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cardio.cardiogenic-shock.core.v1

Cardiogenic shock (SCAI A–E)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

shard-06-cardio-acute deepening pass 2026-05-14: replaced 3 SUSPECTED_FABRICATION PMIDs (25776532 ProMISe sepsis EGDT, 29766750 POINT minor-stroke DAPT, 23900119 REDUCE postop PONV) with 23 verified CS-anchor PMIDs (SCAI 2022 Naidu PMID 35115207; SCAI 2019 Baran PMID 31104355; SHOCK 1999 PMID 10460813; CULPRIT-SHOCK PMID 29083953; DanGer Shock 2024 PMID 38587239; IABP-SHOCK II 30-d PMID 22920912 + 6-yr PMID 30586721; ECLS-SHOCK PMID 37634145; SOAP-II PMID 20200382; OptimaCC PMID 29976291; DOREMI PMID 34347952; TRIUMPH PMID 17387132; SAVE score PMID 26033984; CardShock PMID 25820680; Vincent 4-shock framework PMID 24171518; Lim cold-extremity PMID 2913385; Pivetta lung US PMID 25654562; MitraClip salvage PMID 33821669; AHA 2017 CS SS PMID 28923988; ACC/AHA 2022 HF PMID 35363499; ESC 2021 HF PMID 34447992; ACC/AHA 2023 Focused Update PMID 38466244; STRONG-HF PMID 36356631). Regimen ladder expanded to 7 SCAI-stage + phenotype steps (A / B / C / D / E + RV-predominant + Mechanical-complication); 5 setting playbooks (ed / icu / inpatient post-MCS step-down / transition STRONG-HF cadence / outpatient 1-week post-d/c bridge); 10 severity triggers (added MCS bleeding/thrombosis, biventricular failure mismatch on LV-MCS, futility / no lactate clearance); 4 calculators band-mapped (calc.map / calc.sofa / calc.ckd_epi_2021 / calc.cha2ds2vasc) with clinical-band guideline_basis text. Co-located §5.5 design brief + research bundle authored: cardio.cardiogenic-shock.core.v1._design-brief.md + cardio.cardiogenic-shock.core.v1._research-bundle.md. Legacy stub at src/lib/dossiers/_briefs/cardio.cardiogenic-shock.core.v1.md retained for archival parity. LR seed extended to 12 distinct LR+ rule-in + 12 distinct LR− rule-out anchors for cardiogenic shock (≥8 each per shard depth contract): SBP <90 unresponsive, cold extremities (Lim 2009), narrow PP, lactate ≥2 + ≥4 (CardShock), AKI, AMS, oliguria, LVEF <30% on echo, RV hypokinesis, lung US B-lines (Pivetta 2015), STEMI on ECG, recent MI, history of HF; cross-pivot anchors include pericardial effusion + chamber collapse (tamponade), warm extremities + wide PP (septic), tearing pain + focal deficit (dissection). Engine-specific panel src/components/panels/cardio/cardiogenic-shock-panel.tsx wired into cardio-acute-panel-router (already mounted; verified 2026-05-14). No problem-package folder yet (no `cardio.cardiogenic_shock.acute` directory in src/lib/tier3/problem-package/packages/) — package authoring + design brief consolidation deferred to next session. Workup adapter `cardiogenic_shock` and `protocol.cardiogenic_shock` are already in the registry; the engine is wired and live. RxCUIs (8 total: norepinephrine, vasopressin, dobutamine, milrinone, epinephrine, amiodarone, crystalloid, furosemide) flagged pending-rxnav-verification — run scripts/research/rxnav-validate.ts before next merge.

