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cardio.acute-hf.viral-cardiomyopathy-decompensation.v1

Acute HF — viral cardiomyopathy / myocarditis decompensation (non-shock)

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Phase E variant of cardio.acute-hf.core.v1 — viral cardiomyopathy / acute viral myocarditis presenting as ADHF WITHOUT cardiogenic shock (SCAI A-B). The shock spectrum routes to cardio.cardiogenic-shock.viral-myocarditis.v1. Etiologies: parvovirus B19 (most commonly detected), coxsackievirus/enterovirus (classical), adenovirus, HHV-6, SARS-CoV-2 (acute COVID + MIS-A overlap), influenza, HIV-related. Workup: viral PCR panel (serum + NP) + cardiac troponin (persistent elevation prognostic) + cardiac MRI Lake Louise 2018 (T2 mapping + LGE non-ischemic pattern + native T1) + selective EMB per Cooper 2007 IB criteria (suspected giant cell, eosinophilic, sarcoid - these route to dedicated dossiers). Treatment: standard ADHF (IV loop diuretic per DOSE; nitroglycerin if hypertensive) + cautious GDMT 4-pillar (ARNI/ACEi + BB + MRA + SGLT2i) - some experts delay BB until inflammation settles per AHA 2020. AVOID NSAIDs (worsen outcomes) + class I antiarrhythmics (proarrhythmic in inflamed myocardium). Supportive - no antiviral with proven cardiac benefit (oseltamivir for influenza systemically reasonable; remdesivir for COVID systemically). Corticosteroids ONLY if virus-negative biopsy (TIMIC PMID 19651620) or specific subsets (Lyme, eosinophilic - separate dossiers). Activity restriction 3-6 mo (no competitive sports per Maron PMID 26621650). Recovery POSSIBLE especially parvovirus B19 (~50% recover EF). ICD evaluation at 3-6 mo if EF persistently <35; WCD bridge during recovery window. Transplant referral if end-stage despite optimized GDMT. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (viral 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)

  • symptom
    Recent (1–4 wk) viral prodrome (URI, GI, flu-like) followed by new HF symptoms (dyspnea, orthopnea, edema) + LV dysfunction on echo + elevated troponin → suspect acute viral myocarditis pathway
    recent_viral_prodrome_with_new_hf
  • history
    Patient with known chronic dilated cardiomyopathy (DCM) attributed to remote viral myocarditis presenting with new ADHF (worsening edema, weight gain, NYHA III–IV symptoms) — non-shock spectrum
    chronic_dilated_cmp_remote_viral_myocarditis_with_decompensation
  • lab_abnormality
    Positive viral PCR (parvovirus B19, coxsackievirus, adenovirus, HHV-6, SARS-CoV-2, influenza) in serum or NP swab + new cardiac dysfunction + troponin elevation
    positive_viral_pcr_with_cardiac_dysfunction
  • imaging
    Cardiac MRI with Lake Louise Criteria 2018 positive (T2 edema mapping + LGE non-ischemic pattern + native T1 mapping abnormal) → acute or chronic viral myocarditis
    cardiac_mri_lake_louise_positive_for_myocarditis

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Acute viral myocarditis disproportionately affects younger adults (20–50); chronic DCM from remote viral myocarditis spans all ages; pediatric fulminant cases route to peds-specific dossier
  • recent_viral_illness_or_prior_myocarditis_historyrequired
    history • used at CONTEXT
    Recent (within 4 wk) viral prodrome suggests acute myocarditis; remote myocarditis history suggests chronic DCM decompensation; both spectrums have different prognosis + treatment timelines
  • 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.viral-myocarditis.v1; this engine handles SCAI A–B (warm + wet) only
  • echocardiogram_for_lv_rv_function_pericardial_effusionrequired
    imaging • used at INITIAL_WORKUP
    LV systolic function (regional vs global hypokinesis), RV involvement, pericardial effusion (myopericarditis common), LV thrombus screen if severe dysfunction; serial echo for recovery monitoring
  • cardiac_troponinrequired
    lab • used at INITIAL_WORKUP
    Elevated in active myocarditis (released from injured myocytes); persistent elevation >2 wk portends worse outcome (ESC 2013 Caforio); peak proportional to injury extent
  • bnp_or_nt_probnprequired
    lab • used at INITIAL_WORKUP
    Marker of HF severity; 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 + statin safety
  • viral_pcr_panel_serum_and_nasopharyngeal
    lab • used at BRANCHING_WORKUP
    Parvovirus B19, coxsackievirus, enterovirus, adenovirus, HHV-6, SARS-CoV-2, influenza (seasonal additions); guides etiologic differential + adjusts antiviral candidacy
  • cardiac_mri_with_lake_louise_2018_criteria
    imaging • used at BRANCHING_WORKUP
    Gold standard noninvasive diagnosis: T2 mapping + edema imaging for active inflammation; LGE in non-ischemic pattern (mid-wall, subepicardial — distinguishes from CAD); native T1 mapping for diffuse fibrosis; LGE persistence at follow-up MRI portends worse prognosis (Mahrholdt PMID 16847141)
  • ecg_for_arrhythmia_st_changes_av_blockrequired
    imaging • used at INITIAL_WORKUP
    ECG abnormalities in 85%+ of myocarditis (any T-wave change, ST elevation/depression, low voltage, AV block, VT/VF); persistent QRS prolongation or AV block portends worse prognosis
  • screen_for_giant_cell_eosinophilic_sarcoid_myocarditis_etiology_altering
    history • used at BRANCHING_WORKUP
    These specific etiologies have dedicated treatment (immunosuppression for giant cell/sarcoid; steroids ± targeted therapy for eosinophilic) and route to dedicated dossiers; identification triggers EMB for definitive diagnosis per Cooper 2007 IB criteria

