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cardio.acute-hf.cardiorenal.v1PRODUCTION
cardio.acute-hf.cardiorenal.v1

Acute HF — Type-1 cardiorenal syndrome (ADHF + AKI)

cardiologyacuteadult
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10/12 authored

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

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Detailed

Type-1 CRS = acute HF + concurrent AKI; venous congestion (high CVP) is dominant mechanism; decongestion remains priority despite moderate Cr rise per CARRESS-HF

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Type-1 CRS confirmed

Patient inputs (9)

Older patients more susceptible to cardiorenal injury + slower recovery

Defines AKI severity (KDIGO stages); trend during diuresis. Tolerate ≤30% rise per CARRESS-HF if congestion improving

BUN/Cr ratio + urea-driven prognosis; rising BUN with stable Cr suggests pre-renal congestion phenotype

Sequential nephron blockade + MRA + ARNI dosing risk; K monitoring critical in CRS

Decongestion target marker; >30% drop predicts renal recovery

BP guides decongestion vs perfusion priority; SBP <90 + AKI = SCAI C+ shock with renal involvement

IV escalation must be 2-2.5× home dose per DOSE; cardiorenal often diuretic-resistant

B-line resolution as objective decongestion endpoint when oliguric

IVC diameter + collapsibility for congestion tracking when urine output unreliable

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

Severity triggers (4)

4 need judgement
  • informationallife_threateningcrs_with_severe_aki_kdigo_3_or_oliguria
    KDIGO Stage 3 AKI (Cr rise ≥3× baseline OR Cr ≥4 OR UOP <0.3 mL/kg/h × 24h) during ADHF treatment
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcrs_with_cardiogenic_shock_renal_hypoperfusion
    CRS + SBP <90 + lactate ≥2 + cool extremities + AKI = SCAI C+ shock with renal hypoperfusion
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcrs_with_severe_hyperkalemia
    K >6.0 with EKG changes during CRS treatment (sequential blockade + ACEi/ARNI + MRA exposure)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecrs_with_diuretic_resistance_unresponsive_to_sequential_blockade
    Persistent congestion + AKI despite IV loop + acetazolamide + HCTZ/metolazone × 24-48h
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Type-1 CRS — sequential nephron blockade to achieve euvolemia while tolerating ≤30% Cr rise (CARRESS-HF; ADVOR; CLOROTIC)
axis: cardiorenal_sequential_blockade_phenotype
Selected axis "Type-1 CRS — sequential nephron blockade to achieve euvolemia while tolerating ≤30% Cr rise (CARRESS-HF; ADVOR; CLOROTIC)" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    IV bolus 2-2.5× home dose; if naïve 80 mg IV, then 80-160 mg IV q6-12h or continuous 10-20 mg/h • IV • q6-12h or continuous
    triggers: adhf_with_aki, volume_overload_with_oliguria
    DOSE PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; assess UOP at 2h; do NOT default to UF per CARRESS-HF PMID 23131078
    rxcui 4603
  • acetazolamide
    first line
    CA_inhibitor_diuretic
    500 mg IV daily × 3 days • IV • daily × 3
    triggers: inadequate_loop_response_at_2h, metabolic_alkalosis_during_diuresis
    ADVOR PMID 36027564 — adjunct to IV loop improves decongestion at 3 days without worsening renal function
    rxcui 167
  • hydrochlorothiazide
    second line
    thiazide_diuretic
    25-50 mg PO daily • PO • daily
    triggers: diuretic_resistance_after_loop_plus_acetazolamide
    CLOROTIC PMID 36461706 — HCTZ + IV loop improves decongestion vs loop alone; sequential nephron blockade
    rxcui 5487
  • metolazone
    second line
    thiazide_like_diuretic
    2.5-10 mg PO 30 min before loop • PO • daily or BID
    triggers: HCTZ_unavailable, severe_diuretic_resistance
    Sequential nephron blockade alternative; longer half-life than HCTZ; monitor K + Mg closely
    rxcui 6916
  • empagliflozin
    first line
    SGLT2_inhibitor
    10 mg PO daily — CONTINUE if eGFR >20 • PO • daily
    triggers: cardiorenal_with_egfr_above_20
    EMPULSE PMID 35347356 — reno-cardiac protective; continue in CRS if eGFR >20 unless DKA risk; do NOT discontinue for moderate Cr rise
    rxcui 1545653
  • sacubitril-valsartan
    comorbidity specific
    arni
    HOLD if Cr rise >50% from baseline; restart at 24/26 BID at 50% lower dose once Cr stable • PO • BID
    triggers: hfref_post_decongestion_cr_stable
    Hold during severe Cr rise; restart at lower dose once euvolemic — preserves long-term cardiorenal benefit
    rxcui 1656328
  • enalapril
    comorbidity specific
    acei
    HOLD if Cr rise >50% from baseline; restart at 2.5 mg BID once Cr stable • PO • BID
    triggers: arni_unavailable_post_decongestion
    Same hold-then-restart approach; ACEi/ARB withdrawal during severe AKI is appropriate
    rxcui 203123
  • spironolactone
    comorbidity specific
    mra
    12.5 mg PO daily once Cr stable + K <5 • PO • daily
    triggers: hfref_with_egfr_above_30_and_k_below_5
    RALES PMID 10471456 — start cautiously after CRS resolution; lower starting dose given K + Cr risk
    rxcui 9997
  • carvedilol
    first line
    beta_blocker
    CONTINUE home dose if hemodynamically tolerant; do not reduce solely for AKI • PO • BID
    triggers: hfref_chronic_bb_tolerated
    COPERNICUS PMID 11386262 — chronic BB withdrawal during ADHF associated with worse outcomes; continue unless hypotensive or bradycardic
    rxcui 20352
  • dobutamine
    rescue
    inotrope_beta1
    2.5 µg/kg/min IV titrate • IV • continuous
    triggers: cold_wet_with_aki_unresponsive_to_diuretic
    Inotropic support to enable diuresis when low CO drives renal hypoperfusion; arrhythmia risk
    rxcui 3616

