This handout is for acute hf — alcoholic cardiomyopathy. Your care team identified this based on: heavy chronic alcohol use (>80 g/d men, >40 g/d women, >10 yr) + dilated cardiomyopathy on echo + no obstructive cad.
Other reasons your team may use this plan: dyspnea / orthopnea / edema in patient with known alcohol use disorder or recent binge drinking; echo dilated lv with reduced ef + cardiac mri without ischemic lge pattern in patient with chronic heavy alcohol use; macrocytic anemia (mcv >100) or elevated ggt or ast:alt >2 in hf patient — alcoholic cardiomyopathy clue.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| thiamine | 500 mg IV TID × 2–3 days, then 250 mg IV daily × 5 days, then 100 mg PO daily | IV → PO | TID acute then daily | High-dose IV thiamine for high-risk patients per Royal College of Physicians + Sechi/Serra Lancet Neurol 2007 PMID 17434099; Wernicke prevention; MUST precede glucose to avoid precipitating encephalopathy |
| lorazepam | 2 mg IV/PO q1h prn for CIWA-Ar score ≥10 | IV/PO | symptom-triggered q1h prn | Symptom-triggered lorazepam (Daeppen JAMA Intern Med 2002) reduces benzodiazepine exposure 60% vs fixed-schedule; lorazepam preferred over diazepam in liver disease (no active metabolites) |
| magnesium sulfate | 2 g IV (in banana bag) then 1–2 g IV q12h × 24–48 h | IV | q12h initial | Hypomagnesemia near-universal in chronic alcohol use; aggressive repletion reduces withdrawal seizure risk + supports cardiac stability |
| folic acid | 1 mg IV/PO daily (in banana bag) × 1 wk then daily | IV/PO | daily | Folate deficiency common; megaloblastic anemia component |
| naltrexone | 50 mg PO daily; or 380 mg IM monthly (Vivitrol) | PO or IM | daily PO or monthly IM | COMBINE trial (Anton JAMA 2006) — naltrexone reduces heavy drinking days; monthly IM improves adherence; avoid in active hepatitis or LFT >3x ULN |
| acamprosate | 666 mg PO TID | PO | TID | Acamprosate effective for maintaining abstinence; preferred in liver disease since hepatic metabolism minimal; renally cleared (avoid eGFR <30) |
| furosemide | 40 mg IV (or 2.5x outpatient dose for chronic users — DOSE-AHF PMID 21366472) | IV/PO | q12h titrate to UOP 100–200 mL/h | Standard ADHF decongestion; transition to PO when stable |
| sacubitril-valsartan | 24/26 mg PO BID titrate to 97/103 mg BID | PO | BID | PIONEER-HF (Velazquez NEJM 2019 PMID 30403955) — in-hospital initiation safe; ACC/AHA 2022 HF Class I in HFrEF |
| carvedilol | 3.125 mg PO BID titrate to 25 mg BID | PO | BID | COPERNICUS / CIBIS-II / MERIT-HF; ACC/AHA 2022 Class I; defer initiation until withdrawal complete to avoid masking tachycardia / tremor |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356 + EMPEROR-Reduced PMID 32865377; broad HF benefit; caution with euglycemic DKA in starvation/heavy drinking |
Plan: Alcoholic cardiomyopathy ADHF — thiamine + withdrawal management + GDMT + abstinence regimen
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: 2022 ACC/AHA HF Guideline (Heidenreich) + Awtry/Philippides ACM review + Sechi/Serra Wernicke + VA/DoD AUD CPG 2023 + ATA/SAMHSA TIP 45