Feasibility and implications of patient assessment in the first 24 hours with the 2022 SCAI shock classification in patients with acute coronary syndromes
Authors: Renon F , Liccardo B , D'andrea A , Guida S , Totaro R , Munafo' A R , Calabro' P , Leonardi S , Camporotondo R 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
An update of the Society for Cardiovascular Angiography and Interventions (SCAI) classification of cardiogenic shock has been proposed in 2022, with a refinement of the classification criteria and a revised "A" modifier definition, which restricts cardiac arrests (CA) only to episodes with potential anoxic brain injury.

Purpose
To verify the feasibility of application of the updated SCAI classification in patients with acute coronary syndromes (ACS). To evaluate the prognostic value of the SCAI staging, applied at different timepoints during hospitalization. Finally, we investigated potential predictors of shock stage progression and mortality.

Methods
As part of a large, prospective quality improvement initiative in patients with acute coronary syndrome (ACS), we assigned via chart review a 2022 SCAI shock stage (A to E) at presentation, at 24 hours, as well as at the highest stage during hospitalization. We evaluated the association of the shock stage at presentation and at the highest shock stage during hospitalization, as well as of stage improvement at 24 hours, with in-hospital mortality. Multivariate logistic regression analysis was used to identify predictors of stage deterioration at 24 hours; baseline GRACE ACS 2.0 and CardShock risk scores and first glycaemia were used as covariates. For the analysis of predictors of in-hospital mortality, we considered the CA modifier as per 2022 definition, the GRACE score, developement of sepsis and the need for renal replacement therapy (RRT).

Results
Out of 759 patients of which data were analysed, 373 (49%) were included in the study fulfilling the criteria for one of the five SCAI stages. Of these, 68.6% presented with ST elevation myocardial infarction; 20.4% of patients presented with CA. At presentation, 45% of patients were in stage A, 19.3% in stage B, 21.2% in stage C and 14.5% in stage E; stage D was assigned only at 24 hours. In-hospital mortality was strongly associated with both the shock stage at presentation (OR 1.82; 95% CI 1.53–2.18, P&lt;0.001) and at the highest stage during hospitalization (OR 3.99; 95% CI 3.03–5.27, P&lt;0.001). Lack of improvement at 24 hours was associated with a substantially increased risk of mortality (OR 24.8; 95% CI 13.3–46.2, P&lt;0.001). Predictors of worsening of shock stage at 24 hours were the GRACE (OR 1.06; 95% CI 1.04–1.09, P&lt;0.001) and CardShock (OR 2.61; 95% CI 1.13–6.02, P=0.02) scores. Predictors of mortality were the CA modifier (OR 23.3; 95% CI 9.6–56.1, P&lt;0.001), sepsis (OR 3.5; 95% CI 1.12–10.97, P=0.03) and the need for RRT (OR 30.4; 95% CI 8.5–108.1, P&lt;0.001).

Conclusions
The 2022 update of the SCAI shock stage, assessed both at presentation and as the highest stage during hospitalization, demonstrated a strong association with in-hospital mortality. Given the increased risk of mortality of patients not improving in the first 24 hours, the clinical trajectory of patients may have prognostic and therapeutic implications.