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cardio.acute-hf.with-af-rvr.v1

Acute decompensated HF complicated by atrial fibrillation with rapid ventricular response

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E wave 8 cross-system synthesis composite — ADHF + AF-RVR mutually-amplifying co-morbidity. Inherits decongestion arc from cardio.acute-hf.core.v1 + chronic AF arc from cardio.afib.core.v1 via routing; specializes for the EF-stratified rate-control drug choice (diltiazem avoided in HFrEF), DOAC initiation per CHA₂DS₂-VASc (almost always ≥2 in HF cohort), Mg/K repletion, and ablation referral per CASTLE-AF. Composite physiology: AF-RVR triggers HF decompensation (loss of atrial kick + tachycardia-mediated reduced filling), HF decompensation triggers AF (atrial stretch + neurohormonal activation + electrolyte derangement); each amplifies the other; treating only one without considering the partner yields recurrent decompensation. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (composite-specific differences documented inline in this dossier). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E wave 8 cross-system synthesis composite.

Entry points (3)

  • symptom
    ADHF presentation + AF on ECG with HR ≥110 bpm — composite engine activates
    adhf_with_new_or_uncontrolled_af_rvr
  • imaging
    Known HF patient + new AF-RVR (HR ≥110) on 12-lead ECG → mutually-amplifying decompensation
    ecg_af_with_rvr_in_known_hf
  • lab_abnormality
    Elevated NT-proBNP for age + AF-RVR — composite physiology (loss of atrial kick + tachycardia-mediated)
    nt_probnp_elevated_with_af

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age drives CHA₂DS₂-VASc stroke risk + DOAC dose adjustment + lenient vs strict rate target
  • sbprequired
    vital • used at RED_FLAGS
    HD-unstable (SBP <90 + AF-RVR) → STAT DCCV per ACC/AHA 2024 Class I; SCAI staging if persistent
  • hrrequired
    vital • used at CONTEXT
    Defines RVR (≥110 bpm); rate target lenient <110 per RACE II if EF preserved + asymptomatic; strict <80 if symptomatic
  • spo2required
    vital • used at RED_FLAGS
    Hypoxia from pulmonary edema + tachycardia-mediated reduced filling; NIPPV indication per 3CPO
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    12-lead confirms AF-RVR (irregularly irregular without P waves), excludes flutter, screens for ischemic ECG as composite precipitant
  • echo_lvefrequired
    imaging • used at DIFFERENTIAL
    EF stratifies drug choice — diltiazem relatively contraindicated in HFrEF; digoxin + metoprolol preferred; LA size for ablation candidacy per CASTLE-AF
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    Confirms HF component + decongestion target; trended to assess response
  • creatininerequired
    lab • used at CONTEXT
    eGFR for DOAC dose (apixaban 2.5 BID if 2 of 3 criteria; dabigatran avoid <30); diuretic dosing
  • potassiumrequired
    lab • used at CONTEXT
    Goal K ≥4 to suppress AF; MRA + ARNI dosing risk; arrhythmogenic if low
  • magnesiumrequired
    lab • used at CONTEXT
    Goal Mg ≥2 to suppress AF; empiric repletion in decompensation
  • tshrequired
    lab • used at BRANCHING_WORKUP
    Hyperthyroidism is classic reversible AF precipitant — must screen at first presentation
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Ischemia as composite precipitant; demand ischemia from RVR can drive type-2 NSTEMI
  • current_anticoagulationrequired
    history • used at CONTEXT
    On AC vs not changes DCCV strategy + bleed risk; check INR if warfarin, last DOAC dose timing
  • cha2ds2_vasc_score
    history • used at TREATMENT
    Stroke risk stratification — nearly always ≥2 in HF cohort (HF=+1, age≥65=+1-2); drives DOAC initiation
  • precipitant_screen
    history • used at BRANCHING_WORKUP
    Beyond AF — thyroid, ischemia, infection, NSAID, EtOH, non-adherence drive co-management

12-phase flow (12)

