more precise stage, to guide appropriate and timely precise stage, to guide appropriate and timely escalation of care including transfer to centers escalation of care including transfer to centers more fully equipped (hub and spoke model) more fully equipped (hub and spoke model) 4. 4. Utilize the stages to better define prospectively Utilize the stages to better define prospectively the value of MCS/ECMO and other therapies the value of MCS/ECMO and other therapies use in databases

First Validation of SCAI SHOCK Classification ICU and In-Hospital Mortality

Second Validation of SCAI SHOCK Classification 30 Day Mortality Schrage B, et al. Catheter Cardiovasc Interv 2020

Third Validation of SCAI SHOCK Classification Mortality and Readmission in CS SURVIVORS Jentzer JC, et al. Am Heart J 2020; 219:37-46

FUTURE FUTURE Can we move patients Can we move patients down by early recognition, down by early recognition, escalation/transfer and escalation/transfer and support strategies to support strategies to improve mortality? improve mortality? THANK YOU THANK YOU SCAI leadership and CCI SCAI leadership and CCI Colleagues on the writing Colleagues on the writing group group Endorsing societies (AHA, Endorsing societies (AHA, ACC, STS and SCCM) ACC, STS and SCCM) Wider CV community Wider CV community ( (Altmetric Altmetric Score > 300) Score > 300)