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cardio.acute-hf.alcoholic-cardiomyopathy.v1PRODUCTION
cardio.acute-hf.alcoholic-cardiomyopathy.v1

Acute HF — alcoholic cardiomyopathy

cardiologyacuteadult
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12/12 authored

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

Current phase

Frame

Detailed

Dilated CMP + chronic heavy alcohol use + no obstructive CAD/HTN/valvular cause → alcoholic cardiomyopathy phenotype; thiamine + abstinence are foundation of treatment

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ACM framed

Patient inputs (14)

Middle-aged men predominantly; women susceptible at lower thresholds; age informs withdrawal severity prediction

Threshold for ACM: >80 g/d men, >40 g/d women, >10 yr; quantify with standard drink units; duration informs reversibility potential

AUDIT-C ≥4 in men or ≥3 in women suggests AUD; informs CIWA risk and AUD treatment urgency (Bush JAMA Intern Med 1998)

eGFR for drug dosing (especially loop diuretic, ARNI/ACEi, SGLT2i); KDIGO 2021 race-free

Nutritional deficiency cluster from chronic alcohol; thiamine deficiency drives Wernicke risk; magnesium repletion reduces seizure risk in withdrawal

Concurrent alcoholic liver disease very common; AST:ALT >2 supports alcoholic etiology; INR + albumin assess synthetic function; affects drug metabolism + bleeding risk

Macrocytic anemia (MCV >100) common in alcoholism (folate/B12/direct toxicity); thrombocytopenia from marrow suppression or splenomegaly

Diagnose HF + risk stratify; trend with diuresis

Rule out acute MI; persistently elevated in chronic CMP

Dilated LV with reduced EF, eccentric remodeling; rule out valvular + segmental wall motion (CAD) abnormalities; baseline for recovery tracking

Withdrawal symptoms 6–12 h after last drink, peak 24–72 h; DTs at 48–96 h; informs CIWA monitoring schedule and prophylaxis

Prior delirium tremens or seizure dramatically increases recurrence risk; warrants ICU-level monitoring + scheduled prophylactic benzodiazepine

BP affects ARNI/ACEi initiation; volume status; hypotension during withdrawal complicates GDMT initiation

Dilated CMP without ischemic LGE pattern supports ACM diagnosis; excludes ischemic, amyloid, sarcoid, myocarditis mimics; baseline LV mass and ECV

