cardio.acute-hf.eosinophilic-myocarditis-decompensation.v1

Acute HF — eosinophilic myocarditis decompensation (non-shock)

cardiologyacuteadultacuteinpatienttransitionoutpatient

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Phase E variant of cardio.acute-hf.core.v1 — eosinophilic myocarditis (EM) presenting as ADHF WITHOUT cardiogenic shock (SCAI A-B). The shock spectrum routes to cardio.cardiogenic-shock.eosinophilic-myocarditis.v1. Etiologies (5 main subsets): hypersensitivity/DRESS (drug-induced), parasitic, HES (FIP1L1-PDGFRA+ → imatinib), EGPA/Churg-Strauss, idiopathic. Diagnostic cornerstones: peripheral eosinophilia >1500/µL + cardiac troponin elevation + cardiac MRI subendocardial LGE (classic Loeffler) + EMB selectively. MANDATORY strongyloides screen or empiric ivermectin before steroids (steroids precipitate fatal hyperinfection). Treatment: PULSE METHYLPREDNISOLONE 1 g IV daily × 3-5 d → prednisone 1 mg/kg taper 6-12 mo (RESPONSIVE in most); etiology-specific add-ons (imatinib for FIP1L1-PDGFRA+ HES; mepolizumab for HES PDGFRA-neg or EGPA per MIRRA 2017 PMID 28514601; cyclophosphamide/rituximab for severe EGPA; antiparasitic per organism; drug discontinuation for DRESS). Standard ADHF (DOSE diuretic) + AC for mural thrombus (very common — endocardial damage prothrombotic) + GDMT 4-pillar cautiously + AVOID NSAIDs + AVOID class I antiarrhythmics. PCP prophylaxis with TMP-SMX during chronic steroids. Long-term: eosinophil-count-guided taper, surveillance echo + MRI, ICD if EF <35 at 3-6 mo, transplant if end-stage. Severity triggers: progression to shock (route to shock dossier); strongyloides exposure with planned steroids (life-threatening — empiric ivermectin); mural thrombus with embolic event (urgent AC + imaging); GDMT intolerance during inflammation (delay BB per AHA 2020); eosinophil relapse during taper (re-pulse + mepolizumab); sustained VT or AV block during active EM (amiodarone + temp pacing + WCD bridge). Sibling differentiation: vs viral myocarditis (eosinophilia + steroid responsiveness + subendocardial LGE distinguishes); vs ICI cardiotoxicity (drug exposure history); vs giant-cell myocarditis (more aggressive T-cell immunosuppression needed in giant-cell); vs sarcoid (granulomas on biopsy, ACE level). Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute (Wave 20 recovery batch).

Entry points (4)

lab_abnormality
Peripheral absolute eosinophil count >1500/µL (often >5000) + new ADHF symptoms (dyspnea, orthopnea, edema) + LV dysfunction on echo + elevated troponin → eosinophilic myocarditis until proven otherwise
peripheral_eosinophilia_with_new_hf
history
Recent drug exposure (sulfa, penicillin, minocycline, clozapine, olanzapine, phenytoin, carbamazepine, lamotrigine, allopurinol) + DRESS features (fever, rash, lymphadenopathy, eosinophilia, multiorgan) + new ADHF — drug-induced eosinophilic myocarditis pathway
dress_or_drug_hypersensitivity_with_cardiac_dysfunction
history
Asthma + sinusitis + peripheral eosinophilia + ANCA + new ADHF → EGPA (Churg-Strauss) cardiac involvement; cardiac is leading cause of death in EGPA
egpa_history_or_features_with_new_hf
imaging
Cardiac MRI with subendocardial LGE pattern (classic Loeffler endocarditis distribution) + edema on T2 mapping + peripheral eosinophilia → EM diagnosis with high specificity
cardiac_mri_subendocardial_lge_with_eosinophilia

Required inputs (15)

