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cardio.acute-hf.with-cardiogenic-shock.v1PRODUCTION
cardio.acute-hf.with-cardiogenic-shock.v1

ADHF complicated by cardiogenic shock (composite)

cardiologyacuteadult
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12/12 authored

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

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Detailed

ADHF complicated by SCAI B+ cardiogenic shock — both engines (acute-HF + cardiogenic-shock) run CONCURRENTLY; decongestion-vs-perfusion tension is the central management decision

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Advance when

composite eligibility confirmed (ADHF + shock physiology)

Patient inputs (13)

Older patients have higher CS-complication risk + worse advanced-HF candidacy

Acute-on-chronic vs de novo; prior GDMT regimen guides resumption

Cardiorenal syndrome (Type-1 CRS); diuretic + DOAC + drug renal-dose adjustment

Diuresis-driven hypoK + GDMT MRA gating + arrhythmia risk

Tissue-hypoperfusion marker + clearance trajectory drives MCS escalation

ADHF severity + decongestion trajectory + risk stratification

ACS precipitant rule-out (very common in CS-complicating ADHF)

LV/RV function, valvular acute regurg, tamponade, mechanical complication — drives MCS choice

Ischemia precipitant + AF/RVR vs SR + QRS prolongation for CRT eligibility

SCAI staging + perfusion threshold; MAP target ≥65

Tachycardia component of shock index; BB tolerance gating

Concurrent respiratory failure + hyperoxia avoidance + NIPPV indication

ACS / arrhythmia / infection / non-adherence / drug-toxicity precipitants drive co-management

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningprogression_scai_b_to_d_e
    ADHF-CS escalating from SCAI B (beginning) to SCAI D (deteriorating) or E (extremis) — failing initial pressor + inotrope
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_on_echo
    New harsh holosystolic murmur OR new severe MR/AR/VSR on echo in ADHF-CS context
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_arrhythmia_in_adhf_cs
    Recurrent VT/VF storm in ADHF-CS context — often peri-infarct or scar-mediated
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiorenal_worsening_severe
    Cr rise >50% from baseline + persistent congestion in ADHF-CS — type-1 cardiorenal syndrome
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefutility_in_advanced_adhf_cs
    No lactate clearance + escalating MCS support + multi-organ failure + non-LVAD/transplant candidate
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_advanced_hf_post_recovery
    EF <25% + NYHA III-IV + recurrent decompensations despite max GDMT — advanced HF NYHA D
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategdmt_resumption_intolerance
    GDMT resumption (BB or ARNI) → recurrent hypotension or shock features
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ADHF + cardiogenic shock concurrent regimen — perfusion FIRST, then decongestion
axis: adhf_with_cs_concurrent_management
Selected axis "ADHF + cardiogenic shock concurrent regimen — perfusion FIRST, then decongestion" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor
    0.05 µg/kg/min • IV • continuous; titrate to MAP ≥65
    triggers: adhf_with_sbp_below_90, cardiogenic_shock_scai_b_plus
    SOAP-II PMID 20200382 — first-line vasopressor in cardiogenic shock; arrhythmia rate 12.4% vs 24.1% with dopamine
    rxcui 7512
  • vasopressin
    rescue
    V1_agonist_vasopressor
    0.03 U/min • IV • continuous; not titrated
    triggers: ne_above_0.5_or_rv_failure
    V1-mediated vasoconstriction sparing pulm vasculature; second pressor in refractory shock (AHA 2020 + ACC/AHA 2022 HF)
    rxcui 11149
  • dobutamine
    first line
    inotrope_beta1
    2.5 µg/kg/min • IV • continuous; titrate to perfusion + UOP
    triggers: low_ci_post_pressor, cold_wet_profile
    AHA 2020 Class IIb; restores perfusion enabling diuresis; arrhythmia risk
    rxcui 3616
  • milrinone
    second line
    PDE3_inhibitor
    0.125-0.5 µg/kg/min (no bolus) • IV • continuous; renal adjust
    triggers: bb_dependent, pulmonary_htn, rv_failure
    OPTIME-CHF PMID 11887962; longer half-life; renal adjustment required; alternative inodilator if dobutamine intolerant
    rxcui 52769
  • furosemide
    add on
    loop_diuretic
    IV bolus + continuous infusion 5-20 mg/h AFTER MAP restored to ≥65 • IV • continuous infusion preferred
    triggers: perfusion_restored_decongest_phase
    DOSE PMID 21366472 — decongest only after perfusion adequate; tolerate moderate Cr rise per CARRESS-HF PMID 23131078
    rxcui 4603
  • acetazolamide
    add on
    CA_inhibitor_diuretic
    500 mg IV/PO daily × 3 • IV/PO • once daily
    triggers: inadequate_loop_response, metabolic_alkalosis
    ADVOR PMID 36027564 — improves decongestion at 3 d when added to loop
    rxcui 167
  • sacubitril-valsartan
    comorbidity specific
    ARNI
    24/26 mg BID — ONLY after off IV inotropes + SBP ≥100 + 36h post-ACEi • PO • BID
    triggers: hfref_recovery_post_cs, off_inotrope_24h, sbp_above_100
    PIONEER-HF PMID 30403955 — start in-hospital after stabilization; EMPULSE PMID 35347356 for SGLT2i timing
    rxcui 1656328
  • carvedilol
    comorbidity specific
    mixed_alpha_beta_blocker
    3.125 mg BID — ONLY after off inotrope ≥24h + euvolemic + SBP >100 • PO • BID; titrate q2 wks
    triggers: hfref_recovery_off_inotrope, euvolemic
    COPERNICUS PMID 11386262 — start at low dose once decongested + off inotrope; HOLD during shock
    rxcui 20352
  • spironolactone
    comorbidity specific
    MRA
    12.5-25 mg daily — only after K <5 + eGFR ≥30 • PO • daily
    triggers: hfref_recovery, k_below_5, egfr_above_30
    RALES PMID 10471456 / EMPHASIS-HF PMID 21073363
    rxcui 9997
  • empagliflozin
    first line
    SGLT2_inhibitor
    10 mg daily — start in-hospital once stabilized • PO • daily
    triggers: any_lvef, egfr_above_20
    EMPULSE PMID 35347356 — start in-hospital; safer than ARNI/BB during recovery; reno-cardiac protective
    rxcui 1545653

