Assessment of Shock Severity in Postoperative Cardiac Surgery

Oct 19, 2023
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Authors:
Roeschl T, Hinrichs N, Hommel M, et al.
Citation:
Systematic Assessment of Shock Severity in Postoperative Cardiac Surgery Patients. J Am Coll Cardiol 2023;82:1691-1706.
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • The SCAI shock classification can categorize postoperative CSICU patients into risk groups A to E with increasing CSICU mortality, hospital mortality, length of stay, duration of mechanical ventilation, severity of organ dysfunction, and prevalence of postoperative complications.
  • Furthermore, strong mortality gradients across SCAI shock stages were also observed in relevant subgroups, thereby highlighting its application in various cardiosurgical settings.
  • Due to its simple definitions, built in machine-readable data, the SCAI shock classification may be applied as a triage tool in postoperative care through a fully automated, EHR-integrated application readily available to clinicians.

Study Questions:

What is the diagnostic utility of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification in postoperative cardiac surgery intensive care unit (CSICU) patients?

Methods:

The investigators retrospectively analyzed 26,792 postoperative CSICU admissions at a heart center between 2012 and 2022. Patients were classified into SCAI shock stages A to E using electronic health record (EHR) data. Moreover, the impact of late deterioration (LD) as an additional risk modifier was investigated. Logistic regression was used to determine the association between SCAI shock stages and hospital mortality with and without adjustment for LD and additional clinically relevant confounders. Discrimination was assessed using the area under the receiver operating characteristic (AUROC) and DeLong's test was used to compare AUROCs.

Results:

The proportion of patients in SCAI shock stages A to E were 24.4%, 18.8%, 8.4%, 35.5%, and 12.9%, and crude hospital mortality rates were 0.4%, 0.6%, 3.3%, 4.9%, and 30.2%, respectively. Similarly, the prevalence of postoperative complications and organ dysfunction increased across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted odds ratio [aOR], 1.26-16.59) compared with SCAI shock stage A, as was LD (aOR, 8.2). The SCAI shock classification demonstrated a strong diagnostic performance for hospital mortality (AUROC: 0.84), which noticeably increased when LD was incorporated into the model (AUROC: 0.90).

Conclusions:

The authors report that the SCAI shock classification effectively risk stratifies postoperative CSICU patients for mortality, postoperative complications, and organ dysfunction.

Perspective:

This study reports that the SCAI shock classification can categorize postoperative CSICU patients into risk groups A to E with increasing CSICU mortality, hospital mortality, length of stay, duration of mechanical ventilation, severity of organ dysfunction, and prevalence of postoperative complications. Furthermore, strong mortality gradients across SCAI shock stages were also observed in relevant subgroups, thereby highlighting its application in various cardiosurgical settings. Due to its simple definitions, built in machine-readable data, the SCAI shock classification may be applied as a triage tool in postoperative care through a fully automated EHR-integrated application. Additional studies with differentiation of shock types are needed to evaluate the efficacy of advanced treatment modalities in relation to disease severity.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Cardiac Surgical Procedures, Shock, Cardiogenic


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