Clinical Commander

All dossiers
cardio.acute-hf.acute-decompensated-on-chronic.v1

Acute HF — acute decompensation on chronic HF

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — most common ADHF presentation: pre-existing HFrEF or HFpEF presenting with new decompensation. Specializes precipitant audit (medication non-adherence ~40%, dietary indiscretion, infection, AF/RVR, ACS, HTN urgency, NSAID use, anemia, thyroid disease per Fonarow ADHERE registry), IV loop diuretic at 2-2.5× HOME dose per DOSE (PMID 21366472), CONTINUATION of chronic GDMT (B-CONVINCED PMID 19261681 — do not withdraw chronic BB; PIONEER-HF PMID 30403955 — in-hospital ARNI optimization; EMPULSE PMID 35347356 — SGLT2i continuation), and discharge with intensified GDMT + STRONG-HF cadence (1 wk + biweekly × 6 wk per PMID 36356631). Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (acute-on-chronic specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • problem_list
    Known HFrEF + new dyspnea/edema/weight gain → acute-on-chronic decompensation
    known_hfref_with_new_decompensation
  • problem_list
    Known HFpEF + new dyspnea/edema → acute-on-chronic HFpEF decompensation
    known_hfpef_with_new_decompensation
  • history
    HF readmission within 30 days → high-risk acute-on-chronic with precipitant audit mandatory
    recent_hf_admission_within_30d
  • lab_abnormality
    NT-proBNP elevation above patient baseline + symptom progression in known HF
    nt_probnp_rise_in_chronic_hf

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older patients with chronic HF have higher readmission risk + complex polypharmacy
  • sbprequired
    vital • used at RED_FLAGS
    Wet-warm vs wet-cold profile; chronic HF patients often have low baseline SBP — context-dependent thresholds
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Compare to patient baseline (chronic HF patients have elevated baseline); >50% rise from baseline is significant
  • creatininerequired
    lab • used at CONTEXT
    Compare to baseline; cardiorenal adjustment of GDMT
  • potassiumrequired
    lab • used at CONTEXT
    Chronic MRA + ACEi/ARNI exposure → K monitoring critical
  • home_loop_doserequired
    history • used at TREATMENT
    IV escalation at 2-2.5× home dose per DOSE; chronic patients often have escalating outpatient diuretic doses
  • baseline_lvefrequired
    history • used at CONTEXT
    Baseline EF determines GDMT eligibility (HFrEF vs HFpEF) and prognosis
  • precipitant_screenrequired
    history • used at BRANCHING_WORKUP
    Med adherence, dietary indiscretion, infection, AF, ACS, HTN, NSAIDs — drives precipitant-specific co-management
  • current_gdmt_regimenrequired
    history • used at TREATMENT
    Document chronic ARNI/BB/MRA/SGLT2i + doses; in-hospital optimization opportunity per PIONEER-HF

12-phase flow (10)

  1. 1FRAME
    Acute decompensation of pre-existing HF; identify precipitant + escalate IV diuresis at 2-2.5× home dose; continue chronic GDMT in most cases
    inputs: baseline_lvef, home_loop_dose
    advance: acute-on-chronic phenotype confirmed
  2. 2ENTRY
    Initial stabilization: O2, IV diuresis, vasodilator if HTN, vasopressor if shock; bedside echo if no recent
    inputs: sbp
    advance: initial stabilization done
  3. 3CONTEXT
    Baseline EF, current GDMT regimen + doses, baseline weight, baseline NT-proBNP, comorbidities, prior admissions in 30/90 days
    inputs: age, creatinine, potassium, baseline_lvef, current_gdmt_regimen
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock; ACS as precipitant; severe hyperK from chronic MRA; arrhythmia (AF/RVR); respiratory failure
    inputs: sbp
    actions: cardiogenic_shock, acs_pathway
    advance: red flags screened
  5. 5INITIAL_WORKUP
    NT-proBNP (compare to baseline), BMP, troponin (rule out ACS precipitant), TSH (if not recent), CBC (anemia precipitant), CXR, bedside echo if no recent, ECG (AF? ischemia?)
    inputs: nt_probnp
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Precipitant audit: medication adherence (40% of readmissions), dietary indiscretion, infection (CXR + UA + cultures), AF/RVR (ECG/telemetry), ACS (ECG/troponin), HTN urgency, NSAID use, anemia, thyroid disease
    inputs: precipitant_screen
    advance: precipitant identified or screen complete
  7. 7TREATMENT
    IV loop diuretic at 2-2.5× home dose per DOSE; CONTINUE chronic ARNI/ACEi/ARB unless hypotensive (SBP <90) or severe AKI; CONTINUE BB if hemodynamically tolerant (B-CONVINCED — withdrawal worsens outcomes); CONTINUE MRA if K <5; CONTINUE SGLT2i per EMPULSE; ADD acetazolamide per ADVOR if diuretic-resistant; nitrates if HTN urgency precipitant; in-hospital ARNI optimization per PIONEER-HF if not on max dose
    inputs: sbp, creatinine, potassium, home_loop_dose
    advance: IV diuresis active + chronic GDMT continuation/optimization documented
  8. 8DISPOSITION
    Floor for most acute-on-chronic; CICU if shock or refractory; STRONG-HF cadence post-discharge
    advance: unit assigned + STRONG-HF cadence booked
  9. 9MONITORING
    Daily weight, hourly UOP × 24h then q4h, BMP q12-24h, NT-proBNP at 48-72h + pre-discharge, lung US for residual congestion
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring active
  10. 10FOLLOWUP
    Discharge with intensified GDMT (PIONEER-HF in-hospital ARNI start/up-titration); STRONG-HF cadence (1 wk post-d/c + biweekly × 6 wk); cardiac rehab; precipitant-specific follow-up (e.g., adherence support, AF clinic, dietitian)
    advance: STRONG-HF + cardiac rehab + precipitant follow-up booked