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cardio.acute-hf.alcoholic-cardiomyopathy.v1

Acute HF — alcoholic cardiomyopathy

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E etiology variant of cardio.acute-hf.core.v1 — narrowed to alcoholic cardiomyopathy with acute decompensation. Defined by dilated CMP from chronic heavy alcohol use (>80 g/d men, >40 g/d women, >10 yr typical). 4-fold higher risk of dilated CMP vs non-drinkers. Treatment foundation: THIAMINE 500 mg IV TID × 2-3 d then 250 mg IV daily × 5 d (BEFORE GLUCOSE — Wernicke prevention per Sechi/Serra PMID 17434099); banana bag (multivitamin + thiamine + folate + Mg); CIWA-Ar with symptom-triggered lorazepam (Daeppen JAMA Intern Med 2002 PMID 12095410); GDMT 4-pillar (ARNI/BB/MRA/SGLT2i); naltrexone or acamprosate for AUD (COMBINE PMID 16670409). ABSTINENCE MANDATORY — continued drinking → mortality ~50% at 4 yr (Guzzo-Merello PMID 25218517); 50%+ patients improve LVEF >10 pp if abstinent over 6 mo. Cross-link to gi.cirrhosis.core.v1 if Child-Pugh B/C. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief reuses parent. Status INTEGRATED; authored 2026-05-15 by shard-06-cardio-acute (Phase E wave 17 etiology-variant).

Entry points (5)

  • history
    Heavy chronic alcohol use (>80 g/d men, >40 g/d women, >10 yr) + dilated cardiomyopathy on echo + no obstructive CAD
    heavy_chronic_alcohol_use_with_dilated_cmp
  • symptom
    Dyspnea / orthopnea / edema in patient with known alcohol use disorder or recent binge drinking
    hf_symptoms_in_known_aud
  • imaging
    Echo dilated LV with reduced EF + cardiac MRI without ischemic LGE pattern in patient with chronic heavy alcohol use
    echo_dilated_cmp_without_lge_in_drinker
  • lab_abnormality
    Macrocytic anemia (MCV >100) or elevated GGT or AST:ALT >2 in HF patient — alcoholic cardiomyopathy clue
    macrocytic_anemia_or_elevated_ggt_with_hf
  • history
    Recent binge drinking episode (typically holiday-related, "holiday heart syndrome") + new HF decompensation
    recent_binge_drinking_with_new_hf_decompensation

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Middle-aged men predominantly; women susceptible at lower thresholds; age informs withdrawal severity prediction
  • alcohol_use_history_quantity_durationrequired
    history • used at CONTEXT
    Threshold for ACM: >80 g/d men, >40 g/d women, >10 yr; quantify with standard drink units; duration informs reversibility potential
  • audit_c_scorerequired
    history • used at CONTEXT
    AUDIT-C ≥4 in men or ≥3 in women suggests AUD; informs CIWA risk and AUD treatment urgency (Bush JAMA Intern Med 1998)
  • last_drink_timingrequired
    history • used at RED_FLAGS
    Withdrawal symptoms 6–12 h after last drink, peak 24–72 h; DTs at 48–96 h; informs CIWA monitoring schedule and prophylaxis
  • prior_withdrawal_or_dt_historyrequired
    history • used at RED_FLAGS
    Prior delirium tremens or seizure dramatically increases recurrence risk; warrants ICU-level monitoring + scheduled prophylactic benzodiazepine
  • thiamine_b12_folate_magnesiumrequired
    lab • used at INITIAL_WORKUP
    Nutritional deficiency cluster from chronic alcohol; thiamine deficiency drives Wernicke risk; magnesium repletion reduces seizure risk in withdrawal
  • lft_inr_albuminrequired
    lab • used at INITIAL_WORKUP
    Concurrent alcoholic liver disease very common; AST:ALT >2 supports alcoholic etiology; INR + albumin assess synthetic function; affects drug metabolism + bleeding risk
  • cbc_with_mcvrequired
    lab • used at INITIAL_WORKUP
    Macrocytic anemia (MCV >100) common in alcoholism (folate/B12/direct toxicity); thrombocytopenia from marrow suppression or splenomegaly
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Diagnose HF + risk stratify; trend with diuresis
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Rule out acute MI; persistently elevated in chronic CMP
  • creatininerequired
    lab • used at CONTEXT
    eGFR for drug dosing (especially loop diuretic, ARNI/ACEi, SGLT2i); KDIGO 2021 race-free
  • sbprequired
    vital • used at RED_FLAGS
    BP affects ARNI/ACEi initiation; volume status; hypotension during withdrawal complicates GDMT initiation
  • echo_with_strainrequired
    imaging • used at INITIAL_WORKUP
    Dilated LV with reduced EF, eccentric remodeling; rule out valvular + segmental wall motion (CAD) abnormalities; baseline for recovery tracking
  • cardiac_mri_to_exclude_other_etiologies
    imaging • used at BRANCHING_WORKUP
    Dilated CMP without ischemic LGE pattern supports ACM diagnosis; excludes ischemic, amyloid, sarcoid, myocarditis mimics; baseline LV mass and ECV