outpatient playbook — drug actions (1)

  1. 1. continue GDMT 4-pillar at max tolerated
    rxcui 1656328
    sacubitril-valsartan 97/103 BID + carvedilol 25 BID + spironolactone 25 daily + empagliflozin 10 daily • PO • as scheduled
    trigger: HFrEF chronic post-CS recovery
    ACC/AHA 2022 HF 4-pillar Class I

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ADHF + SBP <90 sustained or vasopressor-dependent — SCAI B+ shock complication; ADHF + cool extremities + lactate ≥2 + AKI + AMS — Nohria-Stevenson cold-wet profile; ADHF + serial lactate rising despite IV diuretic — perfusion failure pattern.

Objective

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

Assessment

**ADHF complicated by cardiogenic shock (composite)** (cardio.acute-hf.with-cardiogenic-shock.v1).
Phenotype framing: Cold-wet vs cold-dry vs warm-wet shock variant; SCAI A-E staging; HFrEF vs HFpEF; etiology phenotype (ischemic / non-ischemic / valvular / inflammatory)
Scope: ADHF complicated by SCAI B+ cardiogenic shock — both engines (acute-HF + cardiogenic-shock) run CONCURRENTLY; decongestion-vs-perfusion tension is the central management decision

No severity triggers fired against current inputs.

Plan

Regimen axis: **ADHF + cardiogenic shock concurrent regimen — perfusion FIRST, then decongestion**.
1. norepinephrine 0.05 µg/kg/min IV continuous; titrate to MAP ≥65 (vasopressor, first line) — SOAP-II PMID 20200382 — first-line vasopressor in cardiogenic shock; arrhythmia rate 12.4% vs 24.1% with dopamine
2. vasopressin 0.03 U/min IV continuous; not titrated (V1_agonist_vasopressor, rescue) — V1-mediated vasoconstriction sparing pulm vasculature; second pressor in refractory shock (AHA 2020 + ACC/AHA 2022 HF)
3. dobutamine 2.5 µg/kg/min IV continuous; titrate to perfusion + UOP (inotrope_beta1, first line) — AHA 2020 Class IIb; restores perfusion enabling diuresis; arrhythmia risk
4. milrinone 0.125-0.5 µg/kg/min (no bolus) IV continuous; renal adjust (PDE3_inhibitor, second line) — OPTIME-CHF PMID 11887962; longer half-life; renal adjustment required; alternative inodilator if dobutamine intolerant
5. furosemide IV bolus + continuous infusion 5-20 mg/h AFTER MAP restored to ≥65 IV continuous infusion preferred (loop_diuretic, add on) — DOSE PMID 21366472 — decongest only after perfusion adequate; tolerate moderate Cr rise per CARRESS-HF PMID 23131078
6. acetazolamide 500 mg IV/PO daily × 3 IV/PO once daily (CA_inhibitor_diuretic, add on) — ADVOR PMID 36027564 — improves decongestion at 3 d when added to loop
7. sacubitril-valsartan 24/26 mg BID — ONLY after off IV inotropes + SBP ≥100 + 36h post-ACEi PO BID (ARNI, comorbidity specific) — PIONEER-HF PMID 30403955 — start in-hospital after stabilization; EMPULSE PMID 35347356 for SGLT2i timing
8. carvedilol 3.125 mg BID — ONLY after off inotrope ≥24h + euvolemic + SBP >100 PO BID; titrate q2 wks (mixed_alpha_beta_blocker, comorbidity specific) — COPERNICUS PMID 11386262 — start at low dose once decongested + off inotrope; HOLD during shock
9. spironolactone 12.5-25 mg daily — only after K <5 + eGFR ≥30 PO daily (MRA, comorbidity specific) — RALES PMID 10471456 / EMPHASIS-HF PMID 21073363
10. empagliflozin 10 mg daily — start in-hospital once stabilized PO daily (SGLT2_inhibitor, first line) — EMPULSE PMID 35347356 — start in-hospital; safer than ARNI/BB during recovery; reno-cardiac protective

