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cardio.acute-hf.with-cardiogenic-shock.v1

ADHF complicated by cardiogenic shock (composite)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E cross-system synthesis composite — ADHF + cardiogenic shock concurrent management. Both cardio.acute-hf.core.v1 and cardio.cardiogenic-shock.core.v1 run concurrently; this composite engine encodes the decongestion-vs-perfusion tension management and the GDMT-resumption sequencing (HOLD chronic during shock; resume as perfusion restored per STRONG-HF cadence). Authored 2026-05-14 by shard-06-cardio-acute orchestrator-direct (subagent quota exhausted, resets 21:20 EDT). Reuses cardio.acute-hf.core.v1 manifest + design_brief pointers. Status INTEGRATED until terminology + RxNav drug-code validation (DB-blocked) — RxCUIs sourced from sibling cardio.acute-hf.core.v1 + cardio.cardiogenic-shock.core.v1 dossiers. Routes via cardio-acute-panel-router fallback to AcuteHfPanel + CardiogenicShockPanel; cross-system handoffs documented in sibling_differentiation arrays.

Entry points (4)

  • symptom
    ADHF + SBP <90 sustained or vasopressor-dependent — SCAI B+ shock complication
    adhf_with_persistent_hypotension
  • symptom
    ADHF + cool extremities + lactate ≥2 + AKI + AMS — Nohria-Stevenson cold-wet profile
    adhf_with_hypoperfusion_signs
  • lab_abnormality
    ADHF + serial lactate rising despite IV diuretic — perfusion failure pattern
    adhf_with_rising_lactate
  • imaging
    ADHF with new severely reduced LVEF on bedside echo + low-output state
    adhf_with_severe_lv_dysfunction_new

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher CS-complication risk + worse advanced-HF candidacy
  • prior_hf_diagnosisrequired
    history • used at CONTEXT
    Acute-on-chronic vs de novo; prior GDMT regimen guides resumption
  • precipitant_screen
    history • used at BRANCHING_WORKUP
    ACS / arrhythmia / infection / non-adherence / drug-toxicity precipitants drive co-management
  • sbprequired
    vital • used at RED_FLAGS
    SCAI staging + perfusion threshold; MAP target ≥65
  • hrrequired
    vital • used at RED_FLAGS
    Tachycardia component of shock index; BB tolerance gating
  • spo2required
    vital • used at RED_FLAGS
    Concurrent respiratory failure + hyperoxia avoidance + NIPPV indication
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue-hypoperfusion marker + clearance trajectory drives MCS escalation
  • creatininerequired
    lab • used at CONTEXT
    Cardiorenal syndrome (Type-1 CRS); diuretic + DOAC + drug renal-dose adjustment
  • potassiumrequired
    lab • used at CONTEXT
    Diuresis-driven hypoK + GDMT MRA gating + arrhythmia risk
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    ADHF severity + decongestion trajectory + risk stratification
  • troponinrequired
    lab • used at INITIAL_WORKUP
    ACS precipitant rule-out (very common in CS-complicating ADHF)
  • echo_urgentrequired
    imaging • used at INITIAL_WORKUP
    LV/RV function, valvular acute regurg, tamponade, mechanical complication — drives MCS choice
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Ischemia precipitant + AF/RVR vs SR + QRS prolongation for CRT eligibility

12-phase flow (12)

