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cardio.acute-hf.acute-decompensated-on-chronic.v1PRODUCTION
cardio.acute-hf.acute-decompensated-on-chronic.v1

Acute HF — acute decompensation on chronic HF

cardiologyacuteadult
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10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute decompensation of pre-existing HF; identify precipitant + escalate IV diuresis at 2-2.5× home dose; continue chronic GDMT in most cases

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acute-on-chronic phenotype confirmed

Patient inputs (9)

Med adherence, dietary indiscretion, infection, AF, ACS, HTN, NSAIDs — drives precipitant-specific co-management

Older patients with chronic HF have higher readmission risk + complex polypharmacy

Compare to baseline; cardiorenal adjustment of GDMT

Chronic MRA + ACEi/ARNI exposure → K monitoring critical

Baseline EF determines GDMT eligibility (HFrEF vs HFpEF) and prognosis

Compare to patient baseline (chronic HF patients have elevated baseline); >50% rise from baseline is significant

Wet-warm vs wet-cold profile; chronic HF patients often have low baseline SBP — context-dependent thresholds

IV escalation at 2-2.5× home dose per DOSE; chronic patients often have escalating outpatient diuretic doses

Document chronic ARNI/BB/MRA/SGLT2i + doses; in-hospital optimization opportunity per PIONEER-HF

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Severity triggers (4)

4 need judgement
  • informationallife_threateningacute_on_chronic_with_acs_precipitant
    Acute decompensation in chronic HF + new ECG changes + troponin rise → ACS as precipitant
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_on_chronic_with_cardiogenic_shock
    Acute-on-chronic HF + SBP <90 + lactate ≥2 + hypoperfusion — high mortality
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_on_chronic_with_severe_hyperkalemia_on_chronic_mra
    K >6.0 with EKG changes during acute-on-chronic HF on chronic MRA + ACEi/ARNI exposure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_readmission_within_30d_with_adherence_issue
    HF readmission within 30 days with documented medication non-adherence (40% of readmissions)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute-on-chronic HF — IV diuresis + CONTINUE chronic GDMT + in-hospital ARNI optimization (DOSE; PIONEER-HF; B-CONVINCED; EMPULSE; STRONG-HF)
axis: acute_on_chronic_hf_continue_optimize_gdmt_phenotype
Selected axis "Acute-on-chronic HF — IV diuresis + CONTINUE chronic GDMT + in-hospital ARNI optimization (DOSE; PIONEER-HF; B-CONVINCED; EMPULSE; STRONG-HF)" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    IV bolus at 2-2.5× home PO dose; if home 80 mg PO daily then 160-200 mg IV q12h or continuous 10-20 mg/h • IV • q6-12h or continuous
    triggers: acute_decompensation_with_congestion
    DOSE PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; assess UOP at 2h; chronic patients often need higher doses
    rxcui 4603
  • torsemide
    second line
    loop_diuretic
    20-40 mg IV (or 100% oral bioavailability if PO) • IV/PO • BID
    triggers: gut_edema_with_furosemide_resistance
    TRANSFORM-HF (Mentz JAMA 2023) — equivalent outcomes vs furosemide; better PO bioavailability if gut edema
    rxcui 38413
  • acetazolamide
    add on
    CA_inhibitor_diuretic
    500 mg IV daily × 3 days • IV • daily × 3
    triggers: inadequate_loop_response, metabolic_alkalosis
    ADVOR PMID 36027564 — adjunct to IV loop improves decongestion at 3 days
    rxcui 167
  • sacubitril-valsartan
    first line
    arni
    CONTINUE home dose; if not on ARNI then start 24/26 BID per PIONEER-HF (24h post-AHF, SBP ≥100, K <5.2, eGFR ≥30) • PO • BID
    triggers: hfref_chronic_or_in_hospital_initiation
    PIONEER-HF PMID 30403955 — in-hospital ARNI initiation/optimization safe + reduces NT-proBNP + 8-week mortality
    rxcui 1656328
  • carvedilol
    first line
    beta_blocker
    CONTINUE home dose if hemodynamically tolerant (SBP ≥90, HR >60); reduce dose 50% only if hypotensive/bradycardic; do NOT discontinue • PO • BID
    triggers: chronic_bb_tolerated
    B-CONVINCED (Jondeau 2009) + COPERNICUS PMID 11386262 — chronic BB withdrawal during ADHF associated with worse outcomes
    rxcui 20352
  • spironolactone
    first line
    mra
    CONTINUE home dose if K <5 + eGFR ≥30; reduce 50% if K 5.0-5.4 • PO • daily
    triggers: hfref_chronic_mra_tolerated
    EMPHASIS-HF PMID 21073363 + RALES PMID 10471456
    rxcui 9997
  • empagliflozin
    first line
    sglt2_inhibitor
    CONTINUE 10 mg PO daily if eGFR >20; if not on SGLT2i then START in-hospital per EMPULSE • PO • daily
    triggers: hf_chronic_or_in_hospital_initiation
    EMPULSE PMID 35347356 — in-hospital initiation/continuation reduces 90-day mortality + readmit
    rxcui 1545653
  • dapagliflozin
    first line
    sglt2_inhibitor
    10 mg PO daily • PO • daily
    triggers: hf_chronic_alternative_to_empa
    DAPA-HF + DELIVER — alternative SGLT2i
    rxcui 1488564
  • nitroglycerin
    add on
    organic_nitrate
    5-200 µg/min IV titrate • IV • continuous
    triggers: hypertensive_decompensation_sbp_above_140, flash_pulmonary_edema
    Afterload reduction in HTN urgency precipitant; ESC 2021 Class IIa
    rxcui 4917