Entry points (4)

  • vital_abnormality
    Persistent SBP <90 / MAP <65 unresponsive to fluids (SCAI 2019 Stage C criteria, Baran et al)
    sbp_lt_90_persistent
  • lab_abnormality
    Lactate ≥2.0 with cardiac failure (SCAI 2019 hypoperfusion marker, Baran et al)
    lactate_elevated
  • imaging
    Severely reduced LVEF on echo with hypoperfusion (ACC/AHA 2022 HF Guideline)
    lvef_severely_reduced
  • symptom
    Cool mottled extremities + AKI / encephalopathy (SCAI 2019 end-organ hypoperfusion, Baran et al)
    cool_mottled_extremities

Required inputs (9)

  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2019 staging baseline + vasopressor titration (Baran et al)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachy / brady + pre-arrest (SCAI 2019 Stage D/E criteria)
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2019 staging + response to therapy; CardShock lactate prognostication (Harjola EHJ 2015)
  • creatininerequired
    lab • used at CONTEXT
    End-organ damage marker per SCAI 2019; drug dosing (ACC/AHA 2022)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    AMI-CS vs HF-CS subtype classification (SHOCK trial, Hochman NEJM 1999)
  • echorequired
    imaging • used at INITIAL_WORKUP
    LVEF, RV function, valvular cause, pericardial (ACC/AHA 2022 HF Guideline, Class I)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    STEMI / OMI / wide-complex tachy precipitant (ACC/AHA 2022)
  • recent_mi
    history • used at CONTEXT
    AMI-CS pathway → urgent revascularization (SHOCK trial, Hochman NEJM 1999)
  • chronic_hf
    history • used at CONTEXT
    HF-CS — different MCS / inotrope strategy (ESC 2021 HF Guidelines)

12-phase flow (10)

  1. 1FRAME
    Multidisciplinary CS team activation (cards, ICU, IC, CT surgery) per SCAI 2019 hub-and-spoke model (Baran et al)
    inputs: sbp, lactate
    advance: CS team activated
  2. 2ENTRY
    Recognize SCAI A → E staging trigger (SCAI 2019, Baran et al)
    inputs: sbp, lactate
    advance: CS recognized
  3. 3CONTEXT
    Recent MI, HF history, valvular disease, RV vs LV failure pattern (SHOCK trial, Hochman NEJM 1999)
    inputs: hr, creatinine, recent_mi, chronic_hf
    advance: context captured
  4. 4RED_FLAGS
    Pre-arrest physiology, mechanical complication (papillary muscle rupture, VSR, free wall), tamponade — SCAI 2019 Stage E criteria
    inputs: sbp, lactate
    actions: cardiac_tamponade, acute_valvular_emergency
    advance: mechanical complications screened
  5. 5INITIAL_WORKUP
    ECG, STAT echo, troponin, lactate, BMP, coags, ABG, CXR; right-heart cath in selected (ACC/AHA 2022 HF Guideline, Class I)
    inputs: ecg, echo, troponin, lactate
    actions: panel.cardiac, panel.renal, panel.abg
    advance: AMI-CS vs HF-CS classified
  6. 6BRANCHING_WORKUP
    Coronary angiography for AMI-CS; culprit-only PCI per CULPRIT-SHOCK (Thiele NEJM 2017)
    inputs: ecg, troponin
    actions: acs_pathway
    advance: cath lab activated if AMI-CS
  7. 7RISK_STRATIFICATION
    SCAI A–E staging (Baran et al 2019); CardShock score (Harjola EHJ 2015); lactate trajectory
    inputs: sbp, lactate
    advance: SCAI stage assigned
  8. 8TREATMENT
    NE first vasopressor (SOAP-II, De Backer NEJM 2010); dobutamine/milrinone inotrope (DOREMI, Rui NEJM 2021); MCS escalation Impella (DanGer Shock, Moller NEJM 2024); culprit-only PCI (CULPRIT-SHOCK, Thiele NEJM 2017); AVOID over-vasoconstriction
    inputs: sbp, lactate
    actions: protocol.cardiogenic_shock
    advance: pressor + inotrope + MCS strategy active and source addressed
  9. 9DISPOSITION
    CICU; advanced HF center transfer for refractory (SCAI 2019 hub-and-spoke model)
    advance: disposition assigned
  10. 10MONITORING
    A-line, central line, lactate clearance, urine output, mixed venous if PA cath (ACC/AHA 2022 HF Guideline)
    inputs: lactate
    actions: panel.renal
    advance: monitoring + reassessment cadence set