SCAI takes on shock-related mortality with door-to-lactate clearance initiative
Despite aggressive efforts to lower cardiogenic shock (CS) rates over the past 20 years, mortality remains high. A new initiative from the Society for Cardiovascular Angiography and Interventions (SCAI) is designed to simplify care for these patients and help reverse that trend for good. SCAI is proposing a new framework for CS, one that establishes lactate clearance as a potential new standardized, time-based marker that can guide treatment decisions.
SCAI announced the new initiative “SCAI Door-to-Lactate Clearance (SCAI DLC) Cardiogenic Shock Initiative: Definition, Hypothesis and Call to Action” Sept. 19 at the SCAI SHOCK conference in Tampa, Florida, with simultaneous publication in JSCAI.[1]
“Cardiogenic shock remains one of the deadliest conditions in cardiovascular medicine, and despite advances in therapies, mortality has remained unacceptably high,” SCAI President Srihari S. Naidu, MD, professor of medicine at New York Medical College and lead author of the new initiative, said in a statement. “One of the challenges is ensuring expedited diagnosis and early management, as well as evaluating that ‘first stab’ at management in the early hours. By prioritizing time to lactate clearance, we aim to create a unifying measure that can be applied across hospitals and health systems to guide decision-making and ultimately save lives.”
Despite progress with the SCAI SHOCK Classification, clinicians still require a reliable method to track treatment effectiveness in real time, helping them decide whether to be more or less aggressive. Naidu said the DLC Initiative offers a practical solution by focusing on lactate, a widely available biomarker of tissue perfusion. Lactate levels have long been recognized as strong predictors of outcomes in critical illness. Persistently elevated lactate is associated with poor survival across multiple datasets in cardiogenic shock and other forms of shock, while timely clearance correlates strongly with recovery and survival.
"As SCAI president, my imperative and call to action is, I want people to figure out ... how they can get all their shock patients lactate cleared within 24 hours. I'm calling this the golden day. I'm challenging people—instead of a door-to-balloon time of 90 minutes, I want a door to lactate clearance in 24 hours. That's my challenge for the year. And if we can move on that, I think that's the last frontier in interventional cardiology," Naidu said in an interview with Cardiovascular Business.
By building lactate clearance into standardized protocols, Naidu said the DLC Initiative aims to provide shock teams with actionable, objective data to guide early management decisions. The position statement recommends measuring lactate at diagnosis and then every two to three hours to evaluate patient response to initial and subsequent interventions. The goal is to achieve lactate clearance from initial levels to below 2 mmol/L within 24 hours of diagnosis, defined by the authors as “door-to-lactate clearance.”
“Lactate has long been known to be a negative prognosticator in many forms of critical illness, including cardiogenic shock,” Sandeep Nathan, MD, MSc, co-author of the DLC Initiative, and associate professor of medicine at the University of Chicago, added in the same statement. “The door-to-lactate clearance initiative is a proposal that builds on this data and is aimed at prospectively characterizing lactate clearance in cardiogenic shock patients with the goal of normalizing tissue perfusion and thereby normalizing lactate on the backdrop of aggressive cardiovascular care.”
Instead of designating what devices to use or a specific care process to follow because of the variables involved in each patient, Naidu said centers are encouraged to use the lactate levels as their guide for how they care for a patient.
He added that this new initiative has been warmly received so far by healthcare providers.
“The reception and buzz around the concept, at smaller hospitals as well as the large tertiary care centers and among the international community, has been very positive at this early juncture, and we are eager to see the wider reception and implementation,” Naidu told Cardiovascular Business.
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]