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cardio.acute-hf.sepsis-induced.v1

Acute HF — sepsis-induced cardiomyopathy (SICM)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — sepsis-induced cardiomyopathy (SICM) specialization. Acute reversible LV dysfunction (LVEF drop ≥10% or new ≤45%) during severe sepsis; affects 30-60% of severe sepsis; cytokine-mediated (TNF-α, IL-1β, IL-6) + nitric oxide overproduction + mitochondrial dysfunction; usually reversible at 7-10 d. SSC bundle primary scaffold with SICM-modified strategy: balanced crystalloid 20-30 mL/kg with reassessment at 15 mL/kg (less volume tolerance), NE first-line, vasopressin add-on, low-dose dobutamine 2.5-5 µg/kg/min only if low CI on serial echo, hydrocortisone 200 mg/day if pressor-dependent. Distinguished from cardio.cardiogenic-shock.septic-mixed.v1 — covers SICM WITHOUT frank cardiogenic shock; route to mixed-shock variant if SCAI C+. GDMT deferred to 90-d re-echo (most recover; lifelong meds without indication if recovers). Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (SICM specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • history
    Severe sepsis or septic shock + new LVEF drop ≥10% absolute (or new LVEF ≤45%) on echo within 48-72h → SICM pathway
    severe_sepsis_with_new_lv_dysfunction
  • lab_abnormality
    Troponin elevation in sepsis WITHOUT ischemic ECG / regional wall motion abnormalities → likely SICM-related demand/depression (rule out type-2 MI)
    troponin_elevation_in_sepsis_without_acs_features
  • imaging
    Global LV hypokinesis (NOT regional) on bedside echo during sepsis — pattern favors SICM over ischemic cardiomyopathy
    echo_global_hypokinesis_in_sepsis
  • symptom
    Pulmonary edema developing during sepsis resuscitation (>30 mL/kg) — flag SICM + over-resuscitation
    sepsis_with_acute_pulmonary_edema_after_initial_resuscitation

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older patients higher SICM incidence (40-60% vs 30% younger); slower recovery trajectory; co-existing baseline CV disease confounds attribution
  • sepsis_source_and_severityrequired
    history • used at CONTEXT
    Source identification (urinary, pulmonary, intra-abdominal, line-associated) + severity (qSOFA / SOFA) drives source control + abx choice + prognosis
  • baseline_lvef_pre_sepsisrequired
    history • used at FRAME
    Anchor pre-sepsis LVEF essential to define SICM (≥10% drop) — without prior echo, must consider chronic HFrEF as alternative; absent pre-data → presume SICM if rapid recovery on serial echo
  • sbp_and_maprequired
    vital • used at RED_FLAGS
    MAP <65 + lactate ≥2 → SCAI shock screen + early NE; SICM superimposed on septic shock has worst outcome
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Hour-1 lactate per SSC; clearance trend (≥10%/h) tracks resuscitation adequacy + organ perfusion
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Troponin elevation in 30-50% of severe sepsis — most are SICM/type-2 MI rather than type-1 (4th UDMI 2018); guides cath need
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Elevated baseline in sepsis (cytokines + RV strain) — use trend not absolute; absolute >1800 + new LV dysfunction supports SICM
  • bedside_echo_with_strainrequired
    imaging • used at INITIAL_WORKUP
    TTE LVEF + global longitudinal strain (GLS); GLS abnormality (less negative than -16%) detects SICM earlier than LVEF; serial day-1, day-3, day-7 echo to track recovery
  • creatininerequired
    lab • used at CONTEXT
    AKI common in sepsis + drives drug dosing (RRT-modified); cardiorenal physiology if BOTH SICM + AKI
  • cultures_and_source_workuprequired
    lab • used at INITIAL_WORKUP
    Blood cultures × 2 + site-specific cultures + source imaging (CT, US) BEFORE abx if no delay; source control non-negotiable

12-phase flow (10)

