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cardio.aortic_stenosis.v1

Aortic stenosis (calcific + bicuspid + rheumatic; high-gradient & low-flow/low-gradient)

cardiologychronicacuteadultgeriatricoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Aortic stenosis dossier — severe = Vmax ≥4 / MG ≥40 / AVA ≤1.0 cm² (indexed ≤0.6); symptomatic severe = Class I AVR. Mean gradient is flow-dependent — use AVA + stroke-volume-index, never gradient alone in low-flow states. SAVR vs TAVR per Heart-Team + surgical risk/age/anatomy/bicuspid/concomitant-CABG; asymptomatic-severe early intervention now evidence-supported (EARLY-TAVR/RECOVERY/AVATAR). Avoid nitrates/ACEi-ARB in critical AS; phenylephrine first if hypotensive; balloon valvuloplasty as bridge only. AS has NO disease-modifying drug therapy — encoded explicitly as data (SEAS/ASTRONOMER/SALTIRE all negative); statin only for independent ASCVD. DEPTH-PASS-2 2026-05-17 (shard-07-cardio-chronic, chronic-valvular deepen): (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (20 verified PMIDs incl. EARLY-TAVR 39466903 / RECOVERY 31733181 / AVATAR 34779220 / PARTNER 3 30883058+37874020 / Evolut LR 30883053 / PARTNER 2 27040324 / SURTAVI 28304219 / CoreValve HR 24678937 / DEDICATE 38588025 / POPULAR-TAVI 32865376 / GALILEO 31733180+31733182 / SEAS 18765433 / ASTRONOMER 20048204 / SALTIRE 15944423; named trials + effect sizes + 95% CI + time-to-event; retrieval 2026-05-17; Consensus→WebSearch fallback logged); (2) cardio.aortic_stenosis.v1 ros+differentials+finding-lrs seed files deepened to chronic floors (12 differentials w/ cohort-anchored priors incl. AS severity/flow strata MECE, 14 ROS, LR rows w/ ≥15 LR+ AND ≥15 LR−, 3 conditional-dependency rules incl. gradient|flow-state and DSE-reserve|baseline-EF, T_test/T_treat in header); (3) 2 regimen axes (severity/symptom-staged ladder + phenotype/intervention matrix) encoding intervention × phenotype gating as DATA + explicit no-disease-modifying-drug encoding; (4) RxCUI bugs fixed: furosemide 4337→4603, metoprolol-succ 866427→221124, rivaroxaban added 1114195, validated vs canonical DrugEffectProfile profiles (non-pharm interventions flagged non_pharm:true); (5) intervention rationales enriched with all-cause-mortality/stroke/rehosp HR+95%CI+horizon from PARTNER/Evolut/RECOVERY/AVATAR/EARLY-TAVR/DEDICATE; (6) evidence.pmids 6→21 (stale 31995342/32413282/31774955/36316127 replaced with verified distinct set); content refreshed to 2020 ACC/AHA + 2021 ESC + EARLY-TAVR-era (TAVR expanded low→prohibitive risk, asymptomatic-severe early-intervention, post-TAVR SAPT/GALILEO contraindication, LFLG flow-state strata). 96-fail RxNav registry baseline OUT OF SCOPE per prompt; no hand-authored CUIs. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA (Siontis TAVI-vs-SAVR Eur Heart J 2019 PMID 31329852 mortality HR 0.88; Ueyama LFLG-AS AVR NMA JACC Interv 2021 PMID 33939605; Awad minimally-invasive SAVR-vs-TAVR Bayesian NMA J Cardiol 2023 PMID 37611742) +USPSTF (explicit "AS is NOT a USPSTF screening topic" flag; adjacent statin-B/aspirin-C-D/tobacco-A hooks documented) +Cochrane (CD012660 TAVI-vs-SAVR + CD009541 balloon valvuloplasty CD-IDs listed as W2-cache stubs, matched PMIDs deferred for live verification — not fabricated) +ICER (PARTNER 3 economic Galper Circulation 2023 PMID 37154049 TAVR cost-saving at 2 y projected dominant lifetime; Zhou Australian CE PMID 33189571 A$3,521/QALY balloon-expandable; Kuntjoro Singapore CE PMID 33000105 S$33,833/QALY) +Pauker-Kassirer thresholds explicit (T_test 5%/T_treat 20-30% asymptomatic severe early-intervention gate; LFLG flow-reserve T_test 10%/T_treat 50%; Class-I symptomatic = trivially-treat) anchored by PMID 7366635 (NEJM 1980); side-car at cardio.aortic_stenosis.v1._depth-pass-3.md. Zero schema churn; all 7 new PMIDs live-verified via PubMed MCP 2026-05-26. evidence.pmids 21→28.

