Table 2: Proposed Expert-based Triggers for Early Transfer to a Cardiogenic Shock Center.
| Potential trigger | Rationale/clinical consideration | Example metrics/observations |
|---|---|---|
| Progression in SCAI shock stage | Increasing severity of shock predicts higher risk of deterioration and need for advanced therapies | Transition from SCAI B to C, or from SCAI C to D/E |
| Rising lactate/worsening metabolic profile | Reflects tissue hypoperfusion and escalating shock | Trend of lactate increasing over 2–6 h, lactate >4–5 mmol/l concerning |
| Escalating vasopressor/inotropic requirements | Indicates worsening hemodynamics despite current therapy | Need for increasing doses or multiple agents to maintain MAP ≥65 mmHg |
| Worsening end-organ perfusion markers | Early organ dysfunction signals high-risk physiology | Rising creatinine, decreasing urine output, rising bilirubin and elevated liver enzymes |
| Hemodynamic instability despite support | Suggests the need for advanced mechanical or surgical support | Persistent hypotension (MAP <65 mmHg) despite fluids/ vasopressors; recurrent arrhythmias |
| Need for MCS | CSCs can initiate or escalate temporary or durable MCS | Impella, ECMO, IABP consideration; failure of current MCS to maintain perfusion |
| High-risk clinical events/cardiac arrest | Post-arrest CS may require advanced interventions only available at CSCs | Recent SCA, refractory VT/VF, or CPR in progress |
| Unstable respiratory status/multiorgan failure | Multisystem compromise increases the benefit of tertiary care | Worsening hypoxemia, ventilator dependence, or need for CRRT |
| Delayed response to initial therapy | Early recognition of therapy failure supports timely transfer | No improvement after 2–4 h of optimized local care |
| Need for advanced procedures not available locally | Certain interventions require tertiary capabilities | High-risk PCI, urgent cardiac surgery, ECMO initiation, advanced heart failure therapies |
This table summarizes potential clinical, laboratory, and hemodynamic features that may prompt consideration for early transfer of patients with CS to a higher-acuity CSC. Although evidence-based thresholds are lacking, these expert-opinion–based triggers aim to standardize escalation decisions, facilitate timely communication between referring and receiving centers, and support the early identification of patients at risk for rapid deterioration. CPR = cardiopulmonary resuscitation; CRRT = continuous renal replacement therapy; CS = cardiogenic shock; CS = cardiogenic shock center; ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump; MAP = mean arterial pressure; MCA = mechanical circulatory support; PCI = percutaneous coronary intervention; SCA = sudden cardiac arrest; SCAI = Society for Cardiovascular Angiography and Interventions; VT = ventricular tachycardia.