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cardio.cardiogenic-shock.scai-d.v1PRODUCTION
cardio.cardiogenic-shock.scai-d.v1

Cardiogenic shock — SCAI Stage D (deteriorating)

cardiologyacuteadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

SCAI D = classic CS not responding to initial therapy → escalating support, MCS active or imminent, deteriorating

Inputs
2
Actions
0
Advance rule
Set
Advance when

D-stage criteria met

Patient inputs (6)

Persistent SBP <90 despite ≥2 hemodynamic agents defines deterioration

New AKI = D-stage organ marker; also drives MCS/contrast safety planning

LVEF + RV strain + valvular + tamponade exclusion before MCS device selection

Trend (not single value) defines deterioration vs response; lactate rise on therapy is a hard MCS trigger

MAP <65 despite NE + inotrope drives MCS escalation per DanGer Shock

Confirms reperfusion completeness; identifies salvageable myocardium pre-MCS

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

Severity triggers (5)

5 need judgement
  • informationallife_threateningpersistent_hypotension_on_ne_plus_dobutamine
    MAP <65 despite NE >0.5 mcg/kg/min + dobutamine ≥5 mcg/kg/min for ≥2h — D-stage hemodynamic floor
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrising_lactate_on_initial_therapy
    Lactate rising or static ≥2 mmol/L for ≥6h despite resuscitation + first-line agents
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmcs_failure_or_inadequate
    Impella CP deployed but persistent MAP <65 + lactate not clearing → escalate to VA-ECMO
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmulti_organ_failure_at_24_72h
    Persistent multi-organ failure (SOFA increasing) at 24-72h despite max MCS + pharmacology — futility threshold
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_aki_on_cs_therapy
    New Cr rise ≥0.3 mg/dL or oliguria <0.5 mL/kg/h × 6h on CS therapy — multi-organ involvement
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

SCAI D escalation regimen — adds MCS + second pressor to parent CS regimen
axis: scai_d_escalation_phenotype
Selected axis "SCAI D escalation regimen — adds MCS + second pressor to parent CS regimen" by default fallback (first axis)
  • norepinephrine
    first line
    alpha_beta_agonist_pressor
    0.05 mcg/kg/min IV titrate to MAP ≥65 • IV • continuous
    triggers: cs_with_map_below_65
    SOAP-II PMID 20200382 — NE preferred over dopamine in CS; first-line per ACC/AHA 2022 + SCAI 2022
    rxcui 7512
  • dobutamine
    first line
    beta1_agonist_inotrope
    2.5 mcg/kg/min IV titrate • IV • continuous
    triggers: cs_with_low_ci
    First-line inotrope in CS per SCAI 2022; CI <2.2 + adequate filling pressure
    rxcui 3616
  • vasopressin
    second line
    v1_agonist_pressor
    0.03 U/min IV (fixed-dose adjunct) • IV • continuous
    triggers: scai_d_persistent_hypotension_on_ne, scai_d_high_ne_dose_above_0.5
    V1-mediated vasoconstriction spares pulmonary vasculature; adjunctive when NE >0.5 mcg/kg/min cannot maintain MAP — VANISH/VASST extrapolation
    rxcui 11149
  • milrinone
    comorbidity specific
    pde3_inhibitor_inotrope
    0.125-0.375 mcg/kg/min IV (no bolus in CS) • IV • continuous
    triggers: scai_d_pulmonary_htn_predominant, scai_d_dobutamine_inadequate
    PDE3 inhibitor preferred when pulmonary HTN dominant; avoid bolus in CS (hypotension risk)
    rxcui 52769
  • epoprostenol_inhaled
    comorbidity specific
    pulmonary_vasodilator
    50 ng/kg/min nebulized • INH • continuous
    triggers: scai_d_with_severe_pulm_htn, scai_d_rv_strain_on_echo
    Inhaled pulmonary vasodilator if RV strain develops on Impella support
    rxcui 8814

outpatient playbook — drug actions (1)

  1. 1. continue 4-pillar GDMT
    rxcui 593411
    ARNI + BB + MRA + SGLT2i at max tolerated • PO • as scheduled
    trigger: Recovered HFrEF
    ACC/AHA 2022 HF Class I (PMID 35363499)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: SBP <90 / MAP <65 despite norepinephrine + dobutamine — SCAI D; Lactate rising or static ≥2 mmol/L despite ≥6h initial therapy — failure to clear; New AKI + transaminitis + altered mentation on first-line therapy — D-stage progression.

