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cardio.acute-hf.core.v1PRODUCTION
cardio.acute-hf.core.v1

Acute decompensated heart failure

cardiologyacuteadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

11/12 authored

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

Current phase

Frame

Detailed

Confirm acute decompensation per ACC/AHA 2022 §10.1; chronic HF titration routes to cardio.hf.core.v1

Inputs
2
Actions
0
Advance rule
Set
Advance when

patient is acutely decompensated (volume overload / hypoperfusion)

Patient inputs (13)

Age-adjusted NT-proBNP cutoffs (PRIDE, Januzzi NEJM 2006)

Cardiorenal syndrome; loop diuretic dosing; SGLT2i gating (ACC/AHA 2022)

Diuresis-driven hypoK; MRA gating per RALES/EMPHASIS-HF (ACC/AHA 2022)

Diagnostic + risk; trended to assess decongestion (ACC/AHA 2022 Class I; ESC 2021)

Wet-warm vs wet-cold profile; CS triggers MCS pathway (ESC 2021 §11; SCAI 2022)

NIPPV indication per 3CPO (Gray NEJM 2008); hypoxic respiratory failure

Respiratory failure trigger (ACC/AHA 2022 §10.1)

AF/ACS/HTN/non-adherence/infection drives co-management (ACC/AHA 2022 §10.2)

Detect home loop diuretic dose for IV escalation 1×–2.5× (DOSE, Felker NEJM 2011)

Wet-warm/wet-cold matrix + GDMT initiation in-hospital (ACC/AHA 2022 Class I)

BLUE protocol B-lines for AHF vs COPD (Lichtenstein Chest 2008)

Pulmonary edema, cardiomegaly, alternate diagnoses (ESC 2021 §11)

Hypoperfusion marker / SCAI 2022 CS stage classification

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningcardiogenic_shock_complicating_adhf
    SBP <90 + lactate ≥2 + hypoperfusion (cool extremities, AKI, AMS) — SCAI 2022 C+
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereflash_pulmonary_edema_with_HTN
    Flash pulmonary edema + SBP >180 + acute respiratory failure (ESC 2021 §11)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprecipitant_acs_or_arrhythmia
    New ECG ischemia / arrhythmia (AF with RVR, VT) precipitating decompensation (ACC/AHA 2022 §10.2)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatediuretic_resistance
    UOP <0.5 mL/kg/h after furosemide ≥160 mg IV equivalent + ≥6 h (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecardiorenal_worsening
    Cr rise >0.3 + persistent congestion in ADHF (CARRESS-HF, Bart NEJM 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehyperK_on_GDMT_initiation
    K+ ≥5.5 on combination ARNI/ACEi + MRA + SGLT2i (ACC/AHA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ADHF — wet/cold profile based decongestion + perfusion + GDMT initiation (Nohria-Stevenson 2002; ACC/AHA 2022)
axis: adhf_profile_basedstep 1 - Step 1 — Warm + Wet (most common, congested + adequately perfused)
Selected step "Step 1 — Warm + Wet (most common, congested + adequately perfused)" — Congestion (B-lines, JVD, edema, NT-proBNP elevated) + SBP ≥90 + warm extremities + lactate <2 (ESC 2021 §11)
  • furosemide
    first line
    loop_diuretic
    IV bolus 2–2.5× total daily home dose (e.g. 80–160 mg IV) • IV • q12h or continuous infusion 5–20 mg/h
    triggers: volume_overload
    DOSE (Felker NEJM 2011) — high-dose intermittent IV loop is reasonable; check urine output at 2 h
    rxcui 4603
  • torsemide
    second line
    loop_diuretic
    20–40 mg IV • IV/PO • BID
    triggers: suboptimal_furosemide_response, gut_edema
    TRANSFORM-HF (Mentz JAMA 2023) — equivalent outcomes; better PO bioavailability
    rxcui 38413
  • bumetanide
    second line
    loop_diuretic
    1–2 mg IV • IV/PO • q4–8h
    triggers: furosemide_resistance
    Alternative loop diuretic (ACC/AHA 2022 §10.3)
    rxcui 1808
  • acetazolamide
    add on
    CA_inhibitor_diuretic
    500 mg IV/PO • IV/PO • once daily × 3
    triggers: inadequate_loop_response, metabolic_alkalosis
    ADVOR (Mullens NEJM 2022) — improves decongestion at 3 d when added to loop
    rxcui 167
  • metolazone
    add on
    thiazide_like_diuretic
    2.5–10 mg • PO • once daily
    triggers: diuretic_resistance, sequential_blockade
    CLOROTIC (Trullàs Eur J Heart Fail 2023) — sequential nephron blockade for refractory congestion
    rxcui 6916
  • hydrochlorothiazide
    add on
    thiazide_diuretic
    25 mg • IV/PO • once daily
    triggers: metolazone_unavailable
    Alternative thiazide for sequential blockade (ESC 2021 §11.3)
    rxcui 5487
  • nitroglycerin
    add on
    organic_nitrate
    5–10 µg/min IV • IV • continuous; titrate by 5 µg/min q5min
    triggers: SBP_above_120, flash_pulmonary_edema, HTN
    Afterload reduction — fastest onset in pulmonary edema (ESC 2021 Class IIa)
    rxcui 4917

outpatient playbook — drug actions (4)

