Clinical Commander

All dossiers
cardio.acute-hf.high-output-anemia.v1

Acute HF — high-output from severe anemia (Hb <7)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — high-output HF from severe anemia (Hb <7). Pathophysiology: reduced O2 delivery → compensatory ↑ CO + ↑ HR + vasodilation; chronic state → LV remodeling. Etiologies: CKD (low EPO), chemo, hemoglobinopathies (thalassemia, sickle), chronic GI bleed, nutritional (iron/B12/folate), hemolysis. Treatment: TRANSFUSION judiciously per FOCUS PMID 22168590 + AABB 2016 PMID 26684776 (target Hb 7-8 stable, 8-9 acute cardiac); SLOW (1 U over 4 h max in HF) + IV LOOP DIURETIC during transfusion (10-20 mg furosemide IV) for TACO prevention (Mehta Transfusion 2017); etiology-specific therapy (IV iron sucrose 200 mg weekly × 5 OR ferric carboxymaltose 750 mg × 1-2 per AFFIRM-AHF PMID 33216035; EPO 50-100 U/kg TIW in CKD per KDIGO 2012; B12/folate; steroids in AIHA). AVOID fluid bolus (worsens TACO), high-dose loop diuretic upfront (worsens dehydration), over-transfusion past Hb 9-10 (no benefit per FOCUS). Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (high-output anemia specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (4)

  • lab_abnormality
    Hb <7 g/dL + HF symptoms (dyspnea, orthopnea, edema, S3 gallop) → high-output anemic HF pathway
    hb_below_7_with_hf_symptoms
  • symptom
    New dyspnea or orthopnea in known severe anemia (CKD on dialysis, MDS, chemotherapy, chronic GI bleed) — escalate to high-output HF workup
    dyspnea_with_known_severe_anemia_or_active_bleed
  • history
    Anginal chest pain at rest with Hb <7 — supply-demand mismatch (Type 2 MI risk) requires urgent transfusion + ischemia workup
    angina_at_rest_with_severe_anemia
  • lab_abnormality
    Acute Hb drop ≥3 g/dL within 24-48 h (active hemorrhage, hemolysis) + new dyspnea/hypotension — emergent crossmatch + transfusion + source control
    rapid_hb_drop_with_hemodynamic_decompensation

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older patients tolerate anemia poorly + higher TACO risk; transfusion threshold may be liberalized in elderly with cardiac comorbidity per FOCUS subset
  • cbc_with_indices_and_smearrequired
    lab • used at INITIAL_WORKUP
    Hb (severity), MCV (etiology — micro/normo/macro), reticulocyte count (production vs destruction), peripheral smear (schistocytes for MAHA, sickle, blasts for leukemia, hypersegmented neutrophils for B12)
  • iron_studies_b12_folate_ldh_haptoglobin_bilirubinrequired
    lab • used at BRANCHING_WORKUP
    Iron-deficient (low ferritin, high TIBC, low TSAT), B12/folate deficient (macrocytic + hypersegs), hemolytic (high LDH, low haptoglobin, high indirect bili, high retic) — drives etiology-specific therapy
  • echo_with_co_estimate_and_chamber_dimensionsrequired
    imaging • used at INITIAL_WORKUP
    High CO state (CI often >4 L/min/m²) with hyperdynamic LV + dilated chambers ± functional MR/TR; rule out coexisting structural disease (AS, severe MR) that would alter management
  • ecg_for_ischemia_or_arrhythmiarequired
    imaging • used at INITIAL_WORKUP
    Type 2 MI from supply-demand mismatch (NSTEMI ECG changes; troponin elevation); AFib not uncommon in elderly anemic HF; rule out STEMI requiring different pathway
  • troponin_high_sensitivityrequired
    lab • used at INITIAL_WORKUP
    Type 2 MI screen — anemia-induced supply-demand mismatch is leading cause of Type 2 MI in elderly; troponin trend differentiates demand ischemia from primary ACS
  • sbp_dbp_hr_for_perfusionrequired
    vital • used at CONTEXT
    Anemic patients often hypotensive due to vasodilation; orthostatic vitals reveal volume status; HR >110 at rest signals decompensation
  • creatinine_egfrrequired
    lab • used at CONTEXT
    CKD common etiology (low EPO); eGFR drives dosing of IV iron + caution with contrast if endoscopy planned; KDIGO Hb 11.5 target in CKD
  • bleeding_source_screen_and_med_reviewrequired
    history • used at CONTEXT
    GI bleed sources (NSAIDs, anticoagulants, antiplatelets, alcohol, prior peptic disease, colon cancer screening status); menstrual losses; chemotherapy/radiation; recent surgery; iron malabsorption (celiac, post-gastrectomy)
  • type_and_crossmatch_with_antibody_screenrequired
    lab • used at TREATMENT
    Pre-transfusion compatibility; identify alloantibodies that prolong crossmatch time (esp. multiparous + multiply transfused — sickle cell, thalassemia)

12-phase flow (10)

