12-phase flow (10)

1. 1FRAME
   Confirm Takotsubo with ADHF (non-shock spectrum) per InterTAK 2018 criteria; postmenopausal female predominant; recent stressor often present (~70%); transient apical (or atypical) ballooning; ABSENT obstructive CAD; recovery is the rule by 4-8 wks; SCAI C+ shock routes to sister shock dossier
   inputs: echocardiogram_with_lvot_gradient_assessment
   advance: Takotsubo ADHF (non-shock) framed
2. 2ENTRY
   Recognize ADHF in Takotsubo context; bedside echo for ballooning + LVOT gradient assessment; ECG + troponin + BNP; SCAI shock screen (route to shock dossier if C+); admit cardiology / telemetry
   inputs: sbp_dbp_for_perfusion_and_shock_screen, echocardiogram_with_lvot_gradient_assessment
   advance: shock excluded + admission decided
3. 3CONTEXT
   Recent stressor identification (emotional vs physical), comorbidities (CAD risk factors as confounders), prior Takotsubo episodes, baseline meds (current BB / inotrope use changes acute strategy), code status, mental health history
   inputs: age, sex, recent_stressor_emotional_or_physical, hr, creatinine_egfr
   advance: context complete + trigger identified or absent confirmed
4. 4RED_FLAGS
   LVOT obstruction subtype (15–25% — different physiology pivots to esmolol + fluids + phenylephrine; AVOID nitrates / diuretics / inotropes); QT prolongation >500 ms with torsades risk; LV thrombus from severe apical akinesia (anticoagulate); progression to SCAI C+ shock (route to shock dossier); mechanical complication (free-wall rupture rare but reported); persistent dysfunction beyond 8 wks (reconsider diagnosis)
   inputs: sbp_dbp_for_perfusion_and_shock_screen, ecg_for_t_wave_inversion_qt_prolongation, electrolytes_k_mg_for_qt_management
   actions: acute_pulm_edema, cardiogenic_shock
   advance: red flags screened + subtype identified
5. 5INITIAL_WORKUP
   CBC + BMP + LFTs + troponin + BNP/NT-proBNP + Mg + lactate + ECG (T-wave inversion + QT prolongation typical) + CXR + bedside echo with LVOT gradient + STAT serial troponin q4-6h × 2-3 to confirm trend; telemetry continuous with QT monitoring
   inputs: cardiac_troponin, bnp_or_nt_probnp, echocardiogram_with_lvot_gradient_assessment, ecg_for_t_wave_inversion_qt_prolongation, electrolytes_k_mg_for_qt_management
   actions: acute_pulm_edema, panel.cardiac, panel.renal
   advance: workup documented
6. 6BRANCHING_WORKUP
   Coronary angiography (mandatory rule-out of obstructive CAD per InterTAK 2018); cardiac MRI for confirmation (regional wall motion + T2 edema + ABSENT LGE distinguishes from ischemic and inflammatory CMP); LV gram for ballooning pattern documentation; differential — pheochromocytoma (24h urine metanephrines), myocarditis (viral PCR + cardiac MRI), cocaine ACS (UDS), acute myocarditis with troponin elevation
   inputs: coronary_angiography_to_rule_out_obstructive_cad, cardiac_mri_for_takotsubo_confirmation
   actions: acs_pathway
   advance: obstructive CAD ruled out + Takotsubo pattern confirmed + mimics excluded
7. 7TREATMENT
   Standard ADHF supportive: IV loop diuretic (furosemide 40-80 mg IV diuretic-naive starting dose per DOSE PMID 21366472; titrate to UOP); supplemental O2 to SpO2 ≥92%; gentle vasodilator (nitroglycerin) ONLY if hypertensive AND non-LVOT subtype; AVOID INOTROPES (worsen catecholamine excess underlying mechanism — dobutamine / milrinone / epinephrine all relatively contraindicated per ESC HFA 2016 Lyon position); β-blocker CAUTIOUS in non-LVOT subtype during acute catecholamine surge (initiate as recovery occurs); LVOT subtype: esmolol + IV fluids + phenylephrine + AVOID nitrates / diuretics / inotropes (preload-dependent physiology); aggressive K (≥4) + Mg (≥2) replacement for QT prolongation; mural-thrombus prophylaxis with warfarin (INR 2-3) or apixaban × 3 mo if EF <35 + apical akinesia per AHA 2022 Class IIa LV thrombus consensus extrapolation; ACEi/ARB initiation per modified InterTAK protocols during recovery for residual dysfunction
   inputs: cardiac_troponin, bnp_or_nt_probnp, sbp_dbp_for_perfusion_and_shock_screen
   advance: ADHF stabilized + subtype-appropriate plan in place
8. 8DISPOSITION
   Cardiology floor for stable ADHF; CICU if borderline hemodynamics or significant LVOT gradient or torsades risk; psychiatry consult if emotional trigger identified; transition to outpatient with close cardiology follow-up + recovery echo at 4-8 wks
   advance: unit + recovery + psych follow-up plan documented
9. 9MONITORING
   Continuous telemetry with QT monitoring (torsades surveillance); daily weight + I/O; daily BMP for diuresis safety; serial troponin trend (peak typically modest — Takotsubo discordance); echo at 48-72h to track recovery trajectory + LVOT gradient evolution; recovery echo at 4-8 wks (Templin PMID 26332547 — typical complete recovery); psychiatry follow-up if emotional trigger
   inputs: cardiac_troponin, bnp_or_nt_probnp, electrolytes_k_mg_for_qt_management
   actions: panel.cardiac, panel.renal
   advance: monitoring active + recovery trajectory documented
10. 10FOLLOWUP
    Cardiology follow-up at 1-2 wks + 4-8 wks (recovery echo) + 3 mo + 6 mo + 12 mo; recovery echo at 4-8 wks confirms complete LV recovery typical (Templin PMID 26332547); discontinue mural-thrombus AC at 3 mo if EF normalized + apical akinesia resolved per AHA 2022 LV thrombus consensus; long-term ARNI/BB after recovery debated case-by-case (no RCT-grade evidence — Lyon 2016 ESC HFA position); psychiatry follow-up if emotional trigger; recurrence ~5-10% lifetime — patient education on stressor mitigation; cardiac MRI at 4-8 wks for LGE persistence assessment if initial atypical pattern
    advance: long-term plan + recovery echo + psych follow-up booked