Cardiogenic Shock Classification

To Predict Mortality In The

Cardiac Intensive Care Unit
Jentzer et al JACC VOL. 74, NO. 17, 2019

Dr Soleiman Aria
MBBS MA(Cantab)
MRCP(UK)
MSc (Cardiology) Student
Basic Physician Trainee
 Case Presentation

• 57-year-old manfrom Derby

• BG of: DES LCx 2010, HTN, Hypercholestrolaemia
• Out of Cardiac Arrest – witnessed by wife
• Down time of 30 mins
• ROSC ECG
• Thrombolysed with transient partial response
• Arrived in Cardiogenic Shock:
• More than 12 hours post arrest
• Had developed GI Bleed enroute
 Case Presentation

• Echo:
• At least Mod biventricular failure
• No effusion

• Bloods:
• See opposite
 Case Presentation

• Echo:
• At least Mod biventricular failure
• No effusion

• Bloods:
• See opposite
 Case Presentation
• Echo:
• At least Mod biventricular failure
• No effusion

• Bloods:
• See opposite

• Vasoactive support:
• Vasoactive Infusions : Norad 40 QS, Dobut 5,
Vasopressin 6, Adrenaline DS20
 Introduction

• Cardiogenic Shock is associated

with high rates of morbidity and
mortality
• Although mortality decreasing
• Still at 35 – 40%
• No established therapies for non-MI
aetiologies of Cardiogenic Shock
Trends in in-hospital mortality of patients with acute myocardial infarction according to
cardiogenic shock (CS).

Reference: Hunziker L, Radovanovic D, Jeger R, et al. Twenty-year trends in the incidence and outcome of cardiogenic shock in AMIS Plus registry. Circ Cardiovasc Interv 2019;
 Introduction

• Culprit vessel revascularization, in

MI, is the only beneficial
intervention
• SHOCK I Trial, NEJM 1999
• 6-month improvement in mortality
only in those aged <75
• Revascularization resulted in Trends in in-hospital mortality of patients with acute myocardial infarction according to
cardiogenic shock (CS).
worse outcome in those aged >75

REFERENCE: HOCHMAN ET AL. EARLY REVASCULARIZATION IN ACUTE MYOCARDIAL INFARCTION COMPLICATED BY CARDIOGENIC SHOCK. SHOCK
INVESTIGATORS. N ENGL J MED 1999
 Introduction

• SHOCK II Trial

Trends in in-hospital of patients with acute myocardial infarction according to cardiogenic

shock (CS).

REFERENCE: HOCHMAN ET AL. EARLY REVASCULARIZATION IN ACUTE MYOCARDIAL INFARCTION COMPLICATED BY CARDIOGENIC SHOCK. SHOCK
INVESTIGATORS. N ENGL J MED 1999
OTHER THERAPIES
Haemodynamic phenotypes of Cardiogenic Shock
 Introduction – SHOCK Definition

Reference: 1- Hochman NEJM 1999 2- Theile NJEM 2012 3-Ponikowski Eur Heart
Journal 2016;
 SHOCK Definition - limitations
• Cardiogenic Shock is Heterogenous with different aetiologies
• Encompasses a spectrum of severity spanning from:
• those at high risk of developing shock
• to those with multiorgan failure
• to those with ongoing cardiac arrest
• Treatment and outcomes might differ in different subset of patient with
different severities
• Until recently – no standardized Classification for Cardiogenic Shock
 PREVIOUS ATTEMPTS AT CLASSIFICATION
• In 2015 and 2017, 2 risk scores were developed
• Specific to cardiogenic shock secondary to myocardial infarction
• Provided mortality risk stratification but did not classify patients based on severity
 New Classification

• In April 2019
• Society for Cardiovascular Angiography and
Interventions (SCAI)
• Proposed a 5-stage classification schema for
Cardiogenic Shock
• Required no calculations
• Can be applied both retrospectively and
prospectively
• Applicable to both clinical care and research
• Based on expert consensus opinion
• Endorsed by ACC, AHA, SCCM and STS
 Aim Of This Study

Examine construct validity of this staging of CS by

demonstrating the ability of SCAI CS classification at
the time of Cardiac ICU admission to predict mortality
in unselected Cardiac ICU patients
 Methods

• Retrospective observational study

• Consecutive adult (>18) patients admitted to CICU
• At Mayo Clinic Hospital St Mary’s Campus
• Between January 2007 and December 2015
• Classified in one of the 5 stages at the time of
admission
• Data from Pt’s first admission was analysed
• Patients who declined authorization for inclusion
were excluded

46% 30% 15% 7% 1%

 Methods

• All relevant data were extracted electronically from the medical records
• The admission value of all vital signs, clinical measurements and laboratory values were of either
the first after CICU admission or the closest to it.
• In addition vital signs were recorded every 15 mins during the first hour of admission
• Admission diagnoses included:
• ACS (43%), heart Failure (46%), SVT, A.fib, VF or VT (12%), Shock, Respiratory failure and Sepsis
 Results
In hospital and CICU Mortality

• In hospital mortality, after multivariate

adjustments: Stage A

• Stage A: 3% Stage B

• Stage B: 7% Stage C

• Stage C: 12% Stage D

• Stage D: 40% Stage E

• Stage E: 67%
 Results

Hospital Mortality of Patients With or Without Cardiac Arrest

 Results
Hospital Mortality as a function of SCAI CS Stage
for different aetiologies
 Discussion

• This classification could be implemented as a clinical and research tool to:

• Identify
• Communicate and the risk of death in patients in and at risk of Cardiogenic Shock
• Predict

• This is the first paper that validates she SCAI shock classification

• The presence of Cardiac arrest significantly increase the mortality risk for any given stage
 Study Limitation
• It is single centre, retrospective, observational study

• The patients analysed were from the year 2007 and

2015
• Intra-Aortic Balloon Pump (IABP) was the
predominant form of mechanical circulatory
support

• Currently many other devices are in use:

• Impella, ECMO, Tandem Heart, iVAC 2L
 SHOCK II Trial
Use Of IABP In Cardiogenic Shock
 Evidence for other Mechanical Support Devices
• They are all haemodynamically more effective than IABP
• All have unproven benefit
• Underpowered Randomised Control Trials

• More Complex and a/w higher rates of complications

• Ongoing Trials:
• IMPELLA CP - DANSHOCK (NCT01633502) 360 patients
• VA ECMO - ECMO – CS (NCT02301819) 120 PATIETNS
• ECMO +/- IMPELLA – REVERSE TRIAL (NCT03421467)

• Unclear if the classification still valid if any of these devices are

proven to reverse / improve outcomes of Cardiogenic Shock
 BACK TO THE CASE

• RIP – 5 DAYS LATER

• CONSIDERED FOR ORGAN DONATION
QUESTIONS