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cardio.cardiogenic-shock.core.v1PRODUCTION
cardio.cardiogenic-shock.core.v1

Cardiogenic shock (SCAI A–E)

cardiologyacuteadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Multidisciplinary CS team activation (cards, ICU, IC, CT surgery) per SCAI 2019 hub-and-spoke model (Baran et al)

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CS team activated

Patient inputs (9)

Compensatory tachy / brady + pre-arrest (SCAI 2019 Stage D/E criteria)

End-organ damage marker per SCAI 2019; drug dosing (ACC/AHA 2022)

AMI-CS vs HF-CS subtype classification (SHOCK trial, Hochman NEJM 1999)

LVEF, RV function, valvular cause, pericardial (ACC/AHA 2022 HF Guideline, Class I)

STEMI / OMI / wide-complex tachy precipitant (ACC/AHA 2022)

SCAI 2019 staging baseline + vasopressor titration (Baran et al)

SCAI 2019 staging + response to therapy; CardShock lactate prognostication (Harjola EHJ 2015)

AMI-CS pathway → urgent revascularization (SHOCK trial, Hochman NEJM 1999)

HF-CS — different MCS / inotrope strategy (ESC 2021 HF Guidelines)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningscai_stage_d_or_e
    Lactate rising on max NE + dobutamine OR cardiac arrest (SCAI 2019 Stage D/E, Baran et al)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningami_cs
    CS within 24 h of STEMI / NSTE-ACS (SHOCK trial, Hochman NEJM 1999)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication
    Acute MR / VSR / free-wall rupture causing shock (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrv_predominant_shock
    Severe RV failure (massive PE, RV infarct, ARDS) with shock (ESC 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_arrhythmic_storm
    Recurrent VT/VF despite amiodarone in CS (AHA ACLS 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmulti_organ_failure_in_cs
    AKI + hepatic dysfunction + AMS + coagulopathy in established CS (SCAI 2022 Stage D/E)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbiventricular_failure_on_lv_mcs
    New / worsening RV failure on LV-only MCS — RV-LV mismatch on biventricular MCS or LV unloading reveals RV failure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfutility_no_lactate_clearance
    Lactate non-clearance after 24 h on max MCS + pressors + inotropes + multi-organ failure + age + frailty + SOFA trajectory worsening
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremcs_bleeding_or_thrombosis
    Major bleeding or device thrombosis on Impella / VA-ECMO — DanGer Shock major bleed 21.8%, limb ischemia 5.6% (Møller NEJM 2024 PMID 38587239)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Cardiogenic shock — vasopressor + inotrope + MCS escalation by SCAI 2019 stage (Baran et al)
axis: cs_vasopressor_inotrope_mcsstep A - Stage A — At Risk (no shock) — SCAI 2019
Selected step "Stage A — At Risk (no shock) — SCAI 2019" — Acute MI / decompensated HF without hemodynamic compromise (SCAI 2019 Stage A, Baran et al)

outpatient playbook — drug actions (4)

  1. 1. continue diuretic at discharge dose; titrate by weight
    rxcui 4603
    furosemide 40–80 mg PO daily — adjust ±20 mg per weight trend • PO • daily
    trigger: Stable euvolemia at d/c
    Maintain euvolemia; smallest dose that holds (TRANSFORM-HF PMID 36648467)
  2. 2. first up-titration of ARNI
    rxcui 1656339
    sacubitril-valsartan 24/26 → 49/51 BID at week 1 • PO • BID
    trigger: SBP ≥100 + K <5.0 + eGFR stable + tolerated 1 week
    STRONG-HF intensive titration cadence; PIONEER-HF safety data (PMID 30415601)
  3. 3. first up-titration of BB
    rxcui 20352
    carvedilol 3.125 → 6.25 BID at week 1 if HR >65 • PO • BID
    trigger: HR >55 + euvolemia + SBP >100
    STRONG-HF; COPERNICUS (PMID 11386263)
  4. 4. add MRA if not yet started
    rxcui 9997
    spironolactone 12.5 → 25 mg daily • PO • daily
    trigger: K <5.0 + eGFR ≥30 + not on at d/c
    Address GDMT gap; RALES (PMID 10471456)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Persistent SBP <90 / MAP <65 unresponsive to fluids (SCAI 2019 Stage C criteria, Baran et al); Lactate ≥2.0 with cardiac failure (SCAI 2019 hypoperfusion marker, Baran et al); Severely reduced LVEF on echo with hypoperfusion (ACC/AHA 2022 HF Guideline).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock (SCAI A–E)** (cardio.cardiogenic-shock.core.v1).
Scope: Multidisciplinary CS team activation (cards, ICU, IC, CT surgery) per SCAI 2019 hub-and-spoke model (Baran et al)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cardiogenic shock — vasopressor + inotrope + MCS escalation by SCAI 2019 stage (Baran et al)** — step "Stage A — At Risk (no shock) — SCAI 2019".