  1. 1FRAME
    SICM = acute reversible LV dysfunction during sepsis (LVEF ↓ ≥10% or new ≤45%); affects 30-60% of severe sepsis; usually reversible at 7-10 d; SSC bundle remains primary scaffold; LV dysfunction modifies fluid + inotrope strategy
    inputs: baseline_lvef_pre_sepsis
    advance: SICM phenotype framed
  2. 2ENTRY
    Recognize SICM in severe sepsis: bedside echo at hour 1-3 (global hypokinesis pattern); SSC bundle simultaneous; early MAP target ≥65 with NE first-line if hypotensive
    inputs: sbp_and_map
    actions: sepsis_bundle
    advance: echo + SSC bundle initiated
  3. 3CONTEXT
    Sepsis source + severity (qSOFA/SOFA), baseline LVEF anchor, comorbidities (CAD, prior HF), drugs at home (BB, ARNI), allergies; prognosis framing
    inputs: sepsis_source_and_severity, baseline_lvef_pre_sepsis, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Septic shock superimposed on SICM (SCAI C+ — worse outcome); persistent lactate ≥4 despite resuscitation; severe RV dysfunction (often missed); mechanical ventilation requirement; AKI (cardiorenal physiology)
    inputs: sbp_and_map, lactate
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    CBC, BMP, lactate, procalcitonin, troponin, NT-proBNP, blood cultures × 2, urinalysis + culture, source imaging (CT/US/CXR), bedside echo with GLS, ECG (rule out ischemic STEMI before attributing troponin to SICM)
    inputs: lactate, troponin, nt_probnp, bedside_echo_with_strain, cultures_and_source_workup
    actions: sepsis_bundle, panel.cardiac, panel.coag
    advance: workup documented
  6. 6BRANCHING_WORKUP
    If regional wall motion abnormality → urgent cath (rule out type-1 MI superimposed); if RV dysfunction predominant + DVT risk → CTA-PE rule out; if persistent SICM + endocarditis suspected → TEE (vegetations + abscess); if culture-negative + persistent fevers → fungal/atypical/non-infectious mimics
    advance: branching decisions made
  7. 7TREATMENT
    SSC bundle + SICM-modified strategy: balanced crystalloid 20-30 mL/kg (FENICE-aware, reassess at 15 mL/kg with dynamic markers); NE first-line for MAP <65; ADD vasopressin 0.03 U/min if NE >0.5; ADD dobutamine 2.5-5 µg/kg/min low-dose if low CI on echo despite adequate MAP; ADRENAL hydrocortisone 200 mg/day if pressor-dependent; abx <60 min + source control; AVOID over-resuscitation (ARDS + worsening SICM); HOLD chronic GDMT (BB, ACEi/ARNI) during active shock — RESTART when stabilized; chronic GDMT only initiated at 90-day re-echo if persistent dysfunction
    inputs: sbp_and_map, lactate, creatinine
    actions: sepsis_bundle
    advance: SSC bundle complete + SICM-modified strategy implemented
  8. 8DISPOSITION
    ICU for septic shock + SICM (most cases); telemetry floor only if SICM without shock + low pressor requirement
    advance: unit assigned
  9. 9MONITORING
    Continuous SpO2 + ECG + arterial line BP; serial lactate q2h until clearance; serial echo (day 1, day 3, day 7) to track LVEF + GLS recovery; daily CBC + BMP + cultures pending; CAM-ICU for delirium; ABCDEF bundle
    inputs: lactate, creatinine
    actions: panel.cardiac, panel.coag
    advance: serial monitoring active
  10. 10FOLLOWUP
    90-day cardiology echo to determine SICM recovery (most do); if persistent dysfunction → start chronic GDMT (4 pillars per ACC/AHA 2022); if recovered → educate patient on sepsis-prevention + future risk; ID follow-up for source control adequacy + suppressive abx if applicable
    advance: 90-day re-echo + GDMT decision made