outpatient playbook — drug actions (1)

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

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cr rise ≥0.3 mg/dL or ≥50% from baseline during ADHF treatment → Type-1 CRS (Ronco 2008; KDIGO AKI); ADHF + oliguria <0.5 mL/kg/h despite adequate diuretic dose → cardiorenal phenotype; Persistent congestion + escalating loop diuretic + worsening renal function → sequential blockade indication.

Objective

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

Assessment

**Acute HF — Type-1 cardiorenal syndrome (ADHF + AKI)** (cardio.acute-hf.cardiorenal.v1).
Scope: Type-1 CRS = acute HF + concurrent AKI; venous congestion (high CVP) is dominant mechanism; decongestion remains priority despite moderate Cr rise per CARRESS-HF

No severity triggers fired against current inputs.

Plan

Regimen axis: **Type-1 CRS — sequential nephron blockade to achieve euvolemia while tolerating ≤30% Cr rise (CARRESS-HF; ADVOR; CLOROTIC)**.
1. furosemide IV bolus 2-2.5× home dose; if naïve 80 mg IV, then 80-160 mg IV q6-12h 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; do NOT default to UF per CARRESS-HF PMID 23131078
2. acetazolamide 500 mg IV daily × 3 days IV daily × 3 (CA_inhibitor_diuretic, first line) — ADVOR PMID 36027564 — adjunct to IV loop improves decongestion at 3 days without worsening renal function
3. hydrochlorothiazide 25-50 mg PO daily PO daily (thiazide_diuretic, second line) — CLOROTIC PMID 36461706 — HCTZ + IV loop improves decongestion vs loop alone; sequential nephron blockade
4. metolazone 2.5-10 mg PO 30 min before loop PO daily or BID (thiazide_like_diuretic, second line) — Sequential nephron blockade alternative; longer half-life than HCTZ; monitor K + Mg closely
5. empagliflozin 10 mg PO daily — CONTINUE if eGFR >20 PO daily (SGLT2_inhibitor, first line) — EMPULSE PMID 35347356 — reno-cardiac protective; continue in CRS if eGFR >20 unless DKA risk; do NOT discontinue for moderate Cr rise
6. sacubitril-valsartan HOLD if Cr rise >50% from baseline; restart at 24/26 BID at 50% lower dose once Cr stable PO BID (arni, comorbidity specific) — Hold during severe Cr rise; restart at lower dose once euvolemic — preserves long-term cardiorenal benefit
7. enalapril HOLD if Cr rise >50% from baseline; restart at 2.5 mg BID once Cr stable PO BID (acei, comorbidity specific) — Same hold-then-restart approach; ACEi/ARB withdrawal during severe AKI is appropriate
8. spironolactone 12.5 mg PO daily once Cr stable + K <5 PO daily (mra, comorbidity specific) — RALES PMID 10471456 — start cautiously after CRS resolution; lower starting dose given K + Cr risk
9. carvedilol CONTINUE home dose if hemodynamically tolerant; do not reduce solely for AKI PO BID (beta_blocker, first line) — COPERNICUS PMID 11386262 — chronic BB withdrawal during ADHF associated with worse outcomes; continue unless hypotensive or bradycardic
10. dobutamine 2.5 µg/kg/min IV titrate IV continuous (inotrope_beta1, rescue) — Inotropic support to enable diuresis when low CO drives renal hypoperfusion; arrhythmia risk

