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cardio.aortic-stenosis.low-flow-low-gradient.v1

Low-flow low-gradient severe aortic stenosis (classical + paradoxical)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

LFLG severe AS — diagnostic-and-decision sub-engine of cardio.aortic_stenosis.v1: DSE + sex-specific CT calcium adjudicate true-vs-pseudo; paradoxical LFLG triggers ATTR screen (ATTR-AS overlap). Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (adjudicate→AVR axis + workups + calculators + panels), test_files, 10-PMID evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): procedure/diagnostic entries (DSE, CT calcium, PYP, SAVR, TAVR) marked non_pharm; GDMT bridge RxCUIs reused from validated cardio.hfref.core.v1. 9 trigger/special-pop branches: classical true-severe, no-contractile-reserve, paradoxical, ATTR overlap, pseudo-severe, AF confounder, CKD, elderly/frailty, decompensated low-output.

Entry points (4)

  • imaging
    Echo: AVA ≤1.0 cm² with mean gradient <40 mmHg / Vmax <4 m/s (discordant)
    ava_le_1_low_gradient
  • imaging
    Echo: stroke volume index <35 mL/m² (low-flow state)
    low_stroke_volume_index
  • symptom
    Exertional dyspnea / syncope / angina with discordant AS
    exertional_dyspnea_syncope_angina
  • problem_list
    HFrEF with concomitant aortic stenosis (classical LFLG query)
    hfref_with_as

Required inputs (12)

  • agerequired
    demographic • used at RISK_STRATIFICATION
    Surgical risk + SAVR vs TAVR decision
  • sexrequired
    demographic • used at BRANCHING_WORKUP
    CT aortic-valve calcium score thresholds are sex-specific (men ≥2000, women ≥1200–1300 AU)
  • lvefrequired
    imaging • used at FRAME
    LVEF <50% = classical LFLG; ≥50% = paradoxical LFLG — different pathways
  • aortic_valve_arearequired
    imaging • used at INITIAL_WORKUP
    AVA ≤1.0 cm² is the severity gate that conflicts with the low gradient
  • mean_gradientrequired
    imaging • used at INITIAL_WORKUP
    <40 mmHg defines the low-gradient discordance
  • stroke_volume_indexrequired
    imaging • used at INITIAL_WORKUP
    SVi <35 mL/m² defines the low-flow state
  • contractile_reserve
    imaging • used at BRANCHING_WORKUP
    Dobutamine stress echo: contractile reserve + true-vs-pseudo severe (classical)
  • aortic_valve_calcium_score
    imaging • used at BRANCHING_WORKUP
    CT Agatston score adjudicates severity when DSE inconclusive / paradoxical
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptomatic true-severe LFLG = AVR indication
  • amyloid_red_flags
    history • used at BRANCHING_WORKUP
    Small restrictive LV + low voltage / neuropathy / carpal tunnel → ATTR screen
  • atrial_fibrillation
    history • used at CONTEXT
    AF + MR worsen the low-flow state and confound severity assessment
  • creatininerequired
    lab • used at TREATMENT
    Contrast for CT calcium / coronary / TAVR planning

12-phase flow (12)

  1. 1FRAME
    Confirm LFLG pattern; classical (LVEF <50%) vs paradoxical (LVEF ≥50%)
    inputs: lvef
    advance: LFLG phenotype assigned
  2. 2ENTRY
    Discordant AVA ≤1.0 / low gradient on echo; HF symptoms
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    LVEF, SVi, AF, MR, LV geometry, symptoms, amyloid red flags
    inputs: atrial_fibrillation
    advance: flow-state confounders catalogued
  4. 4RED_FLAGS
    Decompensated HF, syncope, critically symptomatic AS
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    TTE: AVA, mean gradient, SVi, LVEF, dimensionless index; BNP; ECG
    inputs: aortic_valve_area, mean_gradient, stroke_volume_index
    actions: panel.cardiac
    advance: flow + gradient + AVA quantified
  6. 6BRANCHING_WORKUP
    Dobutamine stress echo (classical); CT aortic-valve calcium score (sex-specific); ATTR amyloid screen if small restrictive LV; coronary assessment
    inputs: contractile_reserve, aortic_valve_calcium_score, amyloid_red_flags, sex
    actions: preop_cardiac
    advance: true-vs-pseudo + amyloid resolved
  7. 7DIFFERENTIAL
    True-severe vs pseudo-severe vs normal-flow low-gradient vs measurement error vs ATTR-CM phenocopy
    inputs: aortic_valve_area, contractile_reserve
    advance: severity adjudicated
  8. 8RISK_STRATIFICATION
    Phenotype, contractile reserve, STS surgical risk, frailty
    inputs: nyha_class, age
    advance: severity + risk + access strategy assigned
  9. 9TREATMENT
    AVR (SAVR/TAVR) for true-severe symptomatic; manage as moderate AS if pseudo-severe; GDMT for classical HFrEF component
    inputs: creatinine
    advance: AVR decision or moderate-AS plan documented
  10. 10DISPOSITION
    Heart-team for valve + access route; advanced HF if no contractile reserve
    inputs: nyha_class
    actions: preop_cardiac
    advance: heart-team plan set
  11. 11MONITORING
    Serial TTE; reassess flow state after GDMT/AF control
    inputs: aortic_valve_area, lvef
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Post-AVR surveillance; route to ATTR-CM engine if amyloid confirmed; HFrEF engine for classical component
    inputs: lvef
    advance: follow-up + escalation triggers documented