outpatient playbook — drug actions (1)

  1. 1. continue 4-pillar GDMT at max tolerated
    rxcui 593411
    ARNI + BB + MRA + SGLT2i at max • PO • as scheduled
    trigger: HFrEF
    ACC/AHA 2022 HF Class I (PMID 35363499)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Known HFrEF + new dyspnea/edema/weight gain → acute-on-chronic decompensation; Known HFpEF + new dyspnea/edema → acute-on-chronic HFpEF decompensation; HF readmission within 30 days → high-risk acute-on-chronic with precipitant audit mandatory.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute HF — acute decompensation on chronic HF** (cardio.acute-hf.acute-decompensated-on-chronic.v1).
Scope: Acute decompensation of pre-existing HF; identify precipitant + escalate IV diuresis at 2-2.5× home dose; continue chronic GDMT in most cases

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute-on-chronic HF — IV diuresis + CONTINUE chronic GDMT + in-hospital ARNI optimization (DOSE; PIONEER-HF; B-CONVINCED; EMPULSE; STRONG-HF)**.
1. furosemide IV bolus at 2-2.5× home PO dose; if home 80 mg PO daily then 160-200 mg IV q12h or continuous 10-20 mg/h IV q6-12h or continuous (loop_diuretic, first line) — DOSE PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; assess UOP at 2h; chronic patients often need higher doses
2. torsemide 20-40 mg IV (or 100% oral bioavailability if PO) IV/PO BID (loop_diuretic, second line) — TRANSFORM-HF (Mentz JAMA 2023) — equivalent outcomes vs furosemide; better PO bioavailability if gut edema
3. acetazolamide 500 mg IV daily × 3 days IV daily × 3 (CA_inhibitor_diuretic, add on) — ADVOR PMID 36027564 — adjunct to IV loop improves decongestion at 3 days
4. sacubitril-valsartan CONTINUE home dose; if not on ARNI then start 24/26 BID per PIONEER-HF (24h post-AHF, SBP ≥100, K <5.2, eGFR ≥30) PO BID (arni, first line) — PIONEER-HF PMID 30403955 — in-hospital ARNI initiation/optimization safe + reduces NT-proBNP + 8-week mortality
5. carvedilol CONTINUE home dose if hemodynamically tolerant (SBP ≥90, HR >60); reduce dose 50% only if hypotensive/bradycardic; do NOT discontinue PO BID (beta_blocker, first line) — B-CONVINCED (Jondeau 2009) + COPERNICUS PMID 11386262 — chronic BB withdrawal during ADHF associated with worse outcomes
6. spironolactone CONTINUE home dose if K <5 + eGFR ≥30; reduce 50% if K 5.0-5.4 PO daily (mra, first line) — EMPHASIS-HF PMID 21073363 + RALES PMID 10471456
7. empagliflozin CONTINUE 10 mg PO daily if eGFR >20; if not on SGLT2i then START in-hospital per EMPULSE PO daily (sglt2_inhibitor, first line) — EMPULSE PMID 35347356 — in-hospital initiation/continuation reduces 90-day mortality + readmit
8. dapagliflozin 10 mg PO daily PO daily (sglt2_inhibitor, first line) — DAPA-HF + DELIVER — alternative SGLT2i
9. nitroglycerin 5-200 µg/min IV titrate IV continuous (organic_nitrate, add on) — Afterload reduction in HTN urgency precipitant; ESC 2021 Class IIa