  1. 1. continue diuretic at discharge dose; titrate by weight
    rxcui 4603
    furosemide 40–80 mg PO daily — adjust ±20 mg per weight trend • PO • daily
    trigger: Stable euvolemia at d/c
    Maintain euvolemia; smallest dose that holds (TRANSFORM-HF, PMID 36648467)
  2. 2. first up-titration of ARNI
    rxcui 1656339
    sacubitril-valsartan 24/26 → 49/51 BID at week 1 • PO • BID
    trigger: SBP ≥100 + K <5.0 + eGFR stable + tolerated 1 week
    STRONG-HF intensive titration cadence; PIONEER-HF safety data (PMID 30415601)
  3. 3. first up-titration of BB
    rxcui 20352
    carvedilol 3.125 → 6.25 BID at week 1 if HR >65 • PO • BID
    trigger: HR >55 + euvolemia + SBP >100
    STRONG-HF; COPERNICUS (PMID 11386263)
  4. 4. add MRA if not yet started
    rxcui 9997
    spironolactone 12.5 → 25 mg daily • PO • daily
    trigger: K <5.0 + eGFR ≥30 + not on at d/c
    Address GDMT gap; RALES (PMID 10471456)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute dyspnea / orthopnea / PND (ACC/AHA 2022 §10.1); Pulmonary edema on exam / lung US B-lines (ESC 2021 §11); NT-proBNP elevated for age (PRIDE, Januzzi NEJM 2006).

Objective

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

Assessment

**Acute decompensated heart failure** (cardio.acute-hf.core.v1).
Phenotype framing: Wet-warm / wet-cold / dry-cold / dry-warm matrix per Nohria-Stevenson 2002; HFrEF vs HFpEF (ACC/AHA 2022)
Scope: Confirm acute decompensation per ACC/AHA 2022 §10.1; chronic HF titration routes to cardio.hf.core.v1

No severity triggers fired against current inputs.

Plan

Regimen axis: **ADHF — wet/cold profile based decongestion + perfusion + GDMT initiation (Nohria-Stevenson 2002; ACC/AHA 2022)** — step "Step 1 — Warm + Wet (most common, congested + adequately perfused)".
1. furosemide IV bolus 2–2.5× total daily home dose (e.g. 80–160 mg IV) IV q12h or continuous infusion 5–20 mg/h (loop_diuretic, first line) — DOSE (Felker NEJM 2011) — high-dose intermittent IV loop is reasonable; check urine output at 2 h
2. torsemide 20–40 mg IV IV/PO BID (loop_diuretic, second line) — TRANSFORM-HF (Mentz JAMA 2023) — equivalent outcomes; better PO bioavailability
3. bumetanide 1–2 mg IV IV/PO q4–8h (loop_diuretic, second line) — Alternative loop diuretic (ACC/AHA 2022 §10.3)
4. acetazolamide 500 mg IV/PO IV/PO once daily × 3 (CA_inhibitor_diuretic, add on) — ADVOR (Mullens NEJM 2022) — improves decongestion at 3 d when added to loop
5. metolazone 2.5–10 mg PO once daily (thiazide_like_diuretic, add on) — CLOROTIC (Trullàs Eur J Heart Fail 2023) — sequential nephron blockade for refractory congestion
6. hydrochlorothiazide 25 mg IV/PO once daily (thiazide_diuretic, add on) — Alternative thiazide for sequential blockade (ESC 2021 §11.3)
7. nitroglycerin 5–10 µg/min IV IV continuous; titrate by 5 µg/min q5min (organic_nitrate, add on) — Afterload reduction — fastest onset in pulmonary edema (ESC 2021 Class IIa)

