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cardio.acute-hf.sepsis-induced.v1PRODUCTION
cardio.acute-hf.sepsis-induced.v1

Acute HF — sepsis-induced cardiomyopathy (SICM)

cardiologyacuteadult
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10/12 authored

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Detailed

SICM = acute reversible LV dysfunction during sepsis (LVEF ↓ ≥10% or new ≤45%); affects 30-60% of severe sepsis; usually reversible at 7-10 d; SSC bundle remains primary scaffold; LV dysfunction modifies fluid + inotrope strategy

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SICM phenotype framed

Patient inputs (10)

Older patients higher SICM incidence (40-60% vs 30% younger); slower recovery trajectory; co-existing baseline CV disease confounds attribution

Source identification (urinary, pulmonary, intra-abdominal, line-associated) + severity (qSOFA / SOFA) drives source control + abx choice + prognosis

AKI common in sepsis + drives drug dosing (RRT-modified); cardiorenal physiology if BOTH SICM + AKI

Anchor pre-sepsis LVEF essential to define SICM (≥10% drop) — without prior echo, must consider chronic HFrEF as alternative; absent pre-data → presume SICM if rapid recovery on serial echo

Hour-1 lactate per SSC; clearance trend (≥10%/h) tracks resuscitation adequacy + organ perfusion

Troponin elevation in 30-50% of severe sepsis — most are SICM/type-2 MI rather than type-1 (4th UDMI 2018); guides cath need

Elevated baseline in sepsis (cytokines + RV strain) — use trend not absolute; absolute >1800 + new LV dysfunction supports SICM

TTE LVEF + global longitudinal strain (GLS); GLS abnormality (less negative than -16%) detects SICM earlier than LVEF; serial day-1, day-3, day-7 echo to track recovery

Blood cultures × 2 + site-specific cultures + source imaging (CT, US) BEFORE abx if no delay; source control non-negotiable

MAP <65 + lactate ≥2 → SCAI shock screen + early NE; SICM superimposed on septic shock has worst outcome

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

Severity triggers (4)