12-phase flow (12)

  1. 1FRAME
    Dilated CMP + chronic heavy alcohol use + no obstructive CAD/HTN/valvular cause → alcoholic cardiomyopathy phenotype; thiamine + abstinence are foundation of treatment
    inputs: alcohol_use_history_quantity_duration
    advance: ACM framed
  2. 2ENTRY
    HF + heavy alcohol → screen for ACM; AUDIT-C; check thiamine status; plan for withdrawal management; THIAMINE BEFORE GLUCOSE
    inputs: audit_c_score, last_drink_timing
    advance: one entry trigger present + thiamine/withdrawal plan
  3. 3CONTEXT
    Quantify alcohol use; AUD screen; prior withdrawal history; nutritional status; concurrent liver disease; baseline labs
    inputs: age, alcohol_use_history_quantity_duration, audit_c_score, prior_withdrawal_or_dt_history, sbp, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Wernicke encephalopathy (confusion + ataxia + ophthalmoplegia triad — often only 1 present); severe alcohol withdrawal (CIWA >15) including seizure or DTs; cardiogenic shock; thiamine-before-glucose protocol violation; concurrent acute alcoholic hepatitis
    inputs: sbp, troponin, nt_probnp, last_drink_timing, prior_withdrawal_or_dt_history
    actions: cardiogenic_shock, acute_pulm_edema
    advance: red flags screened or escalated
  5. 5INITIAL_WORKUP
    NT-proBNP + troponin + BMP + CBC with MCV + LFT + INR + albumin + thiamine + B12 + folate + magnesium + lipid + ECG + echo with strain + CXR + UA
    inputs: nt_probnp, troponin, thiamine_b12_folate_magnesium, lft_inr_albumin, cbc_with_mcv, echo_with_strain
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: baseline workup documented
  6. 6BRANCHING_WORKUP
    Coronary angiography (rule out obstructive CAD); cardiac MRI for LGE pattern (no LGE supports ACM, excludes ischemic + amyloid + sarcoid + myocarditis); hepatology consult if cirrhosis or acute alcoholic hepatitis
    inputs: cardiac_mri_to_exclude_other_etiologies
    advance: CAD excluded + ACM confirmed (or alternative etiology assigned)
  7. 7DIFFERENTIAL
    ACM vs ischemic CMP (CAD on angio) vs hypertensive CMP vs viral myocarditis (acute onset, recent viral illness) vs idiopathic dilated CMP vs cocaine/methamphetamine CMP
    advance: ACM confirmed or alternative assigned
  8. 8RISK_STRATIFICATION
    MAGGIC mortality; PAWSS for withdrawal severity prediction; CIWA-Ar for active withdrawal; CHA2DS2-VASc if AF (holiday heart common); HFrEF GDMT 4-pillar plan
    inputs: nt_probnp, creatinine
    advance: phenotype + risk band documented
  9. 9TREATMENT
    THIAMINE 500 mg IV TID × 2–3 days then 250 mg IV daily × 5 d (BEFORE glucose if hyperglycemic); banana bag (multivitamin + thiamine 100 mg + folate 1 mg + magnesium 2 g IV); CIWA-Ar with lorazepam 2 mg IV/PO q1h prn (symptom-triggered superior to fixed-schedule per Daeppen JAMA Intern Med 2002); standard ADHF supportive (loop diuretic, NIPPV); GDMT 4-pillar (ARNI/BB/MRA/SGLT2i); ABSTINENCE counseling + naltrexone or acamprosate initiation; SUD consult
    inputs: sbp, creatinine, thiamine_b12_folate_magnesium
    actions: protocol.cardiogenic_shock
    advance: thiamine started + CIWA monitoring + GDMT + AUD treatment plan
  10. 10DISPOSITION
    ICU for severe withdrawal (CIWA >15, prior DT, hemodynamic instability); telemetry floor with q2–4h CIWA otherwise; addiction medicine consult
    advance: unit + multidisciplinary team assigned
  11. 11MONITORING
    CIWA-Ar q2–4h × 24 h then per protocol; daily BMP + Mg + thiamine response; daily exam for Wernicke features (ataxia, ophthalmoplegia, confusion); LFT trend; echo at 6 mo to assess recovery on abstinence
    inputs: creatinine, thiamine_b12_folate_magnesium
    actions: panel.renal
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Cardiology + addiction medicine co-clinic; SUD treatment program enrollment; AA / 12-step / SMART recovery; naltrexone or acamprosate continuation; LFT q3 mo on statin; echo at 6 mo (recovery assessment); family support
    advance: AUD treatment + abstinence support + cardiology follow-up booked