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cardio.acute-hf.elderly-frail.v1

Acute HF — frail elderly (age ≥80, CFS ≥6)

cardiologyacuteadultgeriatricacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — frail-elderly (age ≥80 + CFS Rockwood ≥6 OR Fried ≥3) ADHF specialization. Specializes gentler decongestion (1-1.5× home dose, NOT 2-2.5× per DOSE), 25% standard-dose GDMT initiation (carvedilol 1.5625 BID, ARNI 12/13 BID, MRA every-other-day if eGFR 30-45), STRONG-HF SLOW cadence (q4 wk), STOPPFrail-driven deprescribing (statin in advanced HF per CESAR/SAVE-AHF, BZD, anticholinergic, sliding-scale insulin, NSAID), and functional-outcome focus (days at home, NYHA, 6MWT). Mandatory geriatrics + PT/OT + pharmacy consults + early goals-of-care conversation. Falls + delirium + AKI from over-diuresis triad as named severity triggers. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (frail-elderly specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • demographic
    Age ≥80 + ADHF presentation → frail-HF screen + geriatric-aware management
    age_ge_80_with_adhf
  • history
    Clinical Frailty Scale (Rockwood) ≥6 (moderately frail) at baseline → frail HF pathway
    rockwood_cfs_ge_6
  • history
    Fried frailty phenotype ≥3 of 5 (weight loss, exhaustion, weakness, slow gait, low activity) → frail HF pathway
    fried_phenotype_ge_3
  • history
    ≥10 chronic medications + ADHF → STOPPFrail medication review trigger
    polypharmacy_with_adhf

Required inputs (10)

  • agerequired
    demographic • used at FRAME
    Age ≥80 defines variant; biological vs chronological age via frailty stratifies risk
  • clinical_frailty_scalerequired
    history • used at CONTEXT
    Rockwood CFS ≥6 (moderately frail) drives gentler GDMT initiation, deprescribing thresholds, and goals-of-care discussion timing
  • baseline_function_nyha_6mwtrequired
    history • used at CONTEXT
    Pre-admission NYHA + 6MWT (or get-up-and-go time) anchors target functional outcome; helps differentiate true acute decline vs end-stage trajectory
  • medication_count_and_high_risk_classesrequired
    history • used at CONTEXT
    Polypharmacy >5 meds + Beers/STOPP-flagged drugs (anticholinergics, BZDs, NSAIDs, sliding-scale insulin) drive in-hospital deprescribing per STOPPFrail
  • sbp_and_orthostatic_bprequired
    vital • used at CONTEXT
    Standing-supine BP gating GDMT initiation/up-titration; orthostasis (drop ≥20/10) → fall risk → start at 25% standard dose
  • creatininerequired
    lab • used at CONTEXT
    Baseline + trend; tolerate ≤30% rise during decongestion but watch carefully — frail elderly slower to recover from AKI; eGFR for SGLT2i + ARNI dosing
  • potassiumrequired
    lab • used at CONTEXT
    Hyperkalemia risk with MRA + ARNI in eGFR <45 frail elderly; lower starting doses + closer monitoring
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    NT-proBNP elevated baseline in elderly + renal — use trend (>30% drop) rather than absolute
  • cognitive_screen_minicog_or_4atrequired
    history • used at CONTEXT
    Baseline cognition (Mini-Cog or 4AT) anchors delirium detection during admission — BB + diuretic-induced delirium common in frail elderly
  • goals_of_care_and_advance_directivesrequired
    history • used at CONTEXT
    Early GoC conversation (within 48h) — frailty + ADHF carries 1-yr mortality 25-50% per Khan 2020; aligns aggressiveness with patient values

12-phase flow (10)

