Clinical Commander

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cardio.afib.core.v1

Atrial fibrillation (rate / rhythm / anticoagulation)

cardiologyacutechronicadultacuteinpatientoutpatienttransition
Start encounter →Print handoutPRODUCTION

Two regimen axes encoded — AF-CARE/ABC stepwise (C→A→R→E) and phenotype-comorbidity matrix (drug × CHA₂DS₂-VA/renal/HF/valvular gating as data) — with RxNav-validated RxCUIs. Setting playbooks for outpatient, transition, and ED including DCCV / pill-in-pocket / pre-excited AF safety; AC + bleeding action plan with green/yellow/red zones; six severity triggers including pre-excited AF, HD instability, major bleed, missing AC, cryptogenic stroke screen (LOOP/STROKESTOP nuance), and HFrEF ablation candidate. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, AF golden-template mirror) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (22 verified PMIDs; 18 with effect sizes + 95% CI; retrieval-dated 2026-05-16; Consensus→WebSearch fallback logged; cross-dossier routing to cardio.hf.core.v1 / cardio.acute-hf.core.v1 / neuro.ischaemic-stroke.core.v1 / cardio.htn.core.v1); (2) cardio.afib.core.v1 ros+differentials+finding-lrs seed files (13 differentials w/ cohort-anchored priors across irregular-tachy + AF-pattern + secondary-driver partitions, 15 ROS, 39 LR rows = 19 LR+ / 20 LR−, 3 conditional-dependency rules incl. ECG-irregularity|rate-band + CHA₂DS₂-VA band-not-component-multiplied + Holter-post-monitoring precondition, T_test≈2%/T_treat≈10%); (3) 2 regimen axes rebuilt: afib_afcare_abc_stepwise + afib_phenotype_comorbidity (renal-adjusted DOAC dosing + valvular→warfarin-only + HFrEF→ablation encoded as DATA); (4) RxCUI bugs fixed (8): rivaroxaban 1037042→1114195 (1037042 was dabigatran — cross-drug bug), dabigatran 1037045→1037042, metoprolol 6918→metoprolol succinate 221124, flecainide 4203→4441, propafenone 8761→8754, sotalol 36567→9947, dofetilide 3437→49247, esmolol 4177→49737; all 16 AF drugs validate IN/PIN:OK via research:rxnav:validate; (5) content refresh to 2023 ACC/AHA (PMID 38033089/38043043) + 2024 ESC (PMID 39210723): AF-CARE/ABC pathway, CHA₂DS₂-VA sex-neutral, 48h→24h early-CV threshold, cryo first-line ablation, DOAC-preferred, LAAO for AC-contraindicated, renal-adjusted DOAC as data; evidence.pmids 7→22, purged 3 SUSPECTED_FABRICATION + 1 off-scope PMID; terminology arrays extended (I48.91/I48.92, atrial-flutter/MAT SNOMED). Registry has calc.cha2ds2vasc but not yet a sex-neutral CHA₂DS₂-VA entry per 2024 ESC; treat the existing calculator as proxy and flag for upgrade (registry-owned, out of depth-shard scope). Pre-existing registry-level dabigatran reverse-lookup MISMATCH (canonical 1037042 vs RxNav 1546356) is the DrugEffectProfile-registry CUI — aligned TO it per task §3; 96-fail RxNav baseline is registry-owned and out of scope. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA +USPSTF +Cochrane +ICER stubs +decision thresholds, side-car at cardio.afib.core.v1._depth-pass-3.md.