Setting playbook (outpatient) — Long-term HF management with ongoing adherence support + GDMT optimization + ICD/CRT eligibility per MADIT/CARE-HF + cardiac rehab maintenance
10. continue 4-pillar GDMT at max tolerated ARNI + BB + MRA + SGLT2i at max PO as scheduled — HFrEF (ACC/AHA 2022 HF Class I (PMID 35363499))

Non-pharmacologic actions:
- ICD evaluation if EF ≤35 despite GDMT × 3 mo (MADIT-II/SCD-HeFT)
- CRT if QRS ≥150 ms with LBBB + EF ≤35 (CARE-HF/MADIT-CRT)
- Cardiac rehab maintenance
- Influenza + pneumococcal + RSV vaccines
- Adherence support

AVOID / contraindication checks:
- Do_not_withdraw_chronic_bb_during_adhf_unless_hypotensive (B CONVINCED PMID 19261681; COPERNICUS)
- Do_not_withdraw_chronic_arni_acei_unless_severe_aki_or_hypotension (PIONEER HF + ACC/AHA 2022)
- Hold_mra_if_k_above_5.5 (RALES)
- Continue_sglt2i_if_egfr_above_20_unless_dka_risk (EMPULSE; ACC/AHA 2022)
- Avoid_nsaids_in_chronic_hf (precipitant of decompensation)
- Reduce_arni_dose_50_percent_if_severe_aki_then_restart (KDIGO AKI)

Monitoring

Regimen monitoring:
- daily weight morning (decongestion endpoint)
- hourly uop x 24h then q4h (titrate diuretic)
- BMP q12-24h during diuresis (K, Cr trend)
- nt probnp at admission 48h 72h pre discharge (PIONEER-HF biomarker target)
- lung us at 24-48h for residual b lines (objective congestion)
- precipitant audit documented (med adherence, diet, infection, AF, ACS, HTN, NSAIDs, anemia, thyroid)
- echo pre discharge if no recent (LVEF reassessment)
- STRONG-HF pre discharge cadence booked at 1wk then biweekly x 6wk

Setting (outpatient) monitoring:
- Quarterly NT-proBNP + BMP
- Annual echo + 6MWT

Follow-up plan: Discharge with intensified GDMT (PIONEER-HF in-hospital ARNI start/up-titration); STRONG-HF cadence (1 wk post-d/c + biweekly × 6 wk); cardiac rehab; precipitant-specific follow-up (e.g., adherence support, AF clinic, dietitian)
- Close-out criterion: STRONG-HF + cardiac rehab + precipitant follow-up booked

Monitoring phase: Daily weight, hourly UOP × 24h then q4h, BMP q12-24h, NT-proBNP at 48-72h + pre-discharge, lung US for residual congestion

Disposition

Current setting: outpatient — Long-term HF management with ongoing adherence support + GDMT optimization + ICD/CRT eligibility per MADIT/CARE-HF + cardiac rehab maintenance

Disposition criteria:
- Long-term continuation; cross-link to cardio.hfref.core.v1 or cardio.hfpef.core.v1

Escalation triggers (move to higher acuity):
- Recurrent decompensation → reassess GDMT + advanced HF eval
- EF declining despite max GDMT → LVAD/transplant evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute decompensation in chronic HF + new ECG changes + troponin rise → ACS as precipitant
- [LIFE_THREATENING] Acute-on-chronic HF + SBP <90 + lactate ≥2 + hypoperfusion — high mortality
- [LIFE_THREATENING] K >6.0 with EKG changes during acute-on-chronic HF on chronic MRA + ACEi/ARNI exposure

Citations

- 2022 ACC/AHA HF + 2023 Focused Update [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 38264914) [PMID:38264914](https://pubmed.ncbi.nlm.nih.gov/38264914/)
- Cited evidence (PMID 21366472) [PMID:21366472](https://pubmed.ncbi.nlm.nih.gov/21366472/)
- Cited evidence (PMID 30403955) [PMID:30403955](https://pubmed.ncbi.nlm.nih.gov/30403955/)
- Cited evidence (PMID 35347356) [PMID:35347356](https://pubmed.ncbi.nlm.nih.gov/35347356/)

Last reconciled with current guidelines: 2026-05-14.
References