  1. 1FRAME
    ADHF complicated by SCAI B+ cardiogenic shock — both engines (acute-HF + cardiogenic-shock) run CONCURRENTLY; decongestion-vs-perfusion tension is the central management decision
    inputs: sbp, lactate
    advance: composite eligibility confirmed (ADHF + shock physiology)
  2. 2ENTRY
    Mobilize CICU + cardiology + advanced HF team; bedside echo + ECG within 10 min
    inputs: age
    advance: CICU bed + multidisciplinary team activated
  3. 3CONTEXT
    Prior HF diagnosis, prior GDMT, prior MCS, advance directives, code status, advanced-HF candidacy (LVAD/transplant eligibility)
    inputs: prior_hf_diagnosis, sbp, creatinine, potassium
    advance: context complete + GOC documented
  4. 4RED_FLAGS
    SCAI C/D/E shock requiring MCS escalation; ACS precipitant; recurrent VT/VF; mechanical complication (papillary rupture / VSR / free-wall); refractory hyperK on GDMT
    inputs: sbp, lactate, potassium
    actions: cardiogenic_shock, acs_pathway
    advance: red flags screened + escalation team notified
  5. 5INITIAL_WORKUP
    NT-proBNP, troponin, BMP, lactate, ABG, CBC, coag, CXR, urgent echo (LV/RV/valvular/tamponade), 12-lead ECG, urine drug screen if etiology unclear
    inputs: nt_probnp, troponin, lactate, creatinine, potassium, echo_urgent, ecg
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup complete + Nohria-Stevenson profile assigned + SCAI stage documented
  6. 6BRANCHING_WORKUP
    Identify precipitant — ACS (cath if STEMI/NSTEMI), arrhythmia (rate/rhythm control), severe valvular acute regurg (emergent surgery), infection (sepsis bundle), drug toxicity (treat trigger)
    inputs: precipitant_screen
    advance: precipitant identified or empirical management initiated
  7. 7DIFFERENTIAL
    Cold-wet vs cold-dry vs warm-wet shock variant; SCAI A-E staging; HFrEF vs HFpEF; etiology phenotype (ischemic / non-ischemic / valvular / inflammatory)
    inputs: echo_urgent
    advance: profile + SCAI stage + etiology documented
  8. 8RISK_STRATIFICATION
    CardShock score (Harjola PMID 26333869) — 6-tier mortality stratification: age + AMS + prior CABG + ACS + LVEF + GCS + lactate; MAGGIC for chronic background risk; SCAI stage drives MCS escalation
    inputs: sbp, lactate, creatinine
    actions: calc.map, calc.maggic
    advance: risk class + escalation threshold documented
  9. 9TREATMENT
    CONCURRENT: (1) MAP ≥65 with norepinephrine titration (SOAP-II PMID 20200382); (2) inotrope dobutamine 2.5-10 µg/kg/min if low CI (or milrinone if BB-dependent); (3) MCS escalation per DanGer Shock PMID 38587234 — Impella CP for SCAI C; VA-ECMO for SCAI D-E; (4) DECONGESTION carefully — IV loop diuretic ONLY after MAP restored to ≥65 (DOSE PMID 21366472); (5) HOLD chronic GDMT (BB, ARNI, MRA) during shock; resume sequentially as perfusion restored; (6) in-hospital ARNI per PIONEER-HF + SGLT2i per EMPULSE only after off inotropes
    inputs: sbp, creatinine, potassium
    actions: protocol.cardiogenic_shock
    advance: perfusion restored + decongestion underway + GDMT resumption plan documented
  10. 10DISPOSITION
    CICU mandatory; advanced HF program transfer if SCAI D/E or LVAD/transplant candidate; cardiac-surgery consult if mechanical complication
    advance: unit + advanced-HF team consulted + transfer plan if indicated
  11. 11MONITORING
    Continuous arterial line + central line + Foley + telemetry; lactate q2-4h; BMP q6-12h; daily echo for LV recovery + thrombus screen; right heart cath if refractory shock for hemodynamic-guided titration
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring plan + escalation thresholds documented
  12. 12FOLLOWUP
    Advanced-HF clinic follow-up; GDMT 4-pillar resumption per STRONG-HF cadence; ICD/CRT eligibility per LVEF at 40-90 d; LVAD/transplant evaluation if persistent advanced HF; cardiac rehab; mental health (high PTSD risk in CS survivors)
    advance: advanced-HF + EP + cardiac-rehab + mental-health follow-up booked