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateningwernicke_encephalopathy_features
    Confusion + ataxia + ophthalmoplegia (often only 1 of 3 present) in patient with AUD or malnutrition — Wernicke encephalopathy emergency
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_alcohol_withdrawal_ciwa_above_15
    Active alcohol withdrawal with CIWA-Ar >15 (severe) or seizure or delirium tremens
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecovery_vs_continued_drinking_decision
    Discharge or follow-up decision point — patient capacity for abstinence determines prognosis (50%+ LVEF recovery if abstinent vs ~50% mortality at 4 yr if continued drinking)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethiamine_before_glucose_protocol_violation
    IV glucose (D5 fluids, dextrose for hypoglycemia, parenteral nutrition) given without prior thiamine in patient with AUD or malnutrition
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Alcoholic cardiomyopathy ADHF — thiamine + withdrawal management + GDMT + abstinence regimen
axis: alcoholic_cmp_thiamine_abstinence_gdmt
Selected axis "Alcoholic cardiomyopathy ADHF — thiamine + withdrawal management + GDMT + abstinence regimen" by default fallback (first axis)
  • thiamine
    first line
    b_vitamin_essential
    500 mg IV TID × 2–3 days, then 250 mg IV daily × 5 days, then 100 mg PO daily • IV → PO • TID acute then daily
    triggers: suspected_or_confirmed_alcohol_use_disorder, wernicke_features_or_high_risk, before_any_glucose_administration
    High-dose IV thiamine for high-risk patients per Royal College of Physicians + Sechi/Serra Lancet Neurol 2007 PMID 17434099; Wernicke prevention; MUST precede glucose to avoid precipitating encephalopathy
    rxcui 10454
  • lorazepam
    first line
    benzodiazepine_intermediate_acting
    2 mg IV/PO q1h prn for CIWA-Ar score ≥10 • IV/PO • symptom-triggered q1h prn
    triggers: active_alcohol_withdrawal_ciwa_at_least_10, liver_disease_avoiding_long_acting_benzodiazepine
    Symptom-triggered lorazepam (Daeppen JAMA Intern Med 2002) reduces benzodiazepine exposure 60% vs fixed-schedule; lorazepam preferred over diazepam in liver disease (no active metabolites)
    rxcui 6470
  • magnesium sulfate
    first line
    electrolyte_replacement
    2 g IV (in banana bag) then 1–2 g IV q12h × 24–48 h • IV • q12h initial
    triggers: hypomagnesemia_in_alcohol_use, withdrawal_seizure_prophylaxis
    Hypomagnesemia near-universal in chronic alcohol use; aggressive repletion reduces withdrawal seizure risk + supports cardiac stability
    rxcui 6585
  • folic acid
    first line
    b_vitamin_essential
    1 mg IV/PO daily (in banana bag) × 1 wk then daily • IV/PO • daily
    triggers: nutritional_deficiency_in_alcohol_use, macrocytic_anemia
    Folate deficiency common; megaloblastic anemia component
    rxcui 4511
  • naltrexone
    first line
    opioid_receptor_antagonist_aud
    50 mg PO daily; or 380 mg IM monthly (Vivitrol) • PO or IM • daily PO or monthly IM
    triggers: alcohol_use_disorder_seeking_abstinence_or_reduction, no_acute_hepatitis_or_severe_liver_disease
    COMBINE trial (Anton JAMA 2006) — naltrexone reduces heavy drinking days; monthly IM improves adherence; avoid in active hepatitis or LFT >3x ULN
    rxcui 7243
  • acamprosate
    second line
    glutamate_modulator_aud
    666 mg PO TID • PO • TID
    triggers: alcohol_use_disorder_naltrexone_intolerance, severe_liver_disease_avoiding_naltrexone
    Acamprosate effective for maintaining abstinence; preferred in liver disease since hepatic metabolism minimal; renally cleared (avoid eGFR <30)
    rxcui 82819
  • furosemide
    first line
    loop_diuretic
    40 mg IV (or 2.5x outpatient dose for chronic users — DOSE-AHF PMID 21366472) • IV/PO • q12h titrate to UOP 100–200 mL/h
    triggers: volume_overload_adhf
    Standard ADHF decongestion; transition to PO when stable
    rxcui 4603
  • sacubitril-valsartan
    first line
    arni_arb_neprilysin_inhibitor
    24/26 mg PO BID titrate to 97/103 mg BID • PO • BID
    triggers: hfref_with_lvef_below_40, sbp_at_least_100, no_recent_acei_in_36h
    PIONEER-HF (Velazquez NEJM 2019 PMID 30403955) — in-hospital initiation safe; ACC/AHA 2022 HF Class I in HFrEF
    rxcui 1656328
  • carvedilol
    first line
    beta_blocker_alpha_beta_nonselective
    3.125 mg PO BID titrate to 25 mg BID • PO • BID
    triggers: hfref_with_lvef_below_40_euvolemic_sbp_at_least_100, avoid_until_withdrawal_resolved_to_avoid_masking_signs
    COPERNICUS / CIBIS-II / MERIT-HF; ACC/AHA 2022 Class I; defer initiation until withdrawal complete to avoid masking tachycardia / tremor
    rxcui 20352
  • empagliflozin
    first line
    sglt2_inhibitor
    10 mg PO daily • PO • daily
    triggers: hfref_or_hfpef, egfr_at_least_20, no_acute_intoxication
    EMPULSE PMID 35347356 + EMPEROR-Reduced PMID 32865377; broad HF benefit; caution with euglycemic DKA in starvation/heavy drinking
    rxcui 1545653

outpatient playbook — drug actions (2)

  1. 1. continue GDMT lifelong
    rxcui 1656328
    sacubitril-valsartan 97/103 BID + carvedilol 25 BID + spironolactone 25 + empagliflozin 10 • PO • as scheduled
    trigger: maintenance
    ACC/AHA 2022 4-pillar; may down-titrate or discontinue if full LVEF recovery + sustained abstinence per shared decision
  2. 2. continue naltrexone or transition to acamprosate
    rxcui 7517
    per AUD response and tolerability • PO or IM • maintenance
    trigger: sustained AUD treatment
    COMBINE long-term benefit

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Heavy chronic alcohol use (>80 g/d men, >40 g/d women, >10 yr) + dilated cardiomyopathy on echo + no obstructive CAD; Dyspnea / orthopnea / edema in patient with known alcohol use disorder or recent binge drinking; Echo dilated LV with reduced EF + cardiac MRI without ischemic LGE pattern in patient with chronic heavy alcohol use.