4 need judgement
  • informationallife_threateningsicm_with_progression_to_mixed_cardiogenic_septic_shock
    SICM patient developing SCAI C+ shock physiology — persistent hypotension despite NE + vasopressin + adequate MAP target with low CI on echo and rising lactate
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresicm_troponin_elevation_differential_type1_mi_vs_type2_mi_vs_sicm
    Troponin elevation in sepsis patient with new LV dysfunction — must distinguish type-1 MI (occlusive) vs type-2 MI (demand) vs SICM (cytokine-mediated depression)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresicm_with_recurrent_sepsis_episode
    Recurrent severe sepsis episode in patient with prior SICM — increased risk of permanent dysfunction and worse outcomes
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsicm_gdmt_initiation_timing_post_recovery
    SICM patient at 90-day re-echo — decision point for chronic GDMT initiation vs no-treatment if recovered
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Sepsis-induced cardiomyopathy — SSC bundle + SICM-modified fluid/inotrope strategy + deferred GDMT (SSC 2021/2026; Beesley 2018; Chen 2014)
axis: sepsis_induced_cardiomyopathy_phenotype
Selected axis "Sepsis-induced cardiomyopathy — SSC bundle + SICM-modified fluid/inotrope strategy + deferred GDMT (SSC 2021/2026; Beesley 2018; Chen 2014)" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha1_predominant
    0.05 µg/kg/min titrate to MAP ≥65 (75-85 in chronic HTN per SEPSISPAM) • IV • continuous infusion
    triggers: septic_shock_with_sicm, map_below_65_after_initial_resuscitation
    SOAP-II PMID 20200382 + SSC 2021 (PMID 34599691) — first-line vasopressor in septic shock; lower arrhythmia risk vs dopamine; preserved coronary perfusion vs phenylephrine
    rxcui 7512
  • vasopressin
    add on
    vasopressor_v1_agonist
    0.03 U/min fixed (NOT titrated) • IV • continuous infusion
    triggers: septic_shock_requiring_norepinephrine_above_0.5
    VASST PMID 18305265 — catecholamine-sparing add-on; particularly useful in SICM to reduce NE dose + tachyarrhythmia burden
    rxcui 11149
  • dobutamine
    comorbidity specific
    inotrope_beta1_agonist
    2.5-5 µg/kg/min low-dose (NOT 10-20); titrate by serial echo CI • IV • continuous infusion
    triggers: low_cardiac_index_on_serial_echo_despite_adequate_map_in_sicm
    SSC 2021 conditional recommendation; β-adrenergic desensitization in SICM means higher doses often ineffective; favor low-dose targeted at CI <2.5; AVOID if no CI evidence (mortality signal in EGDT trials when used routinely)
    rxcui 3616
  • hydrocortisone
    add on
    corticosteroid_glucocorticoid
    50 mg IV q6h (200 mg/day total) • IV • q6h × 7 days or until pressor-free
    triggers: septic_shock_pressor_dependent_norepinephrine_above_0.25
    ADRENAL PMID 29347874 + APROCCHSS PMID 29490185 — reduces shock duration; modest mortality benefit in pressor-dependent shock; SSC 2021 conditional recommendation
    rxcui 5492
  • vancomycin
    first line
    glycopeptide_antibiotic
    25-30 mg/kg load then 15-20 mg/kg q8-12h (AUC-targeted 400-600) • IV • q8-12h titrate by AUC
    triggers: sepsis_with_mrsa_risk_factors
    IDSA 2020 vancomycin AUC dosing; empirical for MRSA coverage in undifferentiated severe sepsis
    rxcui 11124
  • piperacillin-tazobactam
    first line
    piperacillin_tazobactam
    4.5 g IV q6h (extended infusion 4h preferred per BLING-III) • IV • q6h extended infusion
    triggers: undifferentiated_severe_sepsis_no_pseudomonas_concern
    Broad gram-negative + anaerobic coverage; extended infusion improves outcomes in severe sepsis per BLING-III
    rxcui 74169
  • sodium chloride 0.9% or balanced crystalloid
    first line
    crystalloid_isotonic
    20-30 mL/kg IV bolus over 30-60 min; reassess at 15 mL/kg in SICM with dynamic markers • IV • bolus then maintenance
    triggers: hypotension_in_sepsis_pre_pressor
    SSC 2021 30 mL/kg; SMART (PMID 29485925) favors balanced crystalloid; SICM tolerates less volume — reassess at 15 mL/kg with stroke volume variation / passive leg raise / IVC US
    rxcui 11289

outpatient playbook — drug actions (3)

  1. 1. IF persistent dysfunction at 90 d → start GDMT 4 pillars per ACC/AHA 2022
    rxcui 593411
    empagliflozin 10 mg + sacubitril-valsartan 24/26 BID + carvedilol 3.125 BID + spironolactone 25 mg titrate to target • PO • as scheduled
    trigger: LVEF <40 at 90 d re-echo
    ACC/AHA 2022 HF Guideline (PMID 35363499) — persistent HFrEF post-SICM warrants standard GDMT initiation
  2. 2. IF recovered → no chronic GDMT, ongoing sepsis-prevention bundle
    no chronic HF meds; continue chronic comorbidity-specific meds • PO • as needed
    trigger: LVEF normalized at 90 d
    Avoid lifelong GDMT in recovered SICM without persistent dysfunction
  3. 3. pneumococcal + influenza + COVID vaccinations
    PCV20 if not done; annual influenza; COVID per current schedule • IM • annual + as scheduled
    trigger: sepsis survivor
    CDC ACIP — sepsis survivors at 2x risk of recurrence; vaccines reduce future sepsis episodes

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Severe sepsis or septic shock + new LVEF drop ≥10% absolute (or new LVEF ≤45%) on echo within 48-72h → SICM pathway; Troponin elevation in sepsis WITHOUT ischemic ECG / regional wall motion abnormalities → likely SICM-related demand/depression (rule out type-2 MI); Global LV hypokinesis (NOT regional) on bedside echo during sepsis — pattern favors SICM over ischemic cardiomyopathy.

Objective

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

Assessment

**Acute HF — sepsis-induced cardiomyopathy (SICM)** (cardio.acute-hf.sepsis-induced.v1).
Scope: SICM = acute reversible LV dysfunction during sepsis (LVEF ↓ ≥10% or new ≤45%); affects 30-60% of severe sepsis; usually reversible at 7-10 d; SSC bundle remains primary scaffold; LV dysfunction modifies fluid + inotrope strategy

No severity triggers fired against current inputs.

