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cardio.acute-hf.de-novo.v1PRODUCTION
cardio.acute-hf.de-novo.v1

Acute heart failure — de novo (first presentation)

cardiologyacuteadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

10/12 authored

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

Current phase

Frame

Detailed

De novo AHF = first presentation without prior HF diagnosis; mandates etiology workup + early GDMT after stabilization

Inputs
1
Actions
0
Advance rule
Set
Advance when

de novo phenotype confirmed

Patient inputs (7)

De novo AHF in young patient broadens etiology (myocarditis, peripartum, congenital, drug/toxin)

Cardiorenal interaction; drives diuretic + RAAS dosing

Diagnostic + prognostic; trend predicts response to therapy

ACS rule-out is mandatory in de novo AHF; mild elevation common but persistent rise suggests ischemic etiology

Thyroid disease (hyper/hypo) can precipitate de novo AHF; mandatory in first-presentation workup

LVEF + RV + valvular + pericardial; cornerstone of de novo AHF phenotyping

BP-stratified phenotype: hypertensive AHF (SBP >140) vs normotensive vs hypotensive (cardiogenic shock)

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Severity triggers (5)

5 need judgement
  • informationallife_threateningde_novo_ahf_with_acs_etiology
    De novo AHF + ECG/troponin suggesting ACS — STEMI/NSTEMI/UA workup mandatory
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningde_novo_ahf_with_cardiogenic_shock
    De novo AHF + SBP <90 + lactate ≥2 + cool extremities — cardiogenic shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningde_novo_ahf_fulminant_myocarditis_suspicion
    De novo AHF + young patient + recent viral illness + arrhythmia + rapid EF drop → fulminant myocarditis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningde_novo_ahf_acute_valvular_emergency
    De novo AHF + new severe MR (papillary rupture) or AR (aortic dissection, endocarditis) on echo → emergent CT surgery
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverede_novo_ahf_peripartum_cardiomyopathy
    De novo AHF in pregnancy or <5 mo postpartum without other identifiable etiology → peripartum CMP
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

De novo AHF in-hospital GDMT initiation regimen — PIONEER-HF + EMPULSE-driven, BB only after stabilization
axis: de_novo_ahf_in_hospital_gdmt_phenotype
Selected axis "De novo AHF in-hospital GDMT initiation regimen — PIONEER-HF + EMPULSE-driven, BB only after stabilization" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    40-80 mg IV bolus q6-12h or continuous 5-10 mg/h • IV • q6-12h or continuous
    triggers: de_novo_ahf_with_congestion
    DOSE trial PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; titrate to UOP ≥1 mL/kg/h
    rxcui 4603
  • metolazone
    second line
    thiazide_diuretic_long_acting
    2.5-10 mg PO 30 min before furosemide • PO • daily or BID
    triggers: diuretic_resistance_on_loop_alone
    Sequential nephron blockade for diuretic resistance
    rxcui 6916
  • sacubitril-valsartan
    first line
    arni
    24/26 mg PO BID, titrate q1-2 weeks to 97/103 BID • PO • BID
    triggers: de_novo_hfref_post_stabilization
    PIONEER-HF PMID 30403955 — in-hospital ARNI initiation safe + reduces NT-proBNP; criteria: 24h post-AHF, SBP ≥100, K <5.2, eGFR ≥30
    rxcui 1656328
  • empagliflozin
    first line
    sglt2_inhibitor
    10 mg PO daily • PO • daily
    triggers: de_novo_ahf_in_hospital_initiation
    EMPULSE PMID 35347356 — start in-hospital regardless of EF; clinical benefit at 90d
    rxcui 1545653
  • carvedilol
    first line
    beta_blocker_nonselective_vasodilator
    3.125 mg PO BID, titrate q2 weeks • PO • BID
    triggers: de_novo_hfref_off_iv_inotropes
    COPERNICUS PMID 11386262; ONLY initiate after stabilization off IV inotropes ≥24h + SBP ≥100
    rxcui 20352
  • spironolactone
    first line
    mra
    25 mg PO daily • PO • daily
    triggers: de_novo_hfref_with_eligible_renal_potassium
    RALES PMID 10471456 — EF ≤35 + K <5 + eGFR ≥30
    rxcui 9997
  • enalapril
    second line
    acei
    2.5 mg PO BID titrate • PO • BID
    triggers: arni_intolerant_or_unavailable
    Alternative if ARNI not available; CONSENSUS/SOLVD
    rxcui 203123

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
    ACC/AHA 2022 HF Class I

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New-onset dyspnea + edema + elevated NT-proBNP without prior HF diagnosis → de novo AHF; First-ever echo showing reduced LVEF + clinical AHF — de novo HFrEF; Pregnant or <5 mo postpartum + new AHF → peripartum CMP workup.