Objective

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

Assessment

**Acute HF — alcoholic cardiomyopathy** (cardio.acute-hf.alcoholic-cardiomyopathy.v1).
Phenotype framing: ACM vs ischemic CMP (CAD on angio) vs hypertensive CMP vs viral myocarditis (acute onset, recent viral illness) vs idiopathic dilated CMP vs cocaine/methamphetamine CMP
Scope: Dilated CMP + chronic heavy alcohol use + no obstructive CAD/HTN/valvular cause → alcoholic cardiomyopathy phenotype; thiamine + abstinence are foundation of treatment

No severity triggers fired against current inputs.

Plan

Regimen axis: **Alcoholic cardiomyopathy ADHF — thiamine + withdrawal management + GDMT + abstinence regimen**.
1. thiamine 500 mg IV TID × 2–3 days, then 250 mg IV daily × 5 days, then 100 mg PO daily IV → PO TID acute then daily (b_vitamin_essential, first line) — High-dose IV thiamine for high-risk patients per Royal College of Physicians + Sechi/Serra Lancet Neurol 2007 PMID 17434099; Wernicke prevention; MUST precede glucose to avoid precipitating encephalopathy
2. lorazepam 2 mg IV/PO q1h prn for CIWA-Ar score ≥10 IV/PO symptom-triggered q1h prn (benzodiazepine_intermediate_acting, first line) — Symptom-triggered lorazepam (Daeppen JAMA Intern Med 2002) reduces benzodiazepine exposure 60% vs fixed-schedule; lorazepam preferred over diazepam in liver disease (no active metabolites)
3. magnesium sulfate 2 g IV (in banana bag) then 1–2 g IV q12h × 24–48 h IV q12h initial (electrolyte_replacement, first line) — Hypomagnesemia near-universal in chronic alcohol use; aggressive repletion reduces withdrawal seizure risk + supports cardiac stability
4. folic acid 1 mg IV/PO daily (in banana bag) × 1 wk then daily IV/PO daily (b_vitamin_essential, first line) — Folate deficiency common; megaloblastic anemia component
5. naltrexone 50 mg PO daily; or 380 mg IM monthly (Vivitrol) PO or IM daily PO or monthly IM (opioid_receptor_antagonist_aud, first line) — COMBINE trial (Anton JAMA 2006) — naltrexone reduces heavy drinking days; monthly IM improves adherence; avoid in active hepatitis or LFT >3x ULN
6. acamprosate 666 mg PO TID PO TID (glutamate_modulator_aud, second line) — Acamprosate effective for maintaining abstinence; preferred in liver disease since hepatic metabolism minimal; renally cleared (avoid eGFR <30)
7. furosemide 40 mg IV (or 2.5x outpatient dose for chronic users — DOSE-AHF PMID 21366472) IV/PO q12h titrate to UOP 100–200 mL/h (loop_diuretic, first line) — Standard ADHF decongestion; transition to PO when stable
8. sacubitril-valsartan 24/26 mg PO BID titrate to 97/103 mg BID PO BID (arni_arb_neprilysin_inhibitor, first line) — PIONEER-HF (Velazquez NEJM 2019 PMID 30403955) — in-hospital initiation safe; ACC/AHA 2022 HF Class I in HFrEF
9. carvedilol 3.125 mg PO BID titrate to 25 mg BID PO BID (beta_blocker_alpha_beta_nonselective, first line) — COPERNICUS / CIBIS-II / MERIT-HF; ACC/AHA 2022 Class I; defer initiation until withdrawal complete to avoid masking tachycardia / tremor
10. empagliflozin 10 mg PO daily PO daily (sglt2_inhibitor, first line) — EMPULSE PMID 35347356 + EMPEROR-Reduced PMID 32865377; broad HF benefit; caution with euglycemic DKA in starvation/heavy drinking

Setting playbook (outpatient) — Long-term cardio-addiction co-management: abstinence sustained, GDMT 4-pillar maintenance, recovery assessment at 6 mo (50%+ recover LVEF >10 percentage points if abstinent), family + community support, advanced HF/transplant eval if no recovery despite abstinence
11. continue GDMT lifelong sacubitril-valsartan 97/103 BID + carvedilol 25 BID + spironolactone 25 + empagliflozin 10 PO as scheduled — maintenance (ACC/AHA 2022 4-pillar; may down-titrate or discontinue if full LVEF recovery + sustained abstinence per shared decision)
12. continue naltrexone or transition to acamprosate per AUD response and tolerability PO or IM maintenance — sustained AUD treatment (COMBINE long-term benefit)