agerequired
demographic • used at CONTEXT
EM spans all ages; HES with FIP1L1-PDGFRA more common in middle-aged males; EGPA peaks 30-50 y; pediatric drug-induced cases route to peds-specific dossier
recent_drug_exposure_for_dress_screenrequired
history • used at CONTEXT
Drug timeline (2-8 wk pre-presentation typical for DRESS) + offending agent identification drives discontinuation as first therapeutic step; antibiotics, antipsychotics, anticonvulsants, allopurinol most common
asthma_sinusitis_or_atopy_for_egpa_screenrequired
history • used at CONTEXT
EGPA classic triad: asthma + eosinophilia + vasculitis; cardiac involvement is leading cause of EGPA death; identifies need for cyclophosphamide/rituximab + steroids
travel_or_exposure_history_for_parasitic_screenrequired
history • used at CONTEXT
Parasitic etiology (toxocara, schistosoma, strongyloides, trichinella) requires targeted antiparasitic; STRONGYLOIDES SCREEN MANDATORY before steroids (steroids precipitate fatal hyperinfection)
sbp_dbp_hr_for_perfusion_and_shock_screenrequired
vital • used at RED_FLAGS
SBP <90 + lactate ≥2 + cool extremities → SCAI C+ shock → ROUTE to cardio.cardiogenic-shock.eosinophilic-myocarditis.v1; this engine handles SCAI A-B (warm + wet) only
cbc_with_absolute_eosinophil_countrequired
lab • used at INITIAL_WORKUP
Cornerstone diagnostic — AEC >1500/µL supports EM (>5000 in HES classification); trend over days during steroid response (rapid drop within 48 h supports diagnosis)
cardiac_troponinrequired
lab • used at INITIAL_WORKUP
Elevated in active EM (eosinophil-mediated myocyte injury); persistent elevation despite steroids portends worse outcome
bnp_or_nt_probnprequired
lab • used at INITIAL_WORKUP
HF severity marker; titrate diuresis; trend during admission for response monitoring
creatinine_egfr_with_lftsrequired
lab • used at CONTEXT
eGFR for diuretic + GDMT dosing (ARNI, MRA, SGLT2i thresholds); LFTs for congestive hepatopathy + DRESS hepatic involvement + drug-induced hepatitis screen
strongyloides_serology_mandatory_before_steroidsrequired
lab • used at BRANCHING_WORKUP
Steroids precipitate Strongyloides hyperinfection syndrome (mortality >70%); MUST screen with serology + ivermectin empiric coverage if endemic exposure even pending result; AHA + IDSA recommendation
fip1l1_pdgfra_mutation_testing_for_hes
lab • used at BRANCHING_WORKUP
FIP1L1-PDGFRA fusion (myeloid lineage HES) → IMATINIB curative response; mandatory in HES workup; identifies subset with dramatic targeted therapy response
anca_panel_for_egpa
lab • used at BRANCHING_WORKUP
p-ANCA / MPO-ANCA positive in 30-50% of EGPA; classification per ACR/EULAR 2022; drives cyclophosphamide/rituximab decision
echocardiogram_for_lv_rv_function_thrombus_pericardialrequired
imaging • used at INITIAL_WORKUP
LV dysfunction (often regional + restrictive); MURAL THROMBUS very common in EM (endocardial damage prothrombotic) — apical or biventricular; pericardial effusion; serial echo for recovery
cardiac_mri_with_lake_louise_2018
imaging • used at BRANCHING_WORKUP
Subendocardial LGE distribution classic for EM (vs mid-wall in viral, transmural in giant-cell); T2 edema mapping for active inflammation; native T1 for diffuse fibrosis; serial MRI at 3-6 mo for treatment response
ecg_for_arrhythmia_av_block_low_voltagerequired
imaging • used at INITIAL_WORKUP
ECG abnormalities in 90%+ of EM (T-wave inversion, ST changes, AV block, low voltage from inflammation, pericardial pattern); persistent QRS prolongation portends worse prognosis

12-phase flow (10)

