Heart Failure Management Algorithm

flowchart TD
    A[Heart Failure Diagnosis] --> B{Acute or Chronic?}

    B -->|Acute/Decompensated| C[Stabilization]
    B -->|Chronic/Stable| D[Outpatient GDMT]

    C --> C1[Oxygen/Respiratory Support]
    C --> C2[IV Diuretics]
    C --> C3[Inotropes if needed]
    C --> C4[Treat underlying cause]

    C1 & C2 & C3 & C4 --> E{Cardiogenic Shock?}

    E -->|Yes| F[ICU Management]
    E -->|No| G[Transition to Oral Therapy]

    F --> F1{Refractory?}
    F1 -->|Yes| F2[Consider MCS<br/>VAD > ECMO]
    F1 -->|No| G

    D --> D1[ACE Inhibitor<br/>or ARB]
    D1 --> D2[Add Beta-Blocker<br/>when stable]
    D2 --> D3[Add MRA<br/>if EF remains low]
    D3 --> D4[Consider ARNI<br/>if tolerating ACEi]

    G --> D

    D4 --> H{Adequate Response?}
    H -->|Yes| I[Continue Therapy<br/>Regular Monitoring]
    H -->|No| J{EF <35% + Symptoms?}

    J -->|Yes| K[ICD Evaluation]
    J -->|No| L[Optimize Therapy<br/>Consider Transplant Eval]

    F2 --> M[Transplant Evaluation]
    K --> M
    L --> M

    style F fill:#ff6b6b
    style F2 fill:#ff6b6b
    style M fill:#ffd93d

📋 Text Version (if diagram doesn't render)

**Heart Failure Management Algorithm** 1. **Acute or Chronic?** - **Acute/Decompensated** → Stabilization (O2, IV diuretics, inotropes, treat cause) - Cardiogenic shock? → ICU → Refractory? → MCS (VAD/ECMO) → Transplant eval - No shock → Transition to oral therapy - **Chronic/Stable** → Outpatient GDMT 2. **GDMT Sequence:** - ACEi/ARB → Add beta-blocker when stable → Add MRA if EF still low → Consider ARNI 3. **If Inadequate Response:** EF <35% + symptoms → ICD evaluation → Transplant eval

Guideline-Directed Medical Therapy (GDMT)

First Line: ACE Inhibitor

• Enalapril: 0.1-0.5 mg/kg/day divided BID
• Captopril: 0.5-2 mg/kg/day divided TID
• Target: Maximum tolerated dose

Second Line: Beta-Blocker

• Carvedilol: 0.1-0.5 mg/kg/day divided BID
• Start when euvolemic and stable
• Uptitrate slowly

Third Line: MRA

• Spironolactone: 1-2 mg/kg/day
• Monitor potassium
• Add if EF remains reduced

Fourth Line: Consider ARNI

• Sacubitril/valsartan
• Emerging pediatric data
• Replace ACEi (washout period)

Decompensated HF Management

Diuretics

• Furosemide IV: 1-2 mg/kg q6-12h
• Add thiazide if diuretic resistance

Inotropes (if needed)

• Milrinone: 0.25-0.75 mcg/kg/min
• Dobutamine: 5-20 mcg/kg/min
• Epinephrine: 0.05-0.3 mcg/kg/min

Mechanical Support Indications

• INTERMACS 1-2 (critical cardiogenic shock)
• Bridge to transplant
• Bridge to recovery (myocarditis)