Patient handout

Acute heart failure — de novo (first presentation)

PRODUCTION

1. Your condition

This handout is for acute heart failure — de novo (first presentation). Your care team identified this based on: new-onset dyspnea + edema + elevated nt-probnp without prior hf diagnosis → de novo ahf.

Other reasons your team may use this plan: first-ever echo showing reduced lvef + clinical ahf — de novo hfref; pregnant or <5 mo postpartum + new ahf → peripartum cmp workup.

2. Your medications

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
furosemide	40-80 mg IV bolus q6-12h or continuous 5-10 mg/h	IV	q6-12h or continuous	DOSE trial PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; titrate to UOP ≥1 mL/kg/h
metolazone	2.5-10 mg PO 30 min before furosemide	PO	daily or BID	Sequential nephron blockade for diuretic resistance
sacubitril-valsartan	24/26 mg PO BID, titrate q1-2 weeks to 97/103 BID	PO	BID	PIONEER-HF PMID 30403955 — in-hospital ARNI initiation safe + reduces NT-proBNP; criteria: 24h post-AHF, SBP ≥100, K <5.2, eGFR ≥30
empagliflozin	10 mg PO daily	PO	daily	EMPULSE PMID 35347356 — start in-hospital regardless of EF; clinical benefit at 90d
carvedilol	3.125 mg PO BID, titrate q2 weeks	PO	BID	COPERNICUS PMID 11386262; ONLY initiate after stabilization off IV inotropes ≥24h + SBP ≥100
spironolactone	25 mg PO daily	PO	daily	RALES PMID 10471456 — EF ≤35 + K <5 + eGFR ≥30
enalapril	2.5 mg PO BID titrate	PO	BID	Alternative if ARNI not available; CONSENSUS/SOLVD

Plan: De novo AHF in-hospital GDMT initiation regimen — PIONEER-HF + EMPULSE-driven, BB only after stabilization

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent decompensation → readmit + reassess
EF declining despite the four foundational heart-failure medications → advanced HF eval

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

De novo AHF + ECG/troponin suggesting ACS — STEMI/NSTEMI/UA workup mandatory(life-threatening)
De novo AHF + SBP <90 + lactate ≥2 + cool extremities — cardiogenic shock(life-threatening)
De novo AHF + young patient + recent viral illness + arrhythmia + rapid EF drop → fulminant myocarditis(life-threatening)
De novo AHF in pregnancy or <5 mo postpartum without other identifiable etiology → peripartum CMP
De novo AHF + new severe MR (papillary rupture) or AR (aortic dissection, endocarditis) on echo → emergent CT surgery(life-threatening)

5. Follow-up

STRONG-HF up-titration cadence (weekly visits × 4 wk); cardiac rehab; advanced HF eval if EF <35 + persistent symptoms despite the four foundational heart-failure medications

6. Sources

Guideline: 2022 ACC/AHA HF + 2023 Focused Update + 2025 ACC/AHA ACS