New initiative targets faster shock diagnosis and care with ‘door to lactate clearance’

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 standardized, time-based marker of patient trajectory to improve outcomes in one of the deadliest cardiovascular emergencies.

“SCAI Door to Lactate Clearance (SCAI DLC) Cardiogenic Shock Initiative: Definition, Hypothesis and Call to Action” was unveiled September 19 at the SCAI SHOCK Conference in Tampa, FL, with simultaneous publication in 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, MD, MSCAI, Professor of Medicine at New York Medical College, 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 prioritizing 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.

The DLC Initiative offers a practical solution by focusing on lactate, a widely available biomarker of tissue perfusion. Lactate levels have long been recognized 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 standardized 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 2 mmol/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, MD, MSc, FSCAI, co-author of the DLC Initiative, and Associate Professor of Medicine at the University of Chicago.

“The door to lactate clearance initiative is a proposal that builds on this data and is aimed at prospectively characterizing lactate clearance in cardiogenic shock patients with the goal of normalizing tissue perfusion and thereby normalizing lactate on the backdrop of aggressive cardiovascular care.”

The SCAI Door to Lactate Clearance Cardiogenic Shock Initiative underscores that DLC is both practical and scalable. Smaller hospitals may use failure of lactate clearance as an early signal to reassess patients and consider rapid transfer. At the same time, tertiary centers can integrate lactate trends into decisions about advanced therapies such as mechanical circulatory support.

In both settings, routine lactate monitoring strengthens team communication, standardizes reassessment, and facilitates timely escalation or de-escalation of care.

The initiative calls on investigators to formally evaluate the strengths and shortcomings of lactate clearance prospectively in the years ahead, along with other potential measures in cardiogenic shock management.