  1. 1FRAME
    Composite engine: ADHF + AF-RVR mutually amplify (loss of atrial kick + tachycardia-mediated reduced diastolic filling vs atrial stretch + neurohormonal activation); both engines must run; route to cardio.acute-hf.core.v1 for decongestion + cardio.afib.core.v1 for chronic rate/rhythm/AC
    inputs: ecg, echo_lvef
    advance: composite physiology confirmed
  2. 2ENTRY
    Cardiology consult; if HD-unstable → STAT synchronized DCCV per ACC/AHA 2024 AF Class I; if HD-stable + symptomatic → IV rate control with EF-stratified drug choice
    inputs: age, sbp, hr
    advance: cardiology + DCCV decision documented
  3. 3CONTEXT
    EF, current AC status, K + Mg, TSH (must check at first presentation), home HF/AF regimen, recent EtOH/NSAID/non-adherence
    inputs: echo_lvef, creatinine, potassium, magnesium, current_anticoagulation
    advance: composite context complete
  4. 4RED_FLAGS
    HD-unstable AF-RVR with hypotension (SBP <90) + ADHF → STAT DCCV; cardiogenic shock (SCAI C+) → MCS pathway; severe pulmonary edema → NIPPV per 3CPO; refractory rate control + worsening congestion → escalation to amiodarone or rhythm control
    inputs: sbp, spo2
    actions: cardiogenic_shock, acute_pulm_edema
    advance: red flags screened + immediate stabilization documented
  5. 5INITIAL_WORKUP
    12-lead ECG (confirm AF-RVR + screen ischemia); BMP + Mg + troponin + TSH + NT-proBNP; bedside echo (LVEF + LA size + RV + valvular); CXR + lung US (pulmonary edema, alternate diagnosis)
    inputs: ecg, nt_probnp, creatinine, potassium, magnesium, tsh, troponin
    actions: acute_pulm_edema, afib_new_onset, panel.cardiac, panel.renal
    advance: composite workup documented + EF determined
  6. 6BRANCHING_WORKUP
    Identify decompensation precipitant: thyroid (TSH), ischemia (troponin trend), infection (CBC/cultures), NSAID/EtOH/non-adherence; if AF newly diagnosed → assess for DCCV vs rate-control strategy per RACE-7 ACWAS
    inputs: precipitant_screen, tsh, troponin
    actions: acs_pathway
    advance: precipitant identified or empirical management initiated
  7. 7DIFFERENTIAL
    Stratify by EF — HFrEF (EF <40) vs HFmrEF (40-49) vs HFpEF (≥50) drives drug choice (diltiazem avoided in HFrEF; digoxin + metoprolol preferred); LA size + AF duration drive ablation candidacy per CASTLE-AF
    inputs: echo_lvef
    advance: EF phenotype assigned + drug-choice strategy documented
  8. 8RISK_STRATIFICATION
    CHA₂DS₂-VASc for stroke risk (almost always ≥2 in HF cohort → DOAC); HAS-BLED for bleed (does not preclude AC, identifies modifiable risks); MAGGIC for HF mortality; SCAI staging if hypoperfused
    inputs: age, sbp
    advance: risk class + AC decision documented
  9. 9TREATMENT
    Composite treatment: (1) IV loop diuretic 2-2.5× home dose per DOSE for decongestion; (2) EF-stratified rate control — IV metoprolol 5 mg q5 min × 3 if EF preserved; IV metoprolol + digoxin if EF reduced; AVOID diltiazem in HFrEF; (3) Mg 2 g IV + K to ≥4; (4) DOAC initiation per CHA₂DS₂-VASc (apixaban preferred per ARISTOTLE); (5) DCCV if rate refractory or HD-unstable; (6) consider amiodarone only if refractory + DCCV not feasible; (7) in-hospital GDMT (ARNI/BB/MRA/SGLT2i) per PIONEER-HF/EMPULSE; (8) TSH-driven thyroid management
    inputs: echo_lvef, creatinine, potassium, cha2ds2_vasc_score
    actions: protocol.cardiogenic_shock
    advance: rate/rhythm controlled + decongestion active + DOAC initiated + GDMT plan documented
  10. 10DISPOSITION
    CICU/telemetry if HD-unstable, refractory rate control, post-DCCV monitoring; floor with telemetry if stable; STRONG-HF cadence with cardiology + EP follow-up at 1 week
    advance: unit assigned + telemetry + handoff to AF + HF chronic engines
  11. 11MONITORING
    Continuous telemetry; daily weight, I/O, BMP q24h with K + Mg repletion; NT-proBNP trend; HR target lenient <110 per RACE II if asymptomatic; INR or DOAC adherence; TSH trend if hyperthyroid
    inputs: creatinine, potassium, magnesium
    actions: panel.renal
    advance: composite monitoring plan documented
  12. 12FOLLOWUP
    Cardiology + EP at 1 week per STRONG-HF; ablation candidacy assessment per CASTLE-AF (consider after compensated, especially HFrEF); chronic AC continuation; chronic GDMT up-titration; thyroid follow-up if abnormal
    advance: AC continued + cardiology + EP + thyroid follow-up booked + ablation referral if HFrEF + persistent AF