  1. 1FRAME
    High-output anemic HF — Hb <7 with HF symptoms; reduced O2 delivery → compensatory ↑ CO with vasodilation; treat anemia (transfusion judiciously to avoid TACO) + treat etiology (iron, B12, folate, hemolysis, bleed source); avoid fluid bolus + high-dose loop diuretic upfront
    inputs: cbc_with_indices_and_smear
    advance: high-output anemic HF framed
  2. 2ENTRY
    Recognize the syndrome: severe anemia + HF symptoms + hyperdynamic exam (bounding pulses, wide pulse pressure, systolic flow murmur, S3 gallop) — secure IV access + STAT type/cross + bedside echo + ECG + troponin
    inputs: sbp_dbp_hr_for_perfusion
    advance: workup initiated
  3. 3CONTEXT
    Etiology screen (CKD, chemo, hemoglobinopathy, GI bleed, nutritional, hemolytic, MDS, autoimmune); medication review (NSAIDs, AC, antiplatelets); prior transfusion history (alloantibodies); cardiac history (CAD, valvular, baseline EF); functional status
    inputs: age, creatinine_egfr, bleeding_source_screen_and_med_review
    advance: context complete
  4. 4RED_FLAGS
    Active hemorrhage with hemodynamic instability (massive transfusion protocol if >1500 mL loss); Type 2 MI with ongoing chest pain (urgent transfusion target Hb ≥9 + ischemia workup); TACO during transfusion (acute dyspnea + pulmonary edema within 6 h of transfusion); hemolytic transfusion reaction; severe symptomatic anemia with Hb <5 (life-threatening cardiac decompensation risk); cardiogenic shock with anemia (rare; may need invasive hemodynamics)
    inputs: sbp_dbp_hr_for_perfusion
    actions: acute_pulm_edema, cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    CBC + retic + iron studies + B12 + folate + LDH + haptoglobin + bilirubin + Coombs + peripheral smear + BMP + LFTs + coags + type/cross + troponin + BNP/NT-proBNP + ECG + bedside echo + CXR (TACO baseline) + UA (hemoglobinuria for intravascular hemolysis)
    inputs: cbc_with_indices_and_smear, echo_with_co_estimate_and_chamber_dimensions, ecg_for_ischemia_or_arrhythmia, troponin_high_sensitivity, type_and_crossmatch_with_antibody_screen
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    If iron-deficient + no obvious source → UGI + colonoscopy (mandatory in adult > 50 with new IDA per AGA); if hemolytic → DAT, cold agglutinins, ADAMTS13 if microangiopathic, hemoglobin electrophoresis; if pancytopenic → bone marrow biopsy + flow cytometry; if elderly + macrocytic → MDS workup; if active bleed → endoscopy ± angiography
    inputs: iron_studies_b12_folate_ldh_haptoglobin_bilirubin
    advance: etiology identified or pending stable workup
  7. 7TREATMENT
    TRANSFUSION single-unit at a time per FOCUS/AABB (target Hb 7-8 stable, 8-9 with active cardiac ischemia/decompensation; do NOT exceed 9-10 in chronic compensated anemia); SLOW infusion (1 U over 4 h max in HF) + IV LOOP DIURETIC during transfusion (furosemide 10-20 mg IV with each unit) to prevent TACO; reassess between units; etiology-specific therapy (IV iron sucrose 200 mg IV q week × 5 OR ferric carboxymaltose 750 mg IV × 1-2 doses per AFFIRM-AHF; EPO 50-100 U/kg SC TIW in CKD per KDIGO; B12 1000 µg IM daily × 7 then weekly × 4 then monthly; folate 1 mg PO daily; steroids prednisone 1 mg/kg/d for warm AIHA; rituximab for refractory AIHA); ACTIVE BLEED management — endoscopy + IR + surgery as appropriate; PPI + cessation of NSAIDs/AC if peptic source
    inputs: type_and_crossmatch_with_antibody_screen
    advance: transfusion + etiology-specific therapy initiated
  8. 8DISPOSITION
    ICU if hemodynamically unstable, active bleed, or massive transfusion needed; telemetry floor for moderate decompensated anemic HF; observation for stable transfusion completion; outpatient infusion clinic for elective IV iron once stable
    advance: unit assigned + transfusion plan documented
  9. 9MONITORING
    Continuous SpO2 + ECG + BP during transfusion + 4 h post; vitals q15 min × first hour of each unit + q30 min × second hour; daily CBC to track Hb response (expect 1 g/dL rise per unit if no ongoing loss); daily BMP for AKI / hyperkalemia; daily exam for TACO (new pulmonary crackles, dyspnea, JVD); strict I/O
    inputs: cbc_with_indices_and_smear
    actions: panel.cardiac, panel.renal
    advance: monitoring active
  10. 10FOLLOWUP
    Hematology referral for ongoing etiology workup if not resolved (MDS, hemoglobinopathy, AIHA); GI referral for endoscopy completion if iron-deficient; outpatient IV iron repletion in HF clinic per AFFIRM-AHF/IRONMAN; nephrology for CKD-related anemia + EPO management; PCP + cardiology follow-up at 1-2 weeks; recheck CBC + iron studies at 4-6 weeks; counsel on warning signs (recurrent bleeding, pallor, fatigue)
    advance: long-term plan documented + follow-up scheduled