Vasoactive Intensity Predicts Mortality Beyond SCAI Staging in Cardiogenic Shock

Abstract Background Cardiogenic shock (CS) remains associated with high mortality. Severity is traditionally stratified by the SCAI staging system despite substantial heterogeneity within stages. Whether vasoactive therapy intensity or combination provides additional prognostic information beyond SCAI staging remains unknown. This study assessed whether vasoactive support intensity, quantified by the vasoactive–inotropic score (VIS), improves mortality prediction beyond SCAI staging. Methods In this retrospective bicentric cohort, consecutive adults admitted for CS between 2018 and 2023 were included. The VIS was calculated. The primary outcome was 90-day mortality. Multivariable logistic regression models adjusted for baseline severity assessed interactions with SCAI stage and the incremental prognostic value of VIS using nested models. Results Among 1,167 patients, 90-day mortality increased across SCAI stages C, D, and E (20.1%, 27.4%, and 45.6%; p<0.001, respectively), with substantial heterogeneity within stages. In stage C, dobutamine alone was associated with lower mortality than norepinephrine alone (OR=0.25[0.09–0.74]; p=0.009); in stage E, dobutamine plus norepinephrine was associated with higher mortality (OR=2.39[1.07–5.36]; p=0.028). The number of vasoactive agents was associated with mortality (OR=1.27 per additional agent; p=0.041) but proved a crude marker, providing only marginal incremental discrimination (R2=0.233; Δ=+0.011), with its prognostic information fully captured by VIS (R2=0.286 vs 0.287 with and without number of agents). Adding SCAI stage minimally improved discrimination (R2=0.222 to 0.226; Δ=+0.004), whereas VIS substantially improved model performance (R2=0.286; Δ=+0.060;p<0.001). Conclusion Vasoactive intensity quantified by the vasoactive–inotropic score improved 90-day mortality prediction beyond SCAI staging and the simple count of vasoactive drugs, providing incremental prognostic information beyond SCAI staging.