SCAI: To improve cardiogenic shock outcomes, reduce lactate levels
The Society of Cardiovascular Angiography and Interventions (SCAI) is expanding its focus on improving outcomes in cardiogenic shock with a new initiative centered on measuring and rapidly lowering lactate levels. SCAI President Srihari S. Naidu, MD, professor of medicine at New York Medical College, said the effort is rooted in both emerging evidence and practical experience and aims to bring time-sensitive metabolic targets into the mainstream of shock care, regardless of the devices a hospital has.
SCAI announced its Door to Lactate Clearance (SCAI DLC) Cardiogenic Shock Initiative in September, based on protocols used at Westchester Medical Center, where Naidu practices. The central goal is straightforward: Measure lactate upon patient arrival and work to reduce it, "ideally within six hours, but longer if it takes that,” he said.
Naidu emphasized that lactate data in the management of cardiogenic shock remains observational, but pointed out that prospective evidence in septic shock supports the value of lactate clearance as a marker of improving outcomes. In those settings, clinicians are urged to clear lactate within six to eight hours and consider escalation of care if levels do not improve.
SCAI published a position statement in September, "SCAI Door to Lactate Clearance (SCAI DLC) Cardiogenic Shock Initiative: Definition, Hypothesis, and Call to Action," which called on cardiologists to build evidence to see if there is value in measuring and lower lactate levels. The limited evidence and use at several hospitals suggest the strategy may lead to better outcomes for these patients, who generally have mortality rates of more than 50%. Additional research is needed, SCAI noted.
Naidu said reception to the SCAI position paper has been strong.
“I think it had a really great reception, a lot of press about it, a lot of interaction about this concept,” he noted. “We're a global society, so we should be doing things that anybody in the world can look at and say we could do that here. I have heard from India, Singapore and other places that this makes a lot of sense because [the approach is] agnostic to technology and resources to improve the patient with whatever resources you have."
Naidu said the next step is gathering real-world data. “I'm just waiting for people to put together databases and to look at this because SCAI fully admits that this is a stab at what we think is the next way to manage shock,” he said. While device innovations and hemodynamic classifications have advanced, he argued that a critical dimension is still missing, which is time.
“The time aspect of shock is probably the most important aspect of all,” Naidu said. He said the longer a patient remains in shock, the more mortality rises due to inflammation and progressive organ injury. “So the real benefit of the door to lactate clearance is that we're adding time. We're forcing time into the mix and saying, you got to look at the time because time is going to make things worse if you wait.”
He hopes researchers with large registries will analyze whether lactate is the optimal metric and determine ideal time targets.
“Is it not the best marker? Is something else better? And if it is the best marker, what's the time? Is it 12 hours, 24 hours, six hours, eight hours?” he asked. Ultimately, he envisions a prospective lactate-guided management trial similar to the septic shock literature.
For now, the call to action is broad. Naidu is encouraging teams to test the approach locally and report outcomes. “I'm hoping that we move the needle there.”
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]