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cardio.aortic-regurgitation.chronic.v1

Chronic aortic regurgitation

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Chronic AR — intervention-timing engine with the aorta as co-primary (aortopathy thresholds drive root/ascending surgery independent of valve). Surgical AVR standard; AR a poor TAVR substrate. Sibling-differentiated from AS and from acute AR (emergency). Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (intervention+bridge axis + workups + calculators + panels), test_files, 12-PMID evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): procedure entries (AVR, aortic replacement, transcatheter AR device) marked non_pharm; bridge RxCUIs reused from validated cardio dossiers. 9 trigger/special-pop branches: Class I symptomatic/LV, LVESD IIa, bicuspid aortopathy, syndromic aortopathy, acute AR emergency, pregnancy, CKD, post-AVR LV dysfunction.

Entry points (6)

  • symptom
    Early diastolic decrescendo murmur at LSB
    diastolic_decrescendo_murmur
  • vital_abnormality
    Wide pulse pressure / bounding pulses
    wide_pulse_pressure
  • imaging
    Echo: severe AR (VC >0.6 cm, RF ≥50%, EROA ≥0.30 cm², holodiastolic flow reversal)
    echo_severe_ar
  • imaging
    Bicuspid aortic valve / aortic root or ascending dilatation
    bicuspid_or_root_dilatation
  • symptom
    Exertional dyspnea / reduced exercise tolerance
    exertional_dyspnea
  • problem_list
    Known chronic AR — surveillance visit
    known_chronic_ar

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Surgical risk + bicuspid/syndromic aortopathy probability
  • ar_acuityrequired
    imaging • used at FRAME
    Chronic (compensated dilated LV) vs acute (small non-compliant LV, shock) — acute routes out
  • ar_severityrequired
    imaging • used at INITIAL_WORKUP
    VC/RF/EROA/flow-reversal → ACC/AHA stage
  • lvefrequired
    imaging • used at RISK_STRATIFICATION
    LVEF ≤55% in severe AR = Class I AVR (stage C2)
  • lvesdrequired
    imaging • used at RISK_STRATIFICATION
    LVESD >50 mm (or >25 mm/m² indexed) = Class IIa AVR
  • aortic_diameterrequired
    imaging • used at RISK_STRATIFICATION
    Root/ascending diameter drives aortic replacement independent of valve
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptomatic severe AR (stage D) = Class I AVR
  • syndromic_aortopathy
    history • used at CONTEXT
    Marfan/Loeys-Dietz/vEDS lower aortic surgical threshold + ARB/BB therapy
  • sbprequired
    vital • used at TREATMENT
    HTN raises wall stress — BP control bridge (ACEi/ARB/DHP-CCB)
  • bicuspid_valve
    history • used at CONTEXT
    Bicuspid aortopathy lower threshold + first-degree family screening
  • creatininerequired
    lab • used at TREATMENT
    Contrast for CT aorta + peri-op risk

12-phase flow (12)

  1. 1FRAME
    Confirm chronic AR; if acute severe AR (dissection/endocarditis) → emergency route cardio.aortic-dissection.core.v1 / IE engine
    inputs: ar_acuity
    advance: chronic AR confirmed
  2. 2ENTRY
    Diastolic murmur, wide pulse pressure, bicuspid valve, root dilatation, dyspnea
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Etiology (bicuspid/syndromic/degenerative/rheumatic), BP, symptoms, family history
    inputs: bicuspid_valve, syndromic_aortopathy
    advance: etiology + context complete
  4. 4RED_FLAGS
    Acute severe AR, dissection features, decompensation
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to emergency pathway
  5. 5INITIAL_WORKUP
    TTE: severity, LVEF, LVESD/LVEDD (indexed), root + ascending dimensions; ECG
    inputs: ar_severity
    actions: panel.cardiac
    advance: severity + LV + aortic metrics quantified
  6. 6BRANCHING_WORKUP
    CMR for regurgitant fraction; CT/MR aorta; genetics for syndromic aortopathy; exercise test for symptom status
    inputs: aortic_diameter
    actions: preop_cardiac
    advance: quantification + aortopathy + symptom status resolved
  7. 7DIFFERENTIAL
    Chronic vs acute AR; valve-driven vs aortopathy-driven; mixed AS/AR
    inputs: ar_acuity, ar_severity
    advance: chronic severe AR confirmed/staged
  8. 8RISK_STRATIFICATION
    ACC/AHA stage (C1/C2/D); LVEF ≤55%; LVESD >50 mm (or >25 mm/m²); aortic diameter thresholds
    inputs: lvef, lvesd, aortic_diameter, nyha_class
    advance: stage + intervention class assigned
  9. 9TREATMENT
    AVR timing (Class I/IIa); root/ascending replacement by aortopathy thresholds; BP control + aortopathy medical bridge
    inputs: sbp, creatinine
    advance: intervention decision documented or surveillance plan set
  10. 10DISPOSITION
    Aortic/valve surgical referral; surveillance interval by stage + aortic size
    inputs: nyha_class
    actions: preop_cardiac
    advance: referral or surveillance plan set
  11. 11MONITORING
    Serial TTE + aortic imaging by severity and root size
    inputs: ar_severity, aortic_diameter
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Family screening (bicuspid/syndromic); route to HFrEF engine if LV dysfunction
    inputs: lvef
    advance: follow-up + screening + escalation triggers documented