Entry points (5)

  • symptom
    Classic AS triad — exertional syncope, angina, or HF (2020 ACC/AHA VHD §3.2)
    as_triad_syncope_angina_hf
  • symptom
    Progressive dyspnea on exertion in known AS (2020 ACC/AHA VHD §3.2)
    dyspnea_on_exertion_with_AS
  • imaging
    Late-peaking systolic ejection murmur with diminished/absent A2 (Etchells JAMA 1997 PMID 9032164)
    systolic_ejection_murmur
  • imaging
    Incidental severe AS on screening echo (2020 ACC/AHA VHD §3.2.3)
    incidental_severe_AS_on_echo
  • history
    Established AS in surveillance (2020 ACC/AHA VHD §3.2.4)
    prior_AS_surveillance

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    TAVR vs SAVR + prosthesis selection — TAVR favoured ≥65–80 y per 2020 ACC/AHA VHD §3.2.4 (PMID 33342586)
  • sbprequired
    vital • used at CONTEXT
    Hypotension/shock = critical-AS warning; afterload-dependent (2020 ACC/AHA VHD)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia + bradycardia both worsen fixed-obstruction supply–demand (2020 ACC/AHA VHD)
  • spo2required
    vital • used at CONTEXT
    Pulmonary congestion in decompensated AS (2020 ACC/AHA VHD)
  • bnp_or_ntprobnprequired
    lab • used at INITIAL_WORKUP
    LV-strain marker — markedly ↑ BNP is an asymptomatic-severe early-intervention trigger (2020 ACC/AHA VHD §3.2.3)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Contrast risk + SAVR-vs-TAVR weighting + post-AVR AC dosing (CKD-EPI 2021)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Anemia worsens symptoms; pre-procedure baseline; Heyde GI-bleed screen (2020 ACC/AHA VHD)
  • lipidsrequired
    lab • used at INITIAL_WORKUP
    ASCVD comorbidity ONLY — statin does NOT slow AS (SEAS 18765433 / ASTRONOMER 20048204 / SALTIRE 15944423)
  • tte_severity_gradingrequired
    imaging • used at INITIAL_WORKUP
    Vmax, mean gradient, AVA, dimensionless index, stroke-volume-index, EF — AVA+flow not gradient alone (2020 ACC/AHA VHD §3.2.2)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    LVH, conduction delay, baseline before TAVR PPM risk, AF (2020 ACC/AHA VHD)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Cardiomegaly, pulmonary congestion, valve calcification (2020 ACC/AHA VHD)
  • coronary_angio_or_cta
    imaging • used at BRANCHING_WORKUP
    CAD assessment pre-intervention (2020 ACC/AHA VHD §3.2.4)
  • tavr_sizing_ct
    imaging • used at BRANCHING_WORKUP
    Annular dimensions, calcium pattern, bicuspid morphology, vascular access (2020 ACC/AHA VHD)
  • dobutamine_stress_echo
    imaging • used at BRANCHING_WORKUP
    Classical low-flow/low-gradient AS — true-vs-pseudo-severe by flow reserve; valid only with reduced baseline EF (2020 ACC/AHA VHD §3.2.2)
  • frailty_and_comorbidityrequired
    history • used at CONTEXT
    STS/EuroSCORE + Heart-Team weighting + futility screen (2020 ACC/AHA VHD §3.2.4)
  • current_medsrequired
    medication • used at CONTEXT
    AVOID vasodilators/nitrates/ACEi-ARB in critical AS; reconcile anticoagulant for post-AVR plan (2020 ACC/AHA VHD)

