Stage A Cardiogenic Shock in the SCAI Classification: Limitations and Prospects for Diagnostic Improvement

Cardiogenic shock (CS) remains one of the most critical challenges in emergency cardiology, associated with high mortality rates. Early recognition and prevention of its progression are pivotal, as preventing shock not only improves prognosis but also significantly reduces treatment costs compared with managing established shock. Stage A of the Society for Cardiovascular Angiography and Interventions classification demonstrates substantial clinical and prognostic heterogeneity in real-world practice. The criteria for stage A remain ambiguous: studies vary in defining "extensive myocardial infarction," overlook the impact of infarct localization, and fail to account for microvascular dysfunction and systemic inflammation in disease progression. This results in the inclusion of patients with diametrically opposed risks-from minimal to critical-limiting opportunities for preventive intervention. A key issue is the lack of specific biomarkers to identify patients at genuine risk of shock progression. Emerging evidence highlights the underappreciated roles of microcirculatory disturbances and inflammatory responses. Integrating imaging techniques and inflammatory biomarkers into CS diagnostic algorithms, as supported by recent studies, represents a promising direction. Dynamic reassessment of patient status, including continuous monitoring of lactate, hemodynamics, and organ perfusion markers, is another critical aspect. Early application of mechanical circulatory support in stages A-B reduces mortality but requires precise identification of the target population. Only a multidisciplinary approach incorporating dynamic risk stratification and precision methods can minimize inappropriate use of aggressive therapies or ensure their timely application, thereby improving outcomes in patients at risk of CS.