Plan

Regimen axis: **Sepsis-induced cardiomyopathy — SSC bundle + SICM-modified fluid/inotrope strategy + deferred GDMT (SSC 2021/2026; Beesley 2018; Chen 2014)**.
1. norepinephrine 0.05 µg/kg/min titrate to MAP ≥65 (75-85 in chronic HTN per SEPSISPAM) IV continuous infusion (vasopressor_alpha1_predominant, first line) — SOAP-II PMID 20200382 + SSC 2021 (PMID 34599691) — first-line vasopressor in septic shock; lower arrhythmia risk vs dopamine; preserved coronary perfusion vs phenylephrine
2. vasopressin 0.03 U/min fixed (NOT titrated) IV continuous infusion (vasopressor_v1_agonist, add on) — VASST PMID 18305265 — catecholamine-sparing add-on; particularly useful in SICM to reduce NE dose + tachyarrhythmia burden
3. dobutamine 2.5-5 µg/kg/min low-dose (NOT 10-20); titrate by serial echo CI IV continuous infusion (inotrope_beta1_agonist, comorbidity specific) — SSC 2021 conditional recommendation; β-adrenergic desensitization in SICM means higher doses often ineffective; favor low-dose targeted at CI <2.5; AVOID if no CI evidence (mortality signal in EGDT trials when used routinely)
4. hydrocortisone 50 mg IV q6h (200 mg/day total) IV q6h × 7 days or until pressor-free (corticosteroid_glucocorticoid, add on) — ADRENAL PMID 29347874 + APROCCHSS PMID 29490185 — reduces shock duration; modest mortality benefit in pressor-dependent shock; SSC 2021 conditional recommendation
5. vancomycin 25-30 mg/kg load then 15-20 mg/kg q8-12h (AUC-targeted 400-600) IV q8-12h titrate by AUC (glycopeptide_antibiotic, first line) — IDSA 2020 vancomycin AUC dosing; empirical for MRSA coverage in undifferentiated severe sepsis
6. piperacillin-tazobactam 4.5 g IV q6h (extended infusion 4h preferred per BLING-III) IV q6h extended infusion (piperacillin_tazobactam, first line) — Broad gram-negative + anaerobic coverage; extended infusion improves outcomes in severe sepsis per BLING-III
7. sodium chloride 0.9% or balanced crystalloid 20-30 mL/kg IV bolus over 30-60 min; reassess at 15 mL/kg in SICM with dynamic markers IV bolus then maintenance (crystalloid_isotonic, first line) — SSC 2021 30 mL/kg; SMART (PMID 29485925) favors balanced crystalloid; SICM tolerates less volume — reassess at 15 mL/kg with stroke volume variation / passive leg raise / IVC US

Setting playbook (outpatient) — Long-term cardiology + ID surveillance; 90-d re-echo to determine SICM recovery vs persistent HFrEF; chronic GDMT initiation if persistent dysfunction; sepsis-prevention bundle
8. IF persistent dysfunction at 90 d → start GDMT 4 pillars per ACC/AHA 2022 empagliflozin 10 mg + sacubitril-valsartan 24/26 BID + carvedilol 3.125 BID + spironolactone 25 mg titrate to target PO as scheduled — LVEF <40 at 90 d re-echo (ACC/AHA 2022 HF Guideline (PMID 35363499) — persistent HFrEF post-SICM warrants standard GDMT initiation)
9. IF recovered → no chronic GDMT, ongoing sepsis-prevention bundle no chronic HF meds; continue chronic comorbidity-specific meds PO as needed — LVEF normalized at 90 d (Avoid lifelong GDMT in recovered SICM without persistent dysfunction)
10. pneumococcal + influenza + COVID vaccinations PCV20 if not done; annual influenza; COVID per current schedule IM annual + as scheduled — sepsis survivor (CDC ACIP — sepsis survivors at 2x risk of recurrence; vaccines reduce future sepsis episodes)

Non-pharmacologic actions:
- Cardiology + PCP shared care
- Sepsis-prevention education ongoing
- Cardiac rehab maintenance phase if dysfunction persists