12-phase flow (10)

  1. 1FRAME
    Viral cardiomyopathy / myocarditis ADHF (non-shock): viral injury → LV dysfunction + congestion; supportive ADHF management; standard GDMT cautiously; AVOID NSAIDs; identify etiology-altering subsets (giant cell, eosinophilic, sarcoid → separate dossiers); recovery possible especially parvovirus
    inputs: echocardiogram_for_lv_rv_function_pericardial_effusion
    advance: viral myocarditis ADHF framed
  2. 2ENTRY
    Recognize ADHF presentation in viral context; bedside echo for LV function; ECG + troponin; SCAI shock screen (route to shock dossier if C+); admit telemetry/cardiology
    inputs: sbp_dbp_hr_for_perfusion_and_shock_screen, echocardiogram_for_lv_rv_function_pericardial_effusion
    advance: shock excluded + admission decided
  3. 3CONTEXT
    Viral prodrome timeline; chronic DCM history; immunization status; immunocompromised state (HIV, transplant); medications (ICI, anthracyclines — route to oncology-cardiotoxicity dossiers if applicable); CTD history
    inputs: age, recent_viral_illness_or_prior_myocarditis_history, creatinine_egfr_with_lfts
    advance: context complete
  4. 4RED_FLAGS
    Progression to fulminant requiring MCS (route to shock dossier); high-grade AV block requiring temporary pacing; sustained VT/VF requiring ACLS + ICD eval; suspected giant cell or eosinophilic myocarditis (route to dedicated dossier with EMB); COVID-MIS-A overlap (multi-organ involvement)
    inputs: sbp_dbp_hr_for_perfusion_and_shock_screen, ecg_for_arrhythmia_st_changes_av_block
    actions: acute_pulm_edema, cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    CBC + BMP + LFTs + troponin + BNP/NT-proBNP + ESR/CRP + lactate + ECG + CXR + bedside echo (LV/RV function, pericardial effusion, thrombus screen); telemetry; viral PCR panel (serum + NP swab) + influenza/COVID per season
    inputs: echocardiogram_for_lv_rv_function_pericardial_effusion, cardiac_troponin, bnp_or_nt_probnp, ecg_for_arrhythmia_st_changes_av_block
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Cardiac MRI with Lake Louise 2018 criteria for definitive non-ischemic myocarditis diagnosis; coronary CTA or angiography to exclude CAD if intermediate-risk; viral PCR panel results; EMB SELECTIVELY per Cooper 2007 IB indications (new HF <2 wk + hemodynamic compromise; new HF 2 wk–3 mo + VT/AV block/no response; suspected giant cell/eosinophilic/sarcoid — these route out to dedicated dossiers)
    inputs: cardiac_mri_with_lake_louise_2018_criteria, viral_pcr_panel_serum_and_nasopharyngeal, screen_for_giant_cell_eosinophilic_sarcoid_myocarditis_etiology_altering
    advance: etiology established + RCM/CAD excluded
  7. 7TREATMENT
    Standard ADHF: IV loop diuretic (furosemide 40–80 mg IV diuretic-naive starting dose per DOSE PMID 21366472; titrate to UOP); supplemental O2; gentle vasodilator (nitroglycerin) if hypertensive; INITIATE GDMT 4-pillar cautiously (ARNI/ACEi + BB + MRA + SGLT2i) — some experts delay BB during ACTIVE inflammation (no RCT but reasonable per AHA 2020 PMID 32200645); AVOID NSAIDs (worsen outcomes per AHA 2020); SUPPORTIVE — no antiviral with proven cardiac benefit; oseltamivir for influenza systemically reasonable; remdesivir for COVID systemically; corticosteroids ONLY if virus-negative biopsy per TIMIC PMID 19651620 OR Lyme/eosinophilic subset (separate dossier); arrhythmia mgmt with BB + amiodarone (avoid class I); WCD if EF <35 during 3–6 mo recovery window
    inputs: cardiac_troponin, bnp_or_nt_probnp
    advance: ADHF stabilized + GDMT initiated
  8. 8DISPOSITION
    Cardiology floor for stable ADHF; CICU if hemodynamically borderline or arrhythmia; transition to outpatient with close cardiology follow-up + activity restriction; transplant referral pre-discussion if persistent severe dysfunction
    advance: unit + GDMT + activity-restriction plan documented
  9. 9MONITORING
    Continuous telemetry (arrhythmia surveillance); daily weight + I/O; daily BMP for diuresis safety + GDMT initiation; serial troponin trend (persistent elevation = ongoing injury); echo at d/c + 3 mo + 6 mo for recovery; cardiac MRI at 3–6 mo if initial positive (LGE persistence prognostic); activity restriction 3–6 mo from diagnosis (no competitive sports per Maron PMID 26621650)
    inputs: cardiac_troponin, bnp_or_nt_probnp
    actions: panel.cardiac, panel.renal
    advance: monitoring active
  10. 10FOLLOWUP
    Cardiology follow-up at 1–2 wk + 3 mo + 6 mo + 12 mo; serial echo + cardiac MRI at 3–6 mo; ICD evaluation at 3–6 mo if EF persistently <35; transplant referral if end-stage despite optimized GDMT; activity clearance for return-to-play after 3–6 mo + normal echo + MRI + exercise stress test + holter (per Maron 2015 PMID 26621650 sports cardiology)
    advance: long-term plan + activity-restriction documented