A new initiative by the Society for Cardiovascular Angiography & Interventions (SCAI) proposes a new framework and call to action for managing cardiogenic shock (CS), establishing lactate clearance potentially as the standardised, time-based marker of patient trajectory to improve outcomes.
SCAI’s Door to Lactate Clearance (SCAI DLC) initiative was unveiled 19 September at the SCAI SHOCK conference in (18–20 September, Tampa, USA), with simultaneous publication in the society’s journal, JSCAI.
“Cardiogenic shock remains one of the deadliest conditions in cardiovascular medicine, and despite advances in therapies, mortality has remained unacceptably high,” said SCAI president Srihari S Naidu (New York Medical College, New York, USA) and lead author of the DLC initiative. “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 prioritising 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, introduced in 2019 and updated in 2022, clinicians still require a reliable method to track treatment effectiveness in real-time, helping them decide whether to be more or less aggressive, or seek additional information or help, SCAI says in a press release. The DLC initiative offers a practical solution by focusing on lactate, a widely available biomarker of tissue perfusion.
Lactate levels have long been recognised 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.
By building lactate clearance into standardised protocols, the DLC initiative aims to provide shock teams with actionable, objective data to guide early management decisions. The publication 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 2mmol/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,” said Sandeep Nathan (University of Chicago, Chicago, USA), a co-author of the initiative. “The door to lactate clearance initiative is a proposal that builds on this data and is aimed at prospectively characterising lactate clearance in cardiogenic shock patients with the goal of normalising tissue perfusion and thereby normalising lactate on the backdrop of aggressive cardiovascular care.”
