Beyond One-Size-Fits-All: Exploring Predictive Models for Cardiogenic Shock

Abstract

Dear Dr. Valiente Fernández and colleagues: We would like to express our gratitude for your interest in our work titled "Comparison of the Predictive Performance of Cardiogenic Shock Scores in a Real-World Latin America Country" (1) and for taking the time to provide insightful comments and feedback.Cardiogenic shock is often viewed as a "one-size-fits-all" homogeneous condition, but it can result from various etiologies and lead to significant morbidity and mortality. Therefore, accurate predictive models are essential for effective resource allocation in critical care. However, no scoring system is perfect, and clinical judgment must be exercised at the bedside.Prior studies have shown that some predictors, such as age, blood pressure, and vasopressor use, are readily quantifiable, while others, such as medication adherence and social status, are more complex. We also agree that non-recognized factors like the healthcare system, especially in our country, the late presentation, and the characteristic of our center (reference tertiary center) (2) may influence cardiogenic shock outcomes, giving higher mortality than Europe or United States (3-5). Our research team is committed to addressing this issue, particularly in acute myocardial infarction (AMI)-related cardiogenic shock (6,7).Regarding the U-shaped pattern observed in Figure 2 of our study, we would like to clarify that as we stratified the data by AMI and non-AMI, we found two different conclusions: non-AMI cardiogenic shock had a rollercoaster-shaped AUC, indicating that the models could identify the most severe cases at the outset, followed by a drop, with subsequent improvement driven by complications of the CS episode rather than CS itself. In contrast, the AUC variations in AMI-related cardiogenic shock were minimal. We agree that the differences observed in predictive performance based on the etiology of cardiogenic shock are essential to consider in the clinical setting.Specifically, CS scores have a better prediction ability than non-CS scores (GWTG-HF and ADHERE). We observed that CARDSHOCK, SCAI, and IABPSHOCK-II had the best prognostic information, which can help us promptly provide mechanical circulatory support (MCS). Furthermore, our study has also demonstrated that the etiology of CS matters, and we expect different behaviors to be seen in AMI versus non-AMI etiologies. As shown in Figure 2, there are some hidden nuances and clues for predictions in this figure, that is, if a patient with a non-AMI CS etiology arrives at our unit and we have to quickly decide on futility (<72 hours), the best score system would be SCAI or CARDSHOCK. On the other hand, for intermediate-term mortality (7 days), CARDSHOCK or SCAI may be more informative than IABPSHOCK-II scores to aid us in our decision.The roadmap from the ER➔CCU/ICU➔floor➔discharge is a long one to lower the impact of CS, and we are only just begging to carve the first steps ( 8), but the first steps are crucial in defining etiology, and choosing the best stratifications could allow us to a...