AVOID / contraindication checks:
- Avoid_hold_chronic_BB_during_septic_shock_only_if_hd_unstable (B CONVINCED — chronic BB withdrawal worsens HF outcomes; restart when stabilized)
- Avoid_chronic_acei_arni_during_aki_with_cr_rise_above_50_percent (KDIGO 2024)
- Avoid_hd_inotrope_dobutamine_above_10_in_sicm_with_persistent_low_ci (β adrenergic desensitization; consider milrinone if preserved renal function or VA ECMO)
- Avoid_albumin_5_percent_routinely_in_sepsis (ALBIOS — no mortality benefit; reserve for severe hypoalbuminemia <2.0)
- Avoid_hes_starches_in_sepsis (CHEST + 6S trials — increased AKI + mortality)
- Avoid_dopamine_first_line_in_septic_shock (SOAP II — higher arrhythmia + mortality vs NE)
- Avoid_acute_initiation_chronic_GDMT_during_active_sepsis (defer to post recovery 90 d re echo)
- Hold_metformin_during_sepsis_lactic_acidosis (lactate confounding + lactic acidosis risk)

Monitoring

Regimen monitoring:
- serial echo with LVEF and GLS day 1 day 3 day 7 (track recovery — most resolve at 7-10 d)
- serial lactate q2h until clearance (resuscitation adequacy marker)
- continuous arterial line MAP (titrate NE to ≥65; higher in chronic HTN)
- CVP or dynamic markers PLR SVV (volume responsiveness — FENICE)
- serial troponin to distinguish sicm vs type1 MI (downward trend favors SICM)
- daily BMP with creatinine for AKI (cardiorenal physiology if both AKI + SICM)
- CAM ICU q shift for delirium (ABCDEF bundle)
- 90 day outpatient echo to confirm recovery or identify persistent HFrEF

Setting (outpatient) monitoring:
- 90-d echo, then annual if dysfunction persists
- Annual BMP + NT-proBNP if HFrEF persists

Follow-up plan: 90-day cardiology echo to determine SICM recovery (most do); if persistent dysfunction → start chronic GDMT (4 pillars per ACC/AHA 2022); if recovered → educate patient on sepsis-prevention + future risk; ID follow-up for source control adequacy + suppressive abx if applicable
- Close-out criterion: 90-day re-echo + GDMT decision made

Monitoring phase: Continuous SpO2 + ECG + arterial line BP; serial lactate q2h until clearance; serial echo (day 1, day 3, day 7) to track LVEF + GLS recovery; daily CBC + BMP + cultures pending; CAM-ICU for delirium; ABCDEF bundle

Disposition

Current setting: outpatient — Long-term cardiology + ID surveillance; 90-d re-echo to determine SICM recovery vs persistent HFrEF; chronic GDMT initiation if persistent dysfunction; sepsis-prevention bundle

Disposition criteria:
- Long-term continuation; if SICM recovered + no recurrence → routine PCP; if HFrEF persists → handoff to cardio.hf.core.v1

Escalation triggers (move to higher acuity):
- Recurrent sepsis → admission + reassess for source
- Persistent or worsening dysfunction at 90 d → advanced HF eval
- New AF → CHA2DS2-VASc + AC decision

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SICM patient developing SCAI C+ shock physiology — persistent hypotension despite NE + vasopressin + adequate MAP target with low CI on echo and rising lactate
- [SEVERE] Troponin elevation in sepsis patient with new LV dysfunction — must distinguish type-1 MI (occlusive) vs type-2 MI (demand) vs SICM (cytokine-mediated depression)
- [SEVERE] Recurrent severe sepsis episode in patient with prior SICM — increased risk of permanent dysfunction and worse outcomes

Citations

- Surviving Sepsis Campaign 2021/2026 + Beesley 2018 SICM review + 2022 ACC/AHA HF [PMID:34599691](https://pubmed.ncbi.nlm.nih.gov/34599691/)
- Cited evidence (PMID 29349858) [PMID:29349858](https://pubmed.ncbi.nlm.nih.gov/29349858/)
- Cited evidence (PMID 26323447) [PMID:26323447](https://pubmed.ncbi.nlm.nih.gov/26323447/)
- Cited evidence (PMID 29485925) [PMID:29485925](https://pubmed.ncbi.nlm.nih.gov/29485925/)
- Cited evidence (PMID 30153967) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)

Last reconciled with current guidelines: 2026-05-15.
References