Objective

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

Assessment

**Cardiogenic shock — SCAI Stage D (deteriorating)** (cardio.cardiogenic-shock.scai-d.v1).
Scope: SCAI D = classic CS not responding to initial therapy → escalating support, MCS active or imminent, deteriorating

No severity triggers fired against current inputs.

Plan

Regimen axis: **SCAI D escalation regimen — adds MCS + second pressor to parent CS regimen**.
1. norepinephrine 0.05 mcg/kg/min IV titrate to MAP ≥65 IV continuous (alpha_beta_agonist_pressor, first line) — SOAP-II PMID 20200382 — NE preferred over dopamine in CS; first-line per ACC/AHA 2022 + SCAI 2022
2. dobutamine 2.5 mcg/kg/min IV titrate IV continuous (beta1_agonist_inotrope, first line) — First-line inotrope in CS per SCAI 2022; CI <2.2 + adequate filling pressure
3. vasopressin 0.03 U/min IV (fixed-dose adjunct) IV continuous (v1_agonist_pressor, second line) — V1-mediated vasoconstriction spares pulmonary vasculature; adjunctive when NE >0.5 mcg/kg/min cannot maintain MAP — VANISH/VASST extrapolation
4. milrinone 0.125-0.375 mcg/kg/min IV (no bolus in CS) IV continuous (pde3_inhibitor_inotrope, comorbidity specific) — PDE3 inhibitor preferred when pulmonary HTN dominant; avoid bolus in CS (hypotension risk)
5. epoprostenol_inhaled 50 ng/kg/min nebulized INH continuous (pulmonary_vasodilator, comorbidity specific) — Inhaled pulmonary vasodilator if RV strain develops on Impella support

Setting playbook (outpatient) — Long-term advanced HF follow-up: GDMT maintenance, transplant listing if appropriate, end-of-life planning if not eligible
6. continue 4-pillar GDMT ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — Recovered HFrEF (ACC/AHA 2022 HF Class I (PMID 35363499))

Non-pharmacologic actions:
- Transplant listing maintenance
- Advance care planning if not transplant candidate

AVOID / contraindication checks:
- Vasopressin_avoid_severe_peripheral_ischemia (drug label)
- Milrinone_avoid_severe_aortic_stenosis (vasodilator effect)
- Impella_relative_contraindication_severe_aortic_regurg (device label)
- Impella_avoid_lv_thrombus (embolic risk — DanGer Shock 2024 exclusion)

Monitoring

Regimen monitoring:
- pa catheter continuous for ci pcwp rv stroke work (D-stage standard)
- lactate q1h x 6h then q4h (D-stage clearance benchmark)
- echo daily for lv recovery and device position (Impella position migration risk)
- limb perfusion assessment q2h if femoral access (ischemic complication monitoring)

Setting (outpatient) monitoring:
- Quarterly NT-proBNP + BMP
- Annual echo

Follow-up plan: If recovery: MCS wean, GDMT initiation, advanced HF clinic; if no recovery → SCAI E pathway
- Close-out criterion: recovery vs E-stage decision made

Monitoring phase: Continuous PA catheter; q1h lactate × 6h then q4h; daily echo; SOFA score q12h

Disposition

Current setting: outpatient — Long-term advanced HF follow-up: GDMT maintenance, transplant listing if appropriate, end-of-life planning if not eligible

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1

Escalation triggers (move to higher acuity):
- Recurrent CS → readmit + escalate to chronic engine or hospice

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] MAP <65 despite NE >0.5 mcg/kg/min + dobutamine ≥5 mcg/kg/min for ≥2h — D-stage hemodynamic floor
- [LIFE_THREATENING] Lactate rising or static ≥2 mmol/L for ≥6h despite resuscitation + first-line agents
- [LIFE_THREATENING] Impella CP deployed but persistent MAP <65 + lactate not clearing → escalate to VA-ECMO

Citations

- SCAI 2022 CS staging + 2025 ACC/AHA ACS + 2022 ACC/AHA HF (with 2023 Focused Update) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)
- Cited evidence (PMID 26333869) [PMID:26333869](https://pubmed.ncbi.nlm.nih.gov/26333869/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)
- Cited evidence (PMID 37634145) [PMID:37634145](https://pubmed.ncbi.nlm.nih.gov/37634145/)

Last reconciled with current guidelines: 2026-05-14.
References