1FRAME
Eosinophilic myocarditis ADHF (non-shock; SCAI A-B): peripheral eosinophilia + cardiac dysfunction + STEROID RESPONSIVE; identify etiology subset (drug/DRESS, parasitic, HES with FIP1L1-PDGFRA, EGPA, idiopathic) for targeted therapy in addition to steroids; standard ADHF supportive care; STRONGYLOIDES SCREEN before steroids; AVOID NSAIDs
inputs: cbc_with_absolute_eosinophil_count, echocardiogram_for_lv_rv_function_thrombus_pericardial
advance: EM ADHF framed
2ENTRY
Recognize eosinophilia + ADHF presentation; bedside echo for LV function + mural thrombus; ECG + troponin; SCAI shock screen (route to shock dossier if C+); admit cardiology/telemetry
inputs: sbp_dbp_hr_for_perfusion_and_shock_screen, echocardiogram_for_lv_rv_function_thrombus_pericardial
advance: shock excluded + admission decided
3CONTEXT
Drug timeline (DRESS criteria); asthma/sinusitis (EGPA); travel exposure (parasitic); systemic features (fever, rash, lymphadenopathy, multiorgan); immunocompromise; medications (ICI, anthracyclines route to dedicated dossiers); pregnancy
inputs: age, recent_drug_exposure_for_dress_screen, asthma_sinusitis_or_atopy_for_egpa_screen, travel_or_exposure_history_for_parasitic_screen, creatinine_egfr_with_lfts
advance: context complete + etiology hypothesis prioritized
4RED_FLAGS
Progression to shock (SCAI C+ → shock dossier); high-grade AV block requiring temporary pacing; sustained VT/VF; mural thrombus with embolic events (stroke, peripheral embolism); STRONGYLOIDES exposure with planned steroids (life-threatening hyperinfection if not pre-treated); DRESS multiorgan failure
inputs: sbp_dbp_hr_for_perfusion_and_shock_screen, ecg_for_arrhythmia_av_block_low_voltage
actions: acute_pulm_edema, cardiogenic_shock
advance: red flags screened + strongyloides safety check complete
5INITIAL_WORKUP
CBC with absolute eosinophil count + BMP + LFTs + troponin + BNP/NT-proBNP + ESR/CRP + lactate + ECG + CXR + bedside echo (LV/RV, mural thrombus, pericardial); telemetry; pregnancy test reproductive-age females
inputs: cbc_with_absolute_eosinophil_count, cardiac_troponin, bnp_or_nt_probnp, ecg_for_arrhythmia_av_block_low_voltage, echocardiogram_for_lv_rv_function_thrombus_pericardial
actions: acute_pulm_edema, panel.cardiac, panel.renal, panel.cbc
advance: workup confirms eosinophilia + cardiac dysfunction documented
6BRANCHING_WORKUP
Etiology workup MANDATORY before steroids: STRONGYLOIDES serology (or empiric ivermectin if endemic exposure), stool O&P, schistosoma + toxocara + trichinella serologies; FIP1L1-PDGFRA mutation (HES); ANCA + asthma history (EGPA); drug reconciliation (DRESS RegiSCAR); cardiac MRI with Lake Louise 2018; EMB SELECTIVELY per Cooper 2007 IB criteria (especially for definitive HES vs viral vs giant-cell distinction)
inputs: strongyloides_serology_mandatory_before_steroids, fip1l1_pdgfra_mutation_testing_for_hes, anca_panel_for_egpa, cardiac_mri_with_lake_louise_2018
advance: etiology subset identified or empirically prioritized
7TREATMENT
Standard ADHF: IV loop diuretic (furosemide 40-80 mg IV diuretic-naive per DOSE PMID 21366472); supplemental O2; gentle vasodilator if hypertensive; AVOID NSAIDs. PULSE METHYLPREDNISOLONE 1 g IV daily × 3-5 d (cornerstone) → prednisone 1 mg/kg/d taper over 6-12 mo — RESPONSIVE in most. ETIOLOGY-SPECIFIC: imatinib for FIP1L1-PDGFRA+ HES; mepolizumab for HES PDGFRA-negative or steroid-refractory or EGPA; cyclophosphamide/rituximab for severe EGPA; antiparasitic per organism; discontinue offending drug for DRESS. AC if mural thrombus on echo (warfarin 3-mo; DOAC alternative). GDMT 4-pillar cautiously for HFrEF (some delay BB during active inflammation). AVOID class I antiarrhythmics. WCD bridge if EF <35
inputs: cardiac_troponin, bnp_or_nt_probnp
advance: ADHF stabilized + steroids initiated + etiology-targeted therapy launched
8DISPOSITION
Cardiology floor for stable ADHF; CICU if borderline; transition with close cardiology + hematology + ID/rheum follow-up; transplant referral pre-discussion if persistent severe dysfunction despite optimized therapy
advance: unit + steroid taper + GDMT plan documented
9MONITORING
Continuous telemetry; daily weight + I/O; daily BMP for diuresis safety + steroid hyperglycemia; eosinophil count daily during steroid initiation (rapid drop within 48 h supports response); troponin trend; echo at d/c + 3 mo + 6 mo for recovery + thrombus resolution; cardiac MRI at 3-6 mo for response; eosinophil count at 3 + 6 + 12 mo for relapse surveillance
inputs: cbc_with_absolute_eosinophil_count, cardiac_troponin, bnp_or_nt_probnp
actions: panel.cardiac, panel.cbc
advance: monitoring active
10FOLLOWUP
Cardiology at 1-2 wk + 3 + 6 + 12 mo; hematology for HES q3 mo or rheumatology for EGPA; serial echo + cardiac MRI at 3-6 mo; ICD evaluation at 3-6 mo if EF persistently <35; steroid taper guided by eosinophil count + clinical status (typically 6-12 mo total); long-term GDMT if persistent HFrEF; relapse surveillance with eosinophil count + symptoms
advance: long-term hematology/rheum + cardiology + steroid taper plan documented