Clinical Commander

All dossiers
cardio.acute-hf.diabetic-cardiomyopathy.v1

Acute HF — diabetic cardiomyopathy

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E etiology variant of cardio.acute-hf.core.v1 — narrowed to diabetic cardiomyopathy with acute decompensation. Defined by HFrEF or HFpEF in patient with diabetes WITHOUT obstructive CAD, long-standing HTN, or valvular cause. Pathophysiology: microvascular dysfunction + AGEs + lipotoxicity + diastolic dysfunction. SGLT2i-first treatment paradigm: empagliflozin 10 mg from day 1 per EMPULSE PMID 35347356 (works in HFrEF + HFpEF, diabetic + non-diabetic). STOP glitazones (HF risk) and saxagliptin (SAVOR-TIMI 53 HF signal) immediately. Consider semaglutide 2.4 mg weekly for obese HFpEF per STEP-HFpEF PMID 37877559. HbA1c target 7–8% (NOT strict <7 — ACCORD PMID 18539917 mortality harm). Co-management with endocrinology mandatory. Cross-links to cardio.hfpef.core.v1, cardio.hfref.core.v1, endo.dm2.core.v1. 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)

  • symptom
    Dyspnea / orthopnea / edema in T2DM ≥10 yr without obstructive CAD or long-standing HTN → diabetic cardiomyopathy pathway
    hf_symptoms_in_long_duration_t2dm
  • lab_abnormality
    NT-proBNP elevated + HbA1c >9% + concurrent diabetic microvascular complications (retinopathy/nephropathy/neuropathy)
    elevated_nt_probnp_with_poorly_controlled_diabetes
  • imaging
    Echo Grade II/III diastolic dysfunction + LVH + impaired GLS (global longitudinal strain) in diabetic patient — early diabetic cardiomyopathy
    echo_diastolic_dysfunction_in_diabetic
  • imaging
    Cardiac MRI diffuse subendocardial LGE pattern + increased T1/ECV in diabetic patient with HF
    cmri_diffuse_subendocardial_lge_t1_increased
  • history
    Recurrent ADHF admissions in diabetic patient on insulin or oral agents — workup for diabetic cardiomyopathy etiology
    diabetic_with_recurrent_admissions_for_hf

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Long-duration diabetes is hallmark; older patients more often HFpEF phenotype; younger T1DM with diabetic CMP rare but possible
  • diabetes_type_and_durationrequired
    history • used at CONTEXT
    T2DM > T1DM prevalence; duration ≥10 yr typical; HbA1c trajectory drives pathophysiology severity (AGE accumulation, lipotoxicity)
  • microvascular_complication_burdenrequired
    history • used at CONTEXT
    Retinopathy + nephropathy + neuropathy cluster supports diabetic CMP diagnosis; absence makes alternative etiology more likely
  • antidiabetic_medication_inventoryrequired
    history • used at CONTEXT
    Identify glitazones (must stop — fluid retention precipitates HF) and saxagliptin (HF signal SAVOR-TIMI 53); identify SGLT2i + GLP-1 RA already on board for continuation; insulin regimen for titration
  • hba1crequired
    lab • used at INITIAL_WORKUP
    Chronic glycemic control marker; target 7–8% (not strict <7 per ACCORD PMID 18539917); informs intensification urgency without overshooting
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Diagnose HF + risk stratify; obesity may blunt levels (HFpEF caveat); trend with diuresis
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Rule out acute MI as alternative explanation; persistent low-level elevation common in diabetic CMP from microvascular injury
  • creatininerequired
    lab • used at CONTEXT
    Diabetic nephropathy frequently coexists; eGFR drives SGLT2i eligibility (start ≥20 mL/min per labels), GLP-1 RA dosing (semaglutide ok any eGFR), metformin (avoid if eGFR <30), and loop diuretic dose
  • sbprequired
    vital • used at RED_FLAGS
    BP affects ARNI/ACEi initiation; volume status; SGLT2i can lower BP modestly (5 mmHg) — start with caution if SBP <100
  • glucose_finger_stickrequired
    vital • used at INITIAL_WORKUP
    Hyperglycemia may indicate DKA (T1DM) or HHS (T2DM) superimposed on ADHF — life-threatening combined emergency
  • echo_with_strainrequired
    imaging • used at INITIAL_WORKUP
    LVEF + diastolic function (E/e′) + LV mass + GLS (impaired GLS earliest sign of diabetic CMP); rule out valvular disease and segmental wall motion (CAD)
  • cardiac_mri_for_etiology
    imaging • used at BRANCHING_WORKUP
    Diffuse subendocardial LGE + T1/ECV mapping confirms diffuse interstitial fibrosis pattern of diabetic CMP; excludes ischemic + amyloid + sarcoid mimics
  • cardiac_pet_for_microvascular_ischemia
    imaging • used at BRANCHING_WORKUP
    Rubidium or NH3 PET myocardial flow reserve <2.0 confirms microvascular dysfunction even with normal coronary angiogram — supports diabetic CMP diagnosis

