Early Cardiogenic Shock: Underrecognized and Often Undertreated

 Introduction 

Early cardiogenic shock (CS) remains a significant clinical challenge, often leading to poor outcomes if not identified and managed promptly. Despite its severe implications, it is frequently underrecognized, with only one in four patients having any electronic medical record (EMR) documentation indicating their shock status. These findings were highlighted in a multicenter study presented at the Society for Cardiovascular Angiography and Interventions (SCAI) 2025 Scientific Sessions in Washington, DC. This article summarizes the critical insights from this study and their implications for clinical practice.

SCAI SHOCK Classification and Study Design The SCAI SHOCK classification system, widely adopted for staging cardiogenic shock, includes five stages:

• A (At Risk) – Patients with a potential risk of shock

• B (Beginning) – Patients with isolated hypotension or hypoperfusion

• C (Classic) – Patients with clear evidence of shock

• D (Deteriorating) – Patients with worsening shock

• E (Extremis) – Patients in severe, life-threatening shock

The study included 500 patients admitted to six hospitals within the Brown University Health System between 2017 and 2022. It specifically focused on patients in SCAI Stage B shock, characterized by isolated hypotension or hypoperfusion.

Key Findings: Poor Outcomes in Early Shock Patients in Stage B shock had concerning outcomes, with approximately 25% requiring transfer to a higher level of care, deteriorating to a more severe shock stage, or dying during hospitalization. The median time to this primary endpoint was 16 hours. Importantly, those with poorer outcomes had a median duration of 11 hours in SCAI B shock compared to 5 hours in those with favorable outcomes, defined as survival without shock stage escalation or transfer for higher care.

Predictors of Poor Outcome Several factors were identified as predictors of poor outcomes in SCAI B shock:

• Acute Kidney Injury (AKI) – Strongly correlated with poor outcomes, particularly when present in more advanced stages.

• Diuretic Resistance – Indicated a failing cardiorenal response.

• Oliguria – Decreased urine output in the prior 24 hours was a significant warning sign.

In-hospital mortality rates were notably higher among those with hypotension (15.4%) compared to those with hypoperfusion (9.5%). Deterioration to a higher shock class occurred in 36.3% of those with hypotension, versus 11.8% with hypoperfusion.

Importance of Early Detection and Response The study's lead author emphasized the need for enhanced education across disciplines, including emergency department staff and emergency medical services (EMS), to recognize early cardiogenic shock. Dr. Vallabhajosyula also suggested that smart EMR-based detection tools, similar to those used for sepsis, could significantly improve early recognition and intervention.

Future Directions Improving early detection and documentation of SCAI Stage B shock should be a research priority. Additionally, better understanding the cardiorenal implications of early cardiogenic shock could guide more effective management strategies.

Key Takeaways for Clinicians

• Early Identification is Critical: Recognizing Stage B shock early can significantly alter patient outcomes.

• Monitor for Key Predictors: Watch for AKI, diuretic resistance, and oliguria as critical early indicators of poor prognosis.

• Implement Detection Tools: Consider integrating EMR sniffers to improve early shock recognition.

• Cross-Disciplinary Training Needed: Educate ED and EMS personnel to enhance early shock detection.

Conclusion Early cardiogenic shock presents a high-risk scenario, even in patients with isolated hypotension or hypoperfusion. Proactive detection and timely intervention are essential to improve outcomes, highlighting the need for system-wide awareness and advanced predictive tools.