AHA Proposes Staging System for Pediatric Cardiogenic Shock

The American Heart Association (AHA) has published its first scientific statement dedicated to pediatric cardiogenic shock (CS), proposing a standardized definition and a 5-stage severity classification intended to improve bedside recognition, monitoring, and escalation of care for critically ill children.¹

“Pediatric heart failure–related cardiogenic shock carries high morbidity and mortality but is understudied,” wrote the researchers of the study. “Improving outcomes in pediatric cardiogenic shock hinges on timely diagnosis and appropriate triage, medical management tailored to the cause and phenotype of cardiogenic shock, and optimal timing of escalation to appropriate mechanical circulatory support.”

No Standardized Pediatric Definition

Published pediatric studies report mortality from cardiogenic shock ranging from approximately 25% to 50%, depending on the underlying cause and patient population. Yet, unlike adult CS—which is commonly characterized using the Shock Academic Research Consortium definition and the Society for Cardiovascular Angiography and Interventions (SCAI) staging system—pediatric CS has lacked a standardized bedside definition, contributing to variability in diagnosis and management across institutions.

The writing group, chaired by Kriti Puri, MBBS, of Texas Children’s Hospital, defines pediatric cardiogenic shock as known or suspected cardiac dysfunction resulting in clinical or biochemical evidence of tissue hypoperfusion, including 1 or more findings such as cool extremities, elevated lactate greater than 2 mmol/L, abnormal liver or kidney function tests, irritability, or altered mental status. The authors emphasize that no single clinical finding is sufficient on its own, underscoring the need for integrated clinical assessment.

A 5-Stage Classification

Building on the adult SCAI framework, the statement proposes a 5-stage classification for pediatric CS:

• Stage A (At Risk): Patients with cardiac disease who remain well perfused but are at risk of developing shock
• Stage B (Beginning): Early hemodynamic abnormalities without clear evidence of tissue hypoperfusion
• Stage C (Classic): Established hypoperfusion requiring pharmacologic or other therapeutic intervention
• Stage D (Deteriorating): Worsening shock despite initial therapy, requiring escalating vasoactive support and/or mechanical circulatory support (MCS)
• Stage E (Extremis): Refractory shock requiring cardiopulmonary resuscitation or salvage therapies

Unlike many adult definitions, the pediatric framework does not require hypotension for diagnosing advanced shock, recognizing that low blood pressure is often a late and relatively insensitive marker of circulatory collapse in children.

Frequent Reassessment and Early Escalation

The statement emphasizes that many children with cardiogenic shock deteriorate rapidly, particularly during the first 24 hours after presentation, making frequent reassessment essential. The authors recommend combining serial physical examinations with laboratory markers—including lactate and natriuretic peptides—and, when appropriate, invasive or noninvasive hemodynamic monitoring to identify progression early.

Regarding vasoactive therapy, the statement notes that epinephrine may be an appropriate first-line agent when prehospital pharmacologic support is necessary because of its rapid onset and familiarity in emergency care. By contrast, the authors advise against initiating milrinone before hospital evaluation because of its long half-life and potential hemodynamic effects.

For children requiring MCS, the statement highlights observational evidence suggesting that early left-heart decompression during extracorporeal membrane oxygenation (ECMO) may be associated with lower mortality among patients with dilated cardiomyopathy or myocarditis, although prospective studies are still needed.

Health Equity Considerations

The statement also highlights disparities in pediatric heart failure and cardiogenic shock–related outcomes. Previous studies have found that Black race and Hispanic ethnicity are independently associated with higher mortality among children hospitalized with heart failure–related cardiomyopathy or myocarditis. Black children have also experienced higher rates of ECMO use, ECMO-associated mortality, and cardiac arrest.

Rather than attributing these differences to a single cause, the authors state that the findings warrant further investigation into potential differences in access to advanced pediatric cardiac care, referral patterns, and other structural factors that may contribute to inequities in outcomes.

The publication complements an earlier AHA scientific statement on pediatric acute decompensated heart failure, which also recommended adapting SCAI principles to pediatric critical care while emphasizing the need for disease-specific validation.²

Managed Care Implications

For payers and health systems, the proposed pediatric cardiogenic shock staging framework could help standardize decisions about transfer to centers with pediatric cardiac intensive care and MCS capabilities. The writing group notes that thresholds for escalating care often vary according to institutional experience and the availability of ECMO and other advanced therapies.¹

More consistent staging may also support quality improvement initiatives, benchmarking, and network planning for pediatric cardiac critical care. Because the need for vasoactive infusions, mechanical ventilation, ECMO, and renal replacement therapy is associated with substantially higher resource utilization, earlier recognition of worsening shock could help improve coordination of care while informing resource allocation.

The statement’s discussion of racial and ethnic disparities further suggests that health plans and health systems may wish to evaluate potential barriers to timely escalation of care—including transportation, communication, and other social determinants of health—and consider whether care coordination, referral pathways, or telehealth support could help improve equitable access to specialized pediatric cardiac services.

“This scientific statement provides a diagnostic framework for the bedside clinician, in addition to proposing a pediatric cardiogenic shock definition and severity staging aligned with systems previously validated in other studies,” wrote the researchers. “It outlines the initial approach to diagnosis and stabilization of a child with suspected cardiogenic shock and offers guidance on optimal noninvasive and invasive monitoring strategies to determine clinical trajectory because a significant proportion of children with cardiogenic shock will continue to deteriorate in the first 24 hours.”

References

1. Puri K, Allen K, Jentzer J, et al. Surviving pediatric cardiogenic shock: clinical approach, improving outcomes, and future directions: a scientific statement from the American Heart Association. Circulation. 2026;154:e00-e00. doi:10.1161/CIR.0000000000001461
2. Cabrera AG, Price JF, Hong BJ, et al. Evaluation and management of the child with acute decompensated heart failure: a scientific statement from the American Heart Association. Circulation. 2026;153(19):e1323-e1335. doi:10.1161/CIR.0000000000001428