Setting playbook (outpatient) — Bridge encounter at 1-week post-discharge (the STRONG-HF anchor visit) — confirm euvolemia maintained, complete unfinished GDMT initiation, check for early decompensation signals, set the biweekly titration trajectory before formal handoff to the chronic HF engine
8. continue diuretic at discharge dose; titrate by weight furosemide 40–80 mg PO daily — adjust ±20 mg per weight trend PO daily — Stable euvolemia at d/c (Maintain euvolemia; smallest dose that holds (TRANSFORM-HF, PMID 36648467))
9. first up-titration of ARNI sacubitril-valsartan 24/26 → 49/51 BID at week 1 PO BID — SBP ≥100 + K <5.0 + eGFR stable + tolerated 1 week (STRONG-HF intensive titration cadence; PIONEER-HF safety data (PMID 30415601))
10. first up-titration of BB carvedilol 3.125 → 6.25 BID at week 1 if HR >65 PO BID — HR >55 + euvolemia + SBP >100 (STRONG-HF; COPERNICUS (PMID 11386263))
11. add MRA if not yet started spironolactone 12.5 → 25 mg daily PO daily — K <5.0 + eGFR ≥30 + not on at d/c (Address GDMT gap; RALES (PMID 10471456))

Non-pharmacologic actions:
- Reinforce daily weight log + sodium <2 g/d + fluid <2 L/d if symptomatic (ACC/AHA 2022)
- Cardiac rehab kick-off if not started (ACC/AHA 2022 Class I)
- Confirm next visit booked at week 3 (biweekly through week 6 per STRONG-HF)

AVOID / contraindication checks:
- Beta_blocker_avoid_decompensated_HF_or_inotropes (ACC/AHA 2022 Class III)
- ARNI_36h_washout_from_ACEi (PARADIGM HF, McMurray NEJM 2014)
- MRA_avoid_K_above_5_or_eGFR_below_30 (RALES; ACC/AHA 2022)
- SGLT2i_hold_if_NPO_or_ketoacidosis_risk (ACC/AHA 2022)
- Nitrate_avoid_RV_infarct_or_PDE5 (ESC 2021)
- Morphine_caution_ADHERE (Peacock Am Heart J 2008)

Monitoring

Regimen monitoring:
- daily weight morning (ACC/AHA 2022 Class I)
- I O q4-12h (ACC/AHA 2022 §10.3)
- BMP q12-24h during diuresis (ESC 2021 §11.3)
- NT-proBNP at admission and pre-discharge (ACC/AHA 2022 Class IIa)
- lung US at 24-48h for residual B lines (ESC 2021)
- echo pre-discharge for LV function documentation (ACC/AHA 2022 Class I)
- STRONG-HF pre-discharge visit at 1-2 weeks then q2-weeks x 6 weeks (Mebazaa Lancet 2022)

Setting (outpatient) monitoring:
- Weight log review weekly via patient portal or call (STRONG-HF)
- BMP at next visit (week 3) — earlier if eGFR borderline or K trending up
- NT-proBNP if symptoms recur

Monitoring phase: Daily weight, I/O, BMP q24h during diuresis, NT-proBNP trend (ACC/AHA 2022 Class I)

Disposition

Current setting: outpatient — Bridge encounter at 1-week post-discharge (the STRONG-HF anchor visit) — confirm euvolemia maintained, complete unfinished GDMT initiation, check for early decompensation signals, set the biweekly titration trajectory before formal handoff to the chronic HF engine

Disposition criteria:
- Confirm continuation in transition setting (next biweekly visit week 3) — formal handoff to cardio.hf.core.v1 occurs when all 4 GDMT pillars titrated to max-tolerated dose AND euvolemia maintained ≥4 weeks (per STRONG-HF post-trial cadence)

Escalation triggers (move to higher acuity):
- Weight gain ≥3 lb in 24 h or ≥5 lb in 1 week → diuretic titration per protocol or ED (ACC/AHA 2022)
- Symptomatic hypotension after ARNI up-titration → hold next dose, recheck in 1 week
- K rising > 5.5 → hold MRA first, consider K binder
- Cr rise >30% from discharge baseline → reduce diuretic; reassess volume; route to ED if AKI symptomatic
- NYHA worsening to III+ → expedite cardiology re-evaluation (ACC/AHA 2022 Class I)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 + lactate ≥2 + hypoperfusion (cool extremities, AKI, AMS) — SCAI 2022 C+
- [SEVERE] Flash pulmonary edema + SBP >180 + acute respiratory failure (ESC 2021 §11)
- [SEVERE] New ECG ischemia / arrhythmia (AF with RVR, VT) precipitating decompensation (ACC/AHA 2022 §10.2)

Citations

- 2022 AHA/ACC/HFSA HF Guideline + 2023 AHA/ACC/HFSA Focused Update + 2021/2023 ESC HF [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 34447992) [PMID:34447992](https://pubmed.ncbi.nlm.nih.gov/34447992/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)
- Cited evidence (PMID 21366472) [PMID:21366472](https://pubmed.ncbi.nlm.nih.gov/21366472/)
- Cited evidence (PMID 23131078) [PMID:23131078](https://pubmed.ncbi.nlm.nih.gov/23131078/)

Last reconciled with current guidelines: 2026-05-24.
References