Objective

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

Assessment

**Acute heart failure — de novo (first presentation)** (cardio.acute-hf.de-novo.v1).
Scope: De novo AHF = first presentation without prior HF diagnosis; mandates etiology workup + early GDMT after stabilization

No severity triggers fired against current inputs.

Plan

Regimen axis: **De novo AHF in-hospital GDMT initiation regimen — PIONEER-HF + EMPULSE-driven, BB only after stabilization**.
1. furosemide 40-80 mg IV bolus q6-12h or continuous 5-10 mg/h IV q6-12h or continuous (loop_diuretic, first line) — DOSE trial PMID 21366472 — high-dose IV bolus or continuous infusion equivalent; titrate to UOP ≥1 mL/kg/h
2. metolazone 2.5-10 mg PO 30 min before furosemide PO daily or BID (thiazide_diuretic_long_acting, second line) — Sequential nephron blockade for diuretic resistance
3. sacubitril-valsartan 24/26 mg PO BID, titrate q1-2 weeks to 97/103 BID PO BID (arni, first line) — PIONEER-HF PMID 30403955 — in-hospital ARNI initiation safe + reduces NT-proBNP; criteria: 24h post-AHF, SBP ≥100, K <5.2, eGFR ≥30
4. empagliflozin 10 mg PO daily PO daily (sglt2_inhibitor, first line) — EMPULSE PMID 35347356 — start in-hospital regardless of EF; clinical benefit at 90d
5. carvedilol 3.125 mg PO BID, titrate q2 weeks PO BID (beta_blocker_nonselective_vasodilator, first line) — COPERNICUS PMID 11386262; ONLY initiate after stabilization off IV inotropes ≥24h + SBP ≥100
6. spironolactone 25 mg PO daily PO daily (mra, first line) — RALES PMID 10471456 — EF ≤35 + K <5 + eGFR ≥30
7. enalapril 2.5 mg PO BID titrate PO BID (acei, second line) — Alternative if ARNI not available; CONSENSUS/SOLVD

Setting playbook (outpatient) — Long-term HF management: GDMT maintenance, EF re-echo at 3 mo (de novo CMP may recover), ICD eligibility per MADIT-II/SCD-HeFT if persistent EF ≤35, cardiac rehab completion
8. continue 4-pillar GDMT ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — HFrEF (ACC/AHA 2022 HF Class I)

Non-pharmacologic actions:
- ICD evaluation at 3-6 mo if EF ≤35 despite GDMT (MADIT-II/SCD-HeFT)
- Cardiac rehab maintenance
- Influenza + pneumococcal vaccines

AVOID / contraindication checks:
- Arni_avoid_36h_post_acei (washout to prevent angioedema)
- Arni_avoid_severe_renal_impairment_egfr_below_30 (PIONEER HF exclusion)
- Arni_avoid_hyperkalemia_above_5.2 (PIONEER HF exclusion)
- Bb_avoid_during_iv_inotrope_dependence (acute decompensation worsening)
- Bb_avoid_high_dose_during_acute_congestion (initiate after diuresis adequate)
- Sglt2i_caution_in_dka_risk_t1dm_or_severe_t2dm (drug label)

Monitoring

Regimen monitoring:
- daily weight and io balance (decongestion monitoring)
- daily bmp for k cr during arni titration
- nt probnp at admission 48h 72h and pre discharge (PIONEER-HF biomarker target)
- serial echo at 3 mo for lvef recovery (de novo cardiomyopathy may recover)

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

Follow-up plan: STRONG-HF up-titration cadence (weekly visits × 4 wk); cardiac rehab; advanced HF eval if EF <35 + persistent symptoms despite GDMT
- Close-out criterion: STRONG-HF cadence + cardiac rehab booked

Monitoring phase: Daily weight, I/O, BMP (K, Cr); NT-proBNP trend; daily exam

Disposition

Current setting: outpatient — Long-term HF management: GDMT maintenance, EF re-echo at 3 mo (de novo CMP may recover), ICD eligibility per MADIT-II/SCD-HeFT if persistent EF ≤35, cardiac rehab completion

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 → readmit + reassess
- EF declining despite GDMT → advanced HF eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] De novo AHF + ECG/troponin suggesting ACS — STEMI/NSTEMI/UA workup mandatory
- [LIFE_THREATENING] De novo AHF + SBP <90 + lactate ≥2 + cool extremities — cardiogenic shock
- [LIFE_THREATENING] De novo AHF + young patient + recent viral illness + arrhythmia + rapid EF drop → fulminant myocarditis

Citations

- 2022 ACC/AHA HF + 2023 Focused Update + 2025 ACC/AHA ACS [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 30403955) [PMID:30403955](https://pubmed.ncbi.nlm.nih.gov/30403955/)
- Cited evidence (PMID 35347356) [PMID:35347356](https://pubmed.ncbi.nlm.nih.gov/35347356/)
- Cited evidence (PMID 36356631) [PMID:36356631](https://pubmed.ncbi.nlm.nih.gov/36356631/)

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