12-phase flow (12)

  1. 1FRAME
    Confirm AS by TTE; classify severity (mild/moderate/severe) AND flow-state strata (high-gradient vs classical-LFLG low-EF vs paradoxical-LFLG preserved-EF vs normal-flow-low-gradient) using AVA + stroke-volume-index, NOT gradient alone (2020 ACC/AHA VHD §3.2.2, PMID 33342586)
    inputs: tte_severity_grading
    advance: Severity + flow strata assigned
  2. 2ENTRY
    Syncope / angina / HF / abnormal echo / surveillance (Ross-Braunwald triad; 2020 ACC/AHA VHD §3.2)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Frailty, comorbidity, valve anatomy (bicuspid), prior cardiac surgery, anticoagulant history, vasodilator-risk meds (2020 ACC/AHA VHD §3.2.4)
    inputs: frailty_and_comorbidity, sbp, hr, current_meds
    advance: Context complete; critical-AS vasodilator risk flagged
  4. 4RED_FLAGS
    Symptomatic severe AS, decompensated HF/pulmonary edema, exertional syncope, hemodynamic instability/critical AS (2020 ACC/AHA VHD)
    inputs: sbp, spo2
    actions: acute_pulm_edema
    advance: Stabilised or escalated to acute-HF engine
  5. 5INITIAL_WORKUP
    TTE (primary), ECG, CXR, BNP, BMP, CBC, lipids (2020 ACC/AHA VHD §3.2.3)
    inputs: tte_severity_grading, ecg_12_lead, cxr, bnp_or_ntprobnp, creatinine_egfr, cbc, lipids
    actions: panel.cardiac, panel.cbc, panel.lipid, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    Coronary angio/CTA pre-intervention; TAVR-sizing CT; low-dose dobutamine stress echo for classical LFLG; CMR for fibrosis/viability (2020 ACC/AHA VHD §3.2.2–3.2.4)
    inputs: coronary_angio_or_cta, tavr_sizing_ct, dobutamine_stress_echo
    advance: Branch resolved (incl. LFLG flow-reserve adjudication)
  7. 7DIFFERENTIAL
    Valvular AS vs HOCM dynamic LVOT vs sub/supravalvular AS vs aortic sclerosis vs MR vs AR vs flow/pulmonic-stenosis murmur; assign severity & flow strata (Etchells JAMA 1997 PMID 9032164)
    advance: Etiology + strata assigned
  8. 8RISK_STRATIFICATION
    AHA/ACC stages A–D; STS/EuroSCORE; Heart-Team SAVR-vs-TAVR; asymptomatic-severe early-intervention triggers (EARLY-TAVR HR 0.50 PMID 39466903 / RECOVERY HR 0.09 PMID 31733181 / AVATAR PMID 34779220)
    inputs: tte_severity_grading, frailty_and_comorbidity
    advance: Tier + intervention indication documented
  9. 9TREATMENT
    Definitive valve replacement (SAVR vs TAVR per Heart-Team + surgical risk/age/anatomy); peri-procedural pharmacology only (cautious diuresis, antithrombotic per POPULAR-TAVI/AF-status); NO disease-modifying drug — statin only for independent ASCVD; AVOID vasodilators in critical AS (2020 ACC/AHA VHD §3.2.4)
    inputs: creatinine_egfr, tte_severity_grading
    advance: Intervention plan + antithrombotic documented
  10. 10DISPOSITION
    Admit if decompensated / pre-procedure; outpatient cardiology surveillance otherwise (2020 ACC/AHA VHD)
    advance: Disposition documented
  11. 11MONITORING
    TTE q3–6 mo (very-severe asymptomatic), q6–12 mo (severe asymptomatic), q1–2 y (moderate); 30-d post-AVR echo; valve durability + HALT + PPM surveillance (2020 ACC/AHA VHD §3.2.5; PARTNER 3 5-yr PMID 37874020)
    advance: Schedule documented
  12. 12FOLLOWUP
    Cardiology / valve clinic; endocarditis prophylaxis after prosthetic AVR; lifestyle; vaccinations (2020 ACC/AHA VHD §3.2.5)
    advance: Follow-up booked