Setting playbook (outpatient) — Long-term cardio-renal surveillance; GDMT maintenance; CKD progression prevention; ICD eligibility per MADIT-II if EF <35 persistent
11. continue 4-pillar GDMT ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — HFrEF + Cr stable (ACC/AHA 2022 HF Class I (PMID 35363499))

Non-pharmacologic actions:
- Avoid NSAIDs + nephrotoxic supplements lifelong
- Influenza + pneumococcal + RSV vaccines
- CKD lifestyle counseling

AVOID / contraindication checks:
- Avoid_high_dose_loop_alone_with_worsening_cr_without_sequential_blockade (CARRESS HF + ADVOR + CLOROTIC)
- Avoid_uf_before_diuretic_optimization (CARRESS HF showed UF NOT superior to stepped pharmacologic therapy)
- Hold_acei_arni_if_cr_rise_above_50_percent (KDIGO AKI; ACC/AHA 2022 §10.3)
- Continue_sglt2i_if_egfr_above_20_in_crs (EMPULSE; do not discontinue for moderate Cr rise)
- Avoid_nsaids_iodinated_contrast_aminoglycosides_in_crs (KDIGO AKI; nephrotoxin avoidance)
- Metolazone_monitor_k_mg_q12h (severe hypoK risk)
- Do_not_withdraw_chronic_bb_during_adhf_unless_hypotensive (B CONVINCED, Jondeau 2009)

Monitoring

Regimen monitoring:
- daily weight morning (decongestion endpoint when oliguric)
- hourly uop (titrate diuretic dose)
- BMP q12h during diuresis (K, Mg, Cr, BUN, HCO3 trend)
- nt probnp at admission 48h 72h pre discharge (>30% drop predicts renal recovery)
- lung us at 24-48h for residual b lines (objective congestion endpoint)
- IVC diameter collapsibility when oliguric (alternative congestion marker)
- nephrotoxin audit daily (NSAIDs, contrast, aminoglycosides, vancomycin)

Setting (outpatient) monitoring:
- Quarterly BMP + UACR
- Annual echo

Follow-up plan: Restart ACEi/ARB or ARNI at lower dose once euvolemic + Cr stable; STRONG-HF cadence; nephrology clinic if AKI did not fully resolve; SGLT2i continuation
- Close-out criterion: GDMT restart plan + STRONG-HF + nephrology booked

Monitoring phase: Daily weight, hourly UOP, BMP q12h during diuresis, NT-proBNP trend, lung US/IVC for objective congestion when oliguric, daily review of nephrotoxins

Disposition

Current setting: outpatient — Long-term cardio-renal surveillance; GDMT maintenance; CKD progression prevention; ICD eligibility per MADIT-II if EF <35 persistent

Disposition criteria:
- Long-term continuation; cross-link to cardio.hfref.core.v1 + neph.ckd.core.v1

Escalation triggers (move to higher acuity):
- Recurrent ADHF → readmit + reassess
- eGFR decline >5/yr → nephrology + GDMT review
- EF declining → advanced HF eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] KDIGO Stage 3 AKI (Cr rise ≥3× baseline OR Cr ≥4 OR UOP <0.3 mL/kg/h × 24h) during ADHF treatment
- [LIFE_THREATENING] CRS + SBP <90 + lactate ≥2 + cool extremities + AKI = SCAI C+ shock with renal hypoperfusion
- [LIFE_THREATENING] K >6.0 with EKG changes during CRS treatment (sequential blockade + ACEi/ARNI + MRA exposure)

Citations

- 2022 ACC/AHA HF + 2023 Focused Update + KDIGO AKI 2026 draft [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 23131078) [PMID:23131078](https://pubmed.ncbi.nlm.nih.gov/23131078/)
- Cited evidence (PMID 36027564) [PMID:36027564](https://pubmed.ncbi.nlm.nih.gov/36027564/)
- Cited evidence (PMID 36461706) [PMID:36461706](https://pubmed.ncbi.nlm.nih.gov/36461706/)

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