Setting playbook (outpatient) — Bridge encounter at 1-week post-discharge (the STRONG-HF anchor visit) — confirm euvolemia maintained, complete unfinished GDMT initiation, screen for early CS recurrence signals, set the biweekly titration trajectory; advanced-HF eval if persistent LV dysfunction
1. continue diuretic at discharge dose; titrate by weight furosemide 40–80 mg PO daily — adjust ±20 mg per weight trend PO daily — Stable euvolemia at d/c (Maintain euvolemia; smallest dose that holds (TRANSFORM-HF PMID 36648467))
2. first up-titration of ARNI sacubitril-valsartan 24/26 → 49/51 BID at week 1 PO BID — SBP ≥100 + K <5.0 + eGFR stable + tolerated 1 week (STRONG-HF intensive titration cadence; PIONEER-HF safety data (PMID 30415601))
3. first up-titration of BB carvedilol 3.125 → 6.25 BID at week 1 if HR >65 PO BID — HR >55 + euvolemia + SBP >100 (STRONG-HF; COPERNICUS (PMID 11386263))
4. add MRA if not yet started spironolactone 12.5 → 25 mg daily PO daily — K <5.0 + eGFR ≥30 + not on at d/c (Address GDMT gap; RALES (PMID 10471456))

Non-pharmacologic actions:
- Reinforce daily weight log + sodium <2 g/d + fluid <2 L/d if symptomatic (ACC/AHA 2022)
- Cardiac rehab kick-off if not started (ACC/AHA 2022 Class I)
- Confirm next visit booked at week 3 (biweekly through week 6 per STRONG-HF)
- If LVEF persistently <30% — refer to advanced HF program for LVAD/transplant eval (ACC/AHA 2022 Class I)

AVOID / contraindication checks:
- Beta_blocker_AVOID_in_cardiogenic_shock (ACC/AHA 2022)
- Nitrates_AVOID_RV_infarct_or_severe_hypotension (ACC/AHA 2022)
- Negative_inotropes_AVOID (ESC 2021)
- Diuretics_AVOID_pre_perfusion_restoration (ESC 2021)
- Milrinone_renal_dose_required (DOREMI, Mathew NEJM 2021 PMID 34347952)
- LV_only_Impella_AVOID_in_RV_predominant_CS (ESC 2021 HF Guidelines)
- Routine_epinephrine_AVOID_increases_lactate (OptimaCC, Levy JACC 2018 PMID 29976291)
- Routine_VA_ECMO_AVOID_in_AMI_CS_no_30d_benefit (ECLS SHOCK Thiele NEJM 2023 PMID 37634145)
- Routine_IABP_AVOID_no_mortality_benefit (IABP SHOCK II Thiele NEJM 2012 PMID 22920912 + 6 yr 30586721)

Monitoring

Regimen monitoring:
- arterial line continuous BP (ACC/AHA 2022 Class I)
- central venous access (ACC/AHA 2022)
- lactate q1-2h (CardShock, Harjola EHJ 2015)
- UOP hourly (SCAI 2019 end-organ perfusion marker)
- mixed venous O2 if PA cath in place (ACC/AHA 2022)
- echo at baseline then q24h (ESC 2021)
- serial troponin BNP (ACC/AHA 2022)
- CT imaging if PE or dissection suspected (ACC/AHA 2022)