Setting playbook (outpatient) — Long-term advanced-HF surveillance; ICD/CRT per LVEF at 40-90 d; LVAD/transplant evaluation if persistent severe LV dysfunction; cardiac rehab maintenance; mental health continuity
11. continue GDMT 4-pillar at max tolerated sacubitril-valsartan 97/103 BID + carvedilol 25 BID + spironolactone 25 daily + empagliflozin 10 daily PO as scheduled — HFrEF chronic post-CS recovery (ACC/AHA 2022 HF 4-pillar Class I)

Non-pharmacologic actions:
- ICD interrogation if implanted
- LVAD/transplant work-up if EF persistently <25 + advanced symptoms
- Cardiac rehab maintenance phase
- Mental health continuity

AVOID / contraindication checks:
- Beta_blocker_HOLD_in_acute_cardiogenic_shock (ACC/AHA 2022 HF Class III)
- Diuretic_DEFER_until_MAP_restored_in_CS (DOSE; SCAI 2022)
- ARNI_36h_washout_from_ACEi (PARADIGM HF PMID 25176015)
- MRA_avoid_K_above_5_or_egfr_below_30 (RALES PMID 10471456)
- SGLT2i_hold_if_ketoacidosis_risk (ACC/AHA 2022 HF)
- Nitroglycerin_avoid_RV_infarct_or_PDE5 (ACC/AHA 2025 ACS)

Monitoring

Regimen monitoring:
- arterial line continuous BP (SCAI 2022 Recommendation)
- central line for pressor titration and CVP (AHA 2020 Class I)
- foley for hourly UOP (AHA 2020)
- lactate q2-4h until normalized (SCAI 2022)
- BMP q6-12h during pressor titration
- daily echo for LV recovery and thrombus screen
- right heart cath if refractory shock for hemodynamic-guided titration
- pre-discharge NT-proBNP for trajectory (ACC/AHA 2022 Class IIa)

Setting (outpatient) monitoring:
- Quarterly visits + annual EF + lipid

Follow-up plan: Advanced-HF clinic follow-up; GDMT 4-pillar resumption per STRONG-HF cadence; ICD/CRT eligibility per LVEF at 40-90 d; LVAD/transplant evaluation if persistent advanced HF; cardiac rehab; mental health (high PTSD risk in CS survivors)
- Close-out criterion: advanced-HF + EP + cardiac-rehab + mental-health follow-up booked

Monitoring phase: Continuous arterial line + central line + Foley + telemetry; lactate q2-4h; BMP q6-12h; daily echo for LV recovery + thrombus screen; right heart cath if refractory shock for hemodynamic-guided titration

Disposition

Current setting: outpatient — Long-term advanced-HF surveillance; ICD/CRT per LVEF at 40-90 d; LVAD/transplant evaluation if persistent severe LV dysfunction; cardiac rehab maintenance; mental health continuity

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 chronic engine

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- EF declining → LVAD/transplant

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] ADHF-CS escalating from SCAI B (beginning) to SCAI D (deteriorating) or E (extremis) — failing initial pressor + inotrope
- [LIFE_THREATENING] New harsh holosystolic murmur OR new severe MR/AR/VSR on echo in ADHF-CS context
- [LIFE_THREATENING] Recurrent VT/VF storm in ADHF-CS context — often peri-infarct or scar-mediated

Citations

- 2022 ACC/AHA HF + 2023 Focused Update + SCAI 2022 CS staging + DanGer Shock 2024 + STRONG-HF 2022 [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 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 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)

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