Entry points (5)

  • symptom
    Palpitations / irregular pulse — ESC 2024
    palpitations
  • imaging
    ECG / monitor showing AF — ESC 2024
    ecg_afib
  • symptom
    Dyspnea or fatigue from RVR — ACC/AHA 2023
    rvr_dyspnea
  • problem_list
    Established AF (titration / monitoring visit) — ESC 2024 AF-CARE
    established_af
  • problem_list
    Post-cryptogenic-stroke AF screen (STROKE-AF)
    cryptogenic_stroke

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    CHA₂DS₂-VA scoring + ablation candidacy
  • sexrequired
    demographic • used at CONTEXT
    2024 ESC drops sex from CHA₂DS₂ baseline (CHA₂DS₂-VA)
  • sbprequired
    vital • used at RED_FLAGS
    HD instability triggers DCCV — ACC/AHA 2023
  • hrrequired
    vital • used at CONTEXT
    RVR identification + rate control target — RACE II (Van Gelder NEJM 2010)
  • creatininerequired
    lab • used at TREATMENT
    DOAC dose adjustment (apixaban renal) — ARISTOTLE (Granger NEJM 2011)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Confirm AF vs flutter / WPW pre-excited AF — ESC 2024
  • duration_of_afrequired
    history • used at DIFFERENTIAL
    <48 h vs ≥48 h drives cardioversion AC strategy — ACC/AHA 2023
  • hf
    history • used at CONTEXT
    CASTLE-AF — ablation Class I in HFrEF + AF
  • prior_stroke_tia
    history • used at CONTEXT
    CHA₂DS₂-VA component + secondary prevention
  • bleed_history
    history • used at RISK_STRATIFICATION
    HAS-BLED modifiable factors — ESC 2024
  • tsh
    lab • used at INITIAL_WORKUP
    Hyperthyroidism reversible AF trigger — ESC 2024
  • echo
    imaging • used at INITIAL_WORKUP
    LA size, LVEF, valvular AF (mitral stenosis → warfarin) — ACC/AHA 2023

12-phase flow (11)

  1. 1FRAME
    Confirm AF on ECG; differentiate paroxysmal / persistent / permanent — ESC 2024 classification
    inputs: ecg
    advance: AF documented
  2. 2ENTRY
    Capture trigger + demographics — ESC 2024 AF-CARE pathway
    inputs: age, sex
    advance: demographics + trigger captured
  3. 3CONTEXT
    Vitals, comorbidities (HF, CAD, HTN, DM, CKD, OSA), bleed risk factors — ESC 2024
    inputs: sbp, hr, creatinine, hf, prior_stroke_tia
    advance: context complete
  4. 4RED_FLAGS
    Hemodynamic instability / WPW pre-excited AF / acute decompensated HF — ACC/AHA 2023
    inputs: sbp
    actions: wpw_afib
    advance: no instability or DCCV / non-AVN-blocking strategy initiated
  5. 5INITIAL_WORKUP
    ECG, TSH, BMP, CBC, echo if not on file — ESC 2024
    inputs: ecg, tsh, echo
    actions: panel.cardiac, panel.thyroid
    advance: baseline workup complete
  6. 6DIFFERENTIAL
    Paroxysmal vs persistent vs long-standing persistent vs permanent; valvular vs non-valvular — ESC 2024
    inputs: duration_of_af
    advance: class assigned
  7. 7RISK_STRATIFICATION
    CHA₂DS₂-VA → AC decision; HAS-BLED → modifiable bleed risk; symptom EHRA class
    inputs: age, sex, prior_stroke_tia, bleed_history
    actions: calc.cha2ds2vasc, calc.has_bled
    advance: risk scores documented
  8. 8TREATMENT
    AF-CARE: comorbidity, AC (DOAC preferred non-valvular), rate vs early rhythm control (EAST-AFNET 4), Class IA ablation for paroxysmal
    inputs: creatinine, duration_of_af
    advance: AC + rate/rhythm strategy active and reversible triggers addressed
  9. 9DISPOSITION
    Outpatient vs telemetry admit if RVR/HF; EP referral for ablation candidacy — ACC/AHA 2023
    advance: disposition assigned
  10. 10MONITORING
    INR if warfarin; periodic creatinine for DOAC; rhythm/rate symptom diary — ESC 2024
    inputs: creatinine
    advance: monitoring plan documented
  11. 11FOLLOWUP
    Risk-factor modification (LEGACY): BP, weight, OSA screen (STOP-BANG), alcohol; vaccination
    advance: follow-up scheduled with RFM plan