Setting (outpatient) monitoring:
- Weight log review weekly via patient portal or call (STRONG-HF)
- BMP at next visit (week 3) — earlier if eGFR borderline or K trending up
- NT-proBNP if symptoms recur

Monitoring phase: A-line, central line, lactate clearance, urine output, mixed venous if PA cath (ACC/AHA 2022 HF Guideline)

Disposition

Current setting: outpatient — Bridge encounter at 1-week post-discharge (the STRONG-HF anchor visit) — confirm euvolemia maintained, complete unfinished GDMT initiation, screen for early CS recurrence signals, set the biweekly titration trajectory; advanced-HF eval if persistent LV dysfunction

Disposition criteria:
- Confirm continuation in transition setting (next biweekly visit week 3) — formal handoff to cardio.hf.core.v1 occurs when all 4 GDMT pillars titrated to max-tolerated dose AND euvolemia maintained ≥4 weeks (per STRONG-HF post-trial cadence)

Escalation triggers (move to higher acuity):
- Weight gain ≥3 lb in 24 h or ≥5 lb in 1 week → diuretic titration per protocol or ED (ACC/AHA 2022)
- Symptomatic hypotension after ARNI up-titration → hold next dose, recheck in 1 week
- K rising >5.5 → hold MRA first, consider K binder
- Recurrent shock symptoms (orthostasis + AMS + oliguria) → ED + MCS-capable hub (SCAI 2022)
- NYHA worsening to III+ → expedite cardiology re-evaluation (ACC/AHA 2022 Class I)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Lactate rising on max NE + dobutamine OR cardiac arrest (SCAI 2019 Stage D/E, Baran et al)
- [LIFE_THREATENING] CS within 24 h of STEMI / NSTE-ACS (SHOCK trial, Hochman NEJM 1999)
- [LIFE_THREATENING] Acute MR / VSR / free-wall rupture causing shock (ACC/AHA 2022)

Citations

- SCAI Cardiogenic Shock Classification 2022 (Naidu JACC 2022, PMID 35115207) + AHA Cardiogenic Shock Scientific Statement 2017 (van Diepen Circulation 2017, PMID 28923988) + 2022 AHA/ACC/HFSA HF Guideline (Heidenreich Circulation 2022, PMID 35363499) + ESC HF Guideline 2021 (McDonagh EHJ 2021, PMID 34447992) [PMID:35115207](https://pubmed.ncbi.nlm.nih.gov/35115207/)
- Cited evidence (PMID 31104355) [PMID:31104355](https://pubmed.ncbi.nlm.nih.gov/31104355/)
- Cited evidence (PMID 28923988) [PMID:28923988](https://pubmed.ncbi.nlm.nih.gov/28923988/)
- Cited evidence (PMID 10460813) [PMID:10460813](https://pubmed.ncbi.nlm.nih.gov/10460813/)
- Cited evidence (PMID 29083953) [PMID:29083953](https://pubmed.ncbi.nlm.nih.gov/29083953/)

Last reconciled with current guidelines: 2026-05-14.
References
  • SCAI Cardiogenic Shock Classification 2022 (Naidu JACC 2022, PMID 35115207) + AHA Cardiogenic Shock Scientific Statement 2017 (van Diepen Circulation 2017, PMID 28923988) + 2022 AHA/ACC/HFSA HF Guideline (Heidenreich Circulation 2022, PMID 35363499) + ESC HF Guideline 2021 (McDonagh EHJ 2021, PMID 34447992) — PMID:35115207
  • Cited evidence (PMID 31104355) — PMID:31104355
  • Cited evidence (PMID 28923988) — PMID:28923988
  • Cited evidence (PMID 10460813) — PMID:10460813
  • Cited evidence (PMID 29083953) — PMID:29083953