Non-pharmacologic actions:
- AA / SMART recovery + sponsor + community
- Family / Al-Anon ongoing support
- Annual physical + screening
- Liver disease surveillance (AFP + US per cirrhosis stage)

AVOID / contraindication checks:
- Thiamine_must_precede_glucose (glucose can precipitate Wernicke by depleting remaining thiamine — Sechi/Serra PMID 17434099)
- Diazepam_avoid_in_severe_liver_disease (active metabolites accumulate — use lorazepam)
- Naltrexone_avoid_in_active_hepatitis_or_lft_3x_uln (hepatotoxicity risk)
- Naltrexone_avoid_with_opioid_use_within_7_days (precipitates withdrawal)
- Acamprosate_avoid_egfr_below_30 (renal clearance)
- Beta_blocker_defer_during_active_withdrawal (masks autonomic features)
- Statin_caution_in_active_alcoholic_hepatitis (LFT monitoring; atorvastatin acceptable in mild–moderate)

Monitoring

Regimen monitoring:
- ciwa ar q2 4h x 24h then per protocol
- daily bmp magnesium phosphorus during refeeding
- daily neuro exam for wernicke features
- lft q3 d during admission then q3 mo
- echo at 6 months to assess recovery on abstinence
- aud treatment engagement check at each visit

Setting (outpatient) monitoring:
- Quarterly + annual full restage
- PEth for objective abstinence if relapse concern

Follow-up plan: Cardiology + addiction medicine co-clinic; SUD treatment program enrollment; AA / 12-step / SMART recovery; naltrexone or acamprosate continuation; LFT q3 mo on statin; echo at 6 mo (recovery assessment); family support
- Close-out criterion: AUD treatment + abstinence support + cardiology follow-up booked

Monitoring phase: CIWA-Ar q2–4h × 24 h then per protocol; daily BMP + Mg + thiamine response; daily exam for Wernicke features (ataxia, ophthalmoplegia, confusion); LFT trend; echo at 6 mo to assess recovery on abstinence

Disposition

Current setting: outpatient — Long-term cardio-addiction co-management: abstinence sustained, GDMT 4-pillar maintenance, recovery assessment at 6 mo (50%+ recover LVEF >10 percentage points if abstinent), family + community support, advanced HF/transplant eval if no recovery despite abstinence

Disposition criteria:
- Long-term cardio-addiction continuation; cross-link to cardio.hfref.core.v1 + gi.cirrhosis.core.v1 if applicable

Escalation triggers (move to higher acuity):
- Drinking relapse → re-engage SUD + intensify pharmacotherapy
- No LVEF recovery despite 6+ mo abstinence → advanced HF / transplant eval
- New cirrhosis decompensation → hepatology

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Confusion + ataxia + ophthalmoplegia (often only 1 of 3 present) in patient with AUD or malnutrition — Wernicke encephalopathy emergency
- [LIFE_THREATENING] Active alcohol withdrawal with CIWA-Ar >15 (severe) or seizure or delirium tremens
- [SEVERE] Discharge or follow-up decision point — patient capacity for abstinence determines prognosis (50%+ LVEF recovery if abstinent vs ~50% mortality at 4 yr if continued drinking)

Citations

- 2022 ACC/AHA HF Guideline (Heidenreich) + Awtry/Philippides ACM review + Sechi/Serra Wernicke + VA/DoD AUD CPG 2023 + ATA/SAMHSA TIP 45 [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 20630557) [PMID:20630557](https://pubmed.ncbi.nlm.nih.gov/20630557/)
- Cited evidence (PMID 25218517) [PMID:25218517](https://pubmed.ncbi.nlm.nih.gov/25218517/)
- Cited evidence (PMID 25539675) [PMID:25539675](https://pubmed.ncbi.nlm.nih.gov/25539675/)
- Cited evidence (PMID 17434099) [PMID:17434099](https://pubmed.ncbi.nlm.nih.gov/17434099/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2022 ACC/AHA HF Guideline (Heidenreich) + Awtry/Philippides ACM review + Sechi/Serra Wernicke + VA/DoD AUD CPG 2023 + ATA/SAMHSA TIP 45 — PMID:35363499
  • Cited evidence (PMID 20630557) — PMID:20630557
  • Cited evidence (PMID 25218517) — PMID:25218517
  • Cited evidence (PMID 25539675) — PMID:25539675
  • Cited evidence (PMID 17434099) — PMID:17434099