Updated Staging System Standardizes Cardiogenic Shock Assessment and Monitoring

It remains associated with substantial mortality and can evolve rapidly across emergency, procedural, surgical, and intensive care settings. Clinicians need a consistent way to recognize inadequate organ perfusion and monitor whether treatment is restoring circulation. To help address this challenge, the Society for Cardiovascular Angiography & Interventions (SCAI) has released updated guidance for cardiogenic shock assessment.

The 2026 SCAI SHOCK Classification Expert Consensus Update refines the existing SCAI framework that was introduced in 2019. The classification is used in clinical care, research, and regulatory settings to assess risk, guide evaluation, and communicate shock severity. The update was published in JSCAI in conjunction with AHA Scientific Sessions 2026.

The updated framework places greater emphasis on recognizing hypoperfusion rather than relying on hypotension alone. It also focuses on identifying the underlying shock phenotype and reassessing the patient’s trajectory over time. Serial reassessment includes changes in physical findings, biochemical markers, imaging, and hemodynamics to determine whether the patient is deteriorating or recovering.

The guidance further clarifies staging for patients at risk of shock progression and for those with worsening shock or failure to improve despite treatment. It also refines use of the Arrest modifier in patients with cardiac arrest and uncertain neurologic recovery. Expanded sections address acute myocardial infarction-related, heart failure-related, valvular, right ventricular-predominant, mixed, post-cardiotomy, and pediatric cardiogenic shock.

Implementation guidance encourages routine documentation of staging and serial reassessment during handoffs and multidisciplinary discussions. This applies from emergency medical services and the emergency department through the catheterization laboratory, operating room, and intensive care unit. The update also addresses research applications, including clinical trial eligibility, treatment response evaluation, and comparisons across study populations.

“One area discussed in detail is the differentiation of hypotension and hypoperfusion. A patient's blood pressure may look acceptable even when vital organs are not receiving adequate blood flow. One of the most important messages of this update is that clinicians must look beyond blood pressure alone when assessing shock severity, as perfusion to organs is the clinical arbiter that tracks with survival,” said Srihari S. Naidu, MD, MSCAI, SCAI past president and co-chair of the consensus writing group.

"By emphasizing hypoperfusion over hypotension, along with serial reassessment and patient trajectory, the updated framework helps care teams recognize risk earlier, communicate more effectively and make better-informed treatment decisions as a patient's condition evolves," added Dr. Naidu.

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Society for Cardiovascular Angiography & Interventions