  1. 1FRAME
    Age ≥80 + frailty (CFS ≥6 OR Fried ≥3) ADHF — functional outcomes (days at home, NYHA, 6MWT) prioritized over mortality; gentler doses; deprescribing focus; early GoC
    inputs: age, clinical_frailty_scale
    advance: frailty staged + variant confirmed
  2. 2ENTRY
    Recognize frail-HF phenotype (age ≥80 + CFS ≥6 or Fried ≥3); IV loop at 1-1.5× home dose (NOT 2-2.5× per DOSE — frail elderly tolerate less); bedside echo if not recent
    inputs: sbp_and_orthostatic_bp
    advance: gentler IV diuretic dosed
  3. 3CONTEXT
    Frailty staging (Rockwood CFS, Fried), baseline function (NYHA, 6MWT, get-up-go), cognition (Mini-Cog/4AT), polypharmacy review (STOPPFrail), goals-of-care + advance directives, social supports + caregiver capacity
    inputs: clinical_frailty_scale, baseline_function_nyha_6mwt, medication_count_and_high_risk_classes, cognitive_screen_minicog_or_4at, goals_of_care_and_advance_directives
    advance: geriatric assessment + GoC conversation documented
  4. 4RED_FLAGS
    Delirium (CAM positive — often BB or diuretic-induced); fall during admission; AKI from over-diuresis (KDIGO ≥1); polypharmacy adverse event (BZD/anticholinergic/sliding-scale insulin)
    inputs: cognitive_screen_minicog_or_4at, creatinine, sbp_and_orthostatic_bp
    actions: acute_pulm_edema
    advance: red flags screened + caregivers alerted
  5. 5INITIAL_WORKUP
    BMP, NT-proBNP, troponin, TSH (often missed in elderly), B12 + folate, urinalysis, ECG, CXR, bedside echo if not in last 6 mo; lung US for congestion endpoint when oliguric
    inputs: nt_probnp, creatinine
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    If new severe LV dysfunction → rule out ischemia (low-threshold troponin trend); rule out infiltrative (PYP if HFpEF + thick walls); rule out infection precipitant (UA + CXR + procalcitonin if ill); rule out medication culprit (NSAID, dihydropyridine CCB load)
    advance: precipitant identified
  7. 7TREATMENT
    GENTLER decongestion: IV loop 1-1.5× home dose (e.g., 40-80 mg IV if home 40 PO); reassess at 4h not 2h. GDMT initiation at 25% standard doses (carvedilol 1.5625 mg BID NOT 3.125; sacubitril/valsartan 12/13 BID NOT 24/26; spironolactone 12.5 mg every other day if eGFR 30-45). DEPRESCRIBING: stop statin if NYHA IV + life expectancy <1 yr (CESAR/SAVE-AHF supportive); stop sliding-scale insulin; stop BZD/anticholinergic; stop NSAID. Avoid: high-dose loop alone (AKI + falls + delirium); rapid BP drops; new chronic meds without indication review
    inputs: creatinine, potassium, sbp_and_orthostatic_bp
    advance: gentler decongestion + 25% GDMT + deprescribing plan documented
  8. 8DISPOSITION
    Floor with telemetry + fall precautions + delirium prevention bundle (HELP/ABCDEF); ICU only if shock or refractory pulmonary edema; early PT/OT consult for mobility; geriatrics co-management if frailty severe
    advance: unit + PT/OT + geriatrics consult arranged
  9. 9MONITORING
    Daily weight + supine/standing BP, hourly UOP, BMP q12h during diuresis, CAM-ICU q shift for delirium, fall risk score q shift, daily medication review for STOPP triggers
    inputs: creatinine, potassium, cognitive_screen_minicog_or_4at
    actions: panel.renal
    advance: delirium-aware monitoring active
  10. 10FOLLOWUP
    STRONG-HF SLOW cadence (q4 wk not q2 wk titration in CFS ≥6 per Mebazaa subgroup); 1-wk PCP visit + 2-wk HF clinic (in-home if homebound); home-health PT for fall prevention; medication reconciliation at every visit; advance directives finalized
    advance: home-based follow-up + advance directives + AOM/Tele-HF arranged