12-phase flow (12)

  1. 1FRAME
    HF in diabetic patient without obstructive CAD / long-standing HTN / valvular cause → diabetic cardiomyopathy phenotype; phenotype-first triage drives SGLT2i-first treatment paradigm
    inputs: diabetes_type_and_duration
    advance: diabetic CMP framed
  2. 2ENTRY
    HF symptoms + diabetic + microvascular cluster → screen for diabetic CMP; check HbA1c, current antidiabetics (stop glitazones + saxagliptin)
    inputs: age, diabetes_type_and_duration
    advance: one entry trigger present + meds reviewed
  3. 3CONTEXT
    Diabetes type + duration + HbA1c trajectory + microvascular burden + medication inventory + baseline renal/hepatic function (KDIGO 2021 race-free eGFR)
    inputs: age, diabetes_type_and_duration, microvascular_complication_burden, antidiabetic_medication_inventory, sbp, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Hyperglycemic crisis (DKA in T1DM, HHS in T2DM) superimposed on ADHF; cardiogenic shock; severe hypoglycemia from over-correction; glitazone exposure error → stop and substitute; saxagliptin exposure error → stop
    inputs: sbp, troponin, nt_probnp, glucose_finger_stick
    actions: cardiogenic_shock, acute_pulm_edema
    advance: red flags screened or escalated
  5. 5INITIAL_WORKUP
    NT-proBNP + troponin + BMP + HbA1c + lipid + LFT + CBC + finger-stick glucose + UA (microalbuminuria) + ECG + echo with strain + CXR
    inputs: nt_probnp, troponin, hba1c, creatinine, glucose_finger_stick, echo_with_strain
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: baseline workup documented
  6. 6BRANCHING_WORKUP
    Coronary angiography (rule out obstructive CAD — required to make diabetic CMP diagnosis); cardiac MRI with T1 mapping if etiology unclear (diffuse subendocardial LGE + increased ECV pattern of diabetic CMP); cardiac PET for microvascular ischemia if angiogram unrevealing but ischemia suspected
    inputs: cardiac_mri_for_etiology, cardiac_pet_for_microvascular_ischemia
    advance: CAD excluded + diabetic CMP confirmed (or alternative etiology assigned)
  7. 7DIFFERENTIAL
    Diabetic CMP vs ischemic CMP (CAD on angio) vs hypertensive CMP (long HTN history) vs amyloidosis (thick walls, low voltage, apical sparing) vs HFpEF without specific etiology
    advance: diabetic CMP confirmed or alternative assigned
  8. 8RISK_STRATIFICATION
    MAGGIC mortality estimate; CHA2DS2-VASc if AF; HFrEF (LVEF <40) drives full GDMT 4-pillar; HFpEF (LVEF ≥50) drives SGLT2i + diuretic + STEP-HFpEF candidacy
    inputs: nt_probnp, creatinine
    advance: phenotype + risk band documented
  9. 9TREATMENT
    Standard ADHF supportive (loop diuretic, NIPPV); SGLT2i FIRST (empagliflozin 10 mg or dapagliflozin 10 mg from day 1 per EMPULSE PMID 35347356); STOP glitazones immediately; STOP saxagliptin (SAVOR-TIMI 53 HF signal); insulin glargine + correctional regular if hyperglycemic; consider GLP-1 RA add-on (semaglutide if HFpEF + obese per STEP-HFpEF PMID 37877559); GDMT 4-pillar if HFrEF (ARNI/BB/MRA/SGLT2i); HbA1c target 7–8% (NOT strict <7 — ACCORD harm); avoid hypoglycemia
    inputs: sbp, creatinine, hba1c
    actions: protocol.cardiogenic_shock
    advance: SGLT2i started + harmful antidiabetics stopped + supportive HF therapy
  10. 10DISPOSITION
    Floor for stable ADHF; ICU for cardiogenic shock or DKA/HHS overlap; cardiology + endocrinology co-management
    advance: unit + multidisciplinary team assigned
  11. 11MONITORING
    Daily weight + UOP + BMP; finger-stick glucose q4–6h; HbA1c trajectory; SGLT2i side-effect surveillance (UTI, mycotic infection, euglycemic DKA); GLP-1 RA tolerance (nausea); diuretic-induced AKI surveillance
    inputs: creatinine, glucose_finger_stick
    actions: panel.renal
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Cardiology + endocrinology co-clinic; STRONG-HF–style up-titration weekly × 4; HbA1c at 3 mo; ophthalmology + nephrology follow-up; semaglutide initiation if HFpEF + obesity; CGM consideration
    advance: follow-up + chronic engine handoff scheduled