I. How to Use

When to Use

  • The first AI-assisted and sex-specific risk score to estimate the risk of in-hospital cardiogenic shock in patients presenting with acute coronary syndrome (ACS).

  • The SEX-SHOCK score is endorsed by the SCAI/EAPCI/ACVC and the HFSA.

  • Can be used in any patient with a working diagnosis of ACS, including both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS), who are planned for or have already undergone percutaneous coronary intervention (PCI).

  • Use caution when applying this score to patients who have not undergone PCI.

Pearls / Pitfalls

  • Estimates the risk for the development of in-hospital cardiogenic shock in both female and male patients with ACS who have not yet progressed to classic cardiogenic shock (i.e., SCAI-C or higher).

  • The original study derived and validated this tool in a European patient population, comprising a total of 53,537 patients with ACS, recruited between 2005 and 2022.

  • Does not consider factors such as ethnicity and other socioeconomic factors; caution should be used when generalizing the results to non-White populations.

  • Derived in ACS patients undergoing PCI. While external validation in all patients with ACS is pending, caution should be exercised if used in ACS patients not yet scheduled for PCI.

  • The (likely) time-dependent predictive performance over the hospitalization period was not assessed due to the lack of the exact time-point for in-hospital cardiogenic shock; calculated risk estimates should always be interpreted within the specific clinical context.

Why Use

  • Facilitates early identification of ACS patients at high risk for developing cardiogenic shock during their hospital stay, facilitating clinical decision-making regarding timely invasive management and closer monitoring.

  • May improve the early risk assessment of both female and male ACS patients.

  • Accounts for evolving ACS and cardiogenic shock management strategies, with the potential to personalize and improve contemporary ACS management.

  • Endorsed by the SCAI/EAPCI/ACVC and the HFSA.

II. Next Steps

Advice

  • To be used in conjunction with a detailed medical history and physical examination to help identify female and male ACS patients at high risk of cardiogenic shock, who may benefit from an early invasive approach and/or closer monitoring.

  • Always interpret SEX-SHOCK score results within the specific clinical context.

  • Incorporate clinical judgment and additional laboratory testing when determining a patient’s cardiogenic shock risk and potential benefit from emerging management strategies.

Management

  • Note that randomized interventional trials, comparing management of ACS patients using best clinical practice versus best clinical practice and the SEX-SHOCK score have not been performed yet; thus, the benefit of using the SEX-SHOCK risk score to guide interventional management remains uncertain.

Critical Actions

  • External validation has been performed but is incomplete for all patient populations. Use caution when applying this score to patients who have not undergone PCI.

  • Note that randomized interventional trials, comparing management of ACS patients using best clinical practice versus best clinical practice and the SEX-SHOCK score have not been performed yet; thus, the benefit of using the SEX-SHOCK risk score to guide interventional management remains uncertain.

III. Evidence

Evidence Appraisal

  • Note that this score has high external validity given its development in a Swiss patient population (AMIS-Plus and SPUM-ACS) and external validation in France (RICO)

  • Shows superior predictive performance (across an array of performance metrics) as compared to other risk scores, including the ORBI risk score

Formula

Equations are as follows (sex-stratified β coefficients are listed in the table below):

SEX-SHOCK Score

Y = (Intercept) + β × log2(CRP mg/L + 1) + β × log2(Creatinine µmol/L) + β × ST-segment elevation + β × LVEF 35%-50% + β × LVEF >50% + β × Age >70 years + β × Presentation as cardiac arrest + β × Killip class III + β × Heart rate >90/min + β × SBP <125 and PP <45 mmHg + β × Glycemia >10 mmol/L + β × Culprit lesion of the left main + β × Post-PCI TIMI flow <3

Risk, % = [1 / (1 + e-Y)] × 100

SEX-SHOCKlight Score

Y = (Intercept) + β × log2(CRP mg/L + 1) + β × log2(Creatinine µmol/L) + β × ST-segment elevation + β × LVEF 35%-50% + β × LVEF >50% + β × Age >70 years + β × Presentation as cardiac arrest + β × Killip class III + β × Heart rate >90/min + β × SBP <125 and PP <45 mmHg + β × Glycaemia >10 mmol/L

Risk, % = [1 / (1 + e-Y)] × 100

Models SEX-SHOCK SEX-SHOCKlight
Coefficients Females Males Females Males
(Intercept) -7.08042535 -7.966659951 -7.10191049 -8.000854527
CRP (mg/l)∆ 0.091519247 0.069589203 0.094658425 0.077418932
Creatinine (µmol/l)∆ 0.609175556 0.604010175 0.623783594 0.622161976
ST-segment elevation§ 0.032769134 0.767955919 0.071325651 0.744654373
LVEF 35%-50%§ -1.095259107 -1.272230998 -1.166326971 -1.299423615
LVEF >50%§ -1.947426861 -2.015325176 -2.00779825 -2.067699816
Age >70 years§ 0.182533294 0.263511391 0.225822406 0.283914474
Presentation as cardiac arrest§ 1.256698585 1.14593438 1.231881859 1.139468733
Killip class III§ 1.050255447 0.684880861 1.127706685 0.718468447
Heart rate >90/min§ 0.240740964 0.538557699 0.263606915 0.534582773
SBP <125 and PP <45 mmHg§ 0.819218972 0.706186026 0.842855227 0.720645408
Glycemia >10 mmol/L§ 0.401892719 0.837549978 0.422291381 0.857565834
Culprit lesion of the left main§* 0.639735341 0.903552475 NA NA
Post-PCI TIMI flow <3§* 0.719770781 0.496589182 NA NA

§Yes=1, No=0.
*Only required for SEX-SHOCK (full model). SEX-SHOCK (light) relies on non-PCI related variables only.
∆Note that CRP and creatinine are log2-transformed [CRP = log2(original value + 1); creatinine = log2(original value)] in the SEX-SHOCK models.

Facts & Figures

Eur Heart J, Volume 45, Issue 43, 14 November 2024, Pages 4564–4578, https://doi.org/10.1093/eurheartj/ehae593

Literature

Sex-specific prediction of cardiogenic shock after acute coronary syndromes: the SEX-SHOCK score; Y Wang, M Zeller, V Auffret, G Georgiopoulos, L Räber, M Roffi, C Templin, O Muller, L Liberale, S Ministrini, K Stamatelopoulos, K Stellos, GG Camici, F Montecucco, H Rickli, M Maza, D Radovanovic, Y Cottin, F Chague, D Niederseer, TF Lüscher, S Kraler; Eur Heart J. 2024 Nov 14;45(43):4564-4578. doi: 10.1093/eurheartj/ehae593.

SCAI/EAPCI/ACVC Expert Consensus Statement on Cardiogenic Shock in Women; SJ Baron, JC Chou, T Shah, AR Vest, JD Abbott, M Alasnag, C Aurigemma, E Barbato, L Bellumkonda, AE Bortnick, A Chieffo, RJ van Geuns, CL Grines, S Halvorsen, C Hassager, NK Kapur, SS Naidu, VG Ng, J Saw, AJ Lansky; EuroIntervention. 2025 Aug 18;21(16):894-909; doi: 10.4244/EIJ-D-24-01126.

Acute coronary syndromes: mechanisms, challenges, and new opportunities; S Kraler, C Mueller, P Libby, DL Bhatt; Eur Heart J. 2025 Aug 1;46(29):2866-2889. doi: 10.1093/eurheartj/ehaf289.

Cardiogenic Shock; H Thiele, C Hassager; N Engl J Med. 2026 Jan 1;394(1):62-77. doi: 10.1056/NEJMra2312086.