Serial assessment of shock severity in cardiac intensive care unit patients.

Background One-time assessment of the SCAI shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. Methods and Results Unique admissions to a single academic Level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital mortality was evaluated using logistic regression. Among 2,918 unique CICU patients, 1,537 (52.7%) met criteria for shock during one or more blocks and 266 (9.1%) died in hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital mortality. Each higher admission (aOR 1.36, 95% CI 1.18-1.56, AUC 0.70), maximum (aOR 1.59, 95% CI 1.37-1.85, AUC 0.73) and mean (aOR 2.42, 95% CI 1.99-2.95, AUC 0.78) SCAI shock stage was incrementally associated with higher in-hospital mortality. Discrimination was highest for the mean SCAI shock stage (p <0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted higher mortality (aOR 1.15, 95% CI 1.07-1.24). Conclusions Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.