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cardio.atrial_flutter.with-pe.v1

Atrial flutter with concurrent acute pulmonary embolism

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Phase E variant of cardio.atrial_flutter.v1 — composite atrial flutter + concurrent acute pulmonary embolism. Inherits AC + acute rate/rhythm management from parent; specializes for PE-severity-tiered reperfusion (massive → systemic tPA per ESC 2019 PMID 31504429; sub-massive → CDT/EKOS per OPTALYSE-PE; low-risk → DOAC alone) + RV-protective rate control (REDUCED-DOSE BB or diltiazem; AVOID full doses with RV failure) + dual-indication AC (DOAC at full PE-treatment dose covers both AFL stroke + PE). PEITHO trial (Meyer NEJM 2014 PMID 24716683) supports tenecteplase for sub-massive PE but with significant bleed risk; CDT/EKOS preferred in age >75 or high-bleed-risk per OPTALYSE-PE. PE Response Team (PERT) activation recommended for all massive/sub-massive presentations; multidisciplinary triage between systemic tPA, CDT/EKOS, surgical embolectomy, V-A ECMO. CHA2DS2-VASc + PE indication → lifelong full-dose AC if AFL persistent or unprovoked PE. Routes long-term AFL ablation to typical/atypical variants per ECG morphology; 3-mo follow-up echo for CTEPH screen mandatory. Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (4)

  • symptom
    Atrial flutter on monitor + acute dyspnea / pleuritic chest pain / unexplained tachycardia → CT-PA to evaluate concurrent PE
    aflutter_with_acute_dyspnea_pleuritic_pain
  • imaging
    CT-PA confirmed PE in patient with atrial flutter on telemetry — composite event
    cta_pe_with_aflutter_on_telemetry
  • imaging
    New AFL on ECG with RV strain pattern (S1Q3T3, T-wave inversions V1-V4, RBBB) → STAT CT-PA
    rv_strain_pattern_with_new_aflutter
  • history
    Syncope or pre-syncope in patient with known AFL — exclude massive PE before attributing to RVR
    syncope_with_known_aflutter_unexplained

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    CHA2DS2-VASc + PE severity scoring (PESI) + frailty/bleed-risk for thrombolysis decision
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 with PE = massive PE (Class I thrombolysis); SBP <90 with AFL RVR = unstable arrhythmia → DCCV; both states warrant ICU
  • hrrequired
    vital • used at CONTEXT
    AFL RVR + PE-induced sinus tachy combine to drive demand ischemia + RV failure; HR target 80–110
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia from V/Q mismatch in PE; supplemental O2 if SpO2 <90%; HFNC or BiPAP for respiratory failure
  • cta_perequired
    imaging • used at INITIAL_WORKUP
    CT-PA gold standard for PE diagnosis; clot burden + RV/LV ratio + central vs peripheral location drives severity tiering — ESC 2019 (PMID 31504429)
  • echo_rv_strainrequired
    imaging • used at INITIAL_WORKUP
    Bedside echo for RV strain (McConnell sign, septal flattening, dilated IVC, TAPSE <16); drives sub-massive PE classification + thrombolysis decision — ESC 2019
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Confirm AFL morphology + rate; look for RV strain pattern (S1Q3T3, RBBB, anterior T-wave inversions); rule out STEMI mimics
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Troponin elevation in PE indicates RV strain/microinfarction → sub-massive classification; persistent elevation portends worse outcomes — ESC 2019
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    NT-proBNP rise reflects RV pressure overload; elevation supports sub-massive PE; combined with troponin for risk tiering — ESC 2019
  • d_dimer
    lab • used at INITIAL_WORKUP
    D-dimer often elevated in AFL alone (low specificity); use to support clinical pre-test probability per Wells/Geneva but CT-PA is definitive given pre-test probability already raised
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    eGFR for DOAC dose adjustment (PE treatment dose) + contrast for CT-PA + IV contrast risk
  • platelets_inr_pttrequired
    lab • used at INITIAL_WORKUP
    Baseline coags pre-thrombolysis screening (tPA contraindicated if plt <100k or INR >1.7) + AC initiation
  • lactaterequired
    lab • used at RED_FLAGS
    Lactate elevation indicates tissue hypoperfusion from RV failure / shock; >2 mmol/L raises concern for massive PE
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    CHA2DS2-VASc for AFL stroke risk; combined with PE indication → indefinite full-dose AC if AFL persistent
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED + PE-thrombolysis bleed contraindications (recent surgery, GI bleed, prior ICH, current AC)
  • pfo_history_or_paradoxical_embolism_signs
    history • used at BRANCHING_WORKUP
    Patent foramen ovale with right-to-left shunt → paradoxical embolism risk (stroke despite PE); bubble study on TTE

12-phase flow (12)

  1. 1FRAME
    Atrial flutter + acute pulmonary embolism — composite event with two parallel decisions: (1) PE severity triage (massive vs sub-massive vs low-risk) drives reperfusion (systemic tPA / CDT-EKOS / AC alone); (2) AFL rate control with RV-protective dosing (BB/diltiazem cautious — RV failure intolerant) + dual AC indication (CHA2DS2-VASc + PE → DOAC full dose). ESC 2019 PE (PMID 31504429) + ACC/AHA 2024 AF (PMID 38753446)
    inputs: cta_pe, echo_rv_strain
    advance: composite AFL + PE confirmed
  2. 2ENTRY
    AFL on telemetry + acute dyspnea / pleuritic pain / RV strain on ECG → STAT CT-PA; or CT-PA confirmed PE + AFL on monitor
    inputs: age, spo2
    advance: engine entered
  3. 3CONTEXT
    PE risk factors (recent immobilization, surgery, malignancy, OCP/HRT, prior VTE), AFL chronicity + prior AC, bleed history, comorbidities, allergies, baseline functional status
    inputs: hr, cha2ds2_vasc_factors, bleeding_history
    advance: context complete
  4. 4RED_FLAGS
    Massive PE (SBP <90 + RV failure → systemic thrombolysis Class I); AFL with hemodynamic instability (DCCV — but consider PE as primary cause first); progressive hypoxemic respiratory failure (HFNC/BiPAP/intubation with caution due to PEEP-induced RV afterload); rising lactate signaling tissue hypoperfusion
    inputs: sbp, spo2, lactate
    actions: tachycardia
    advance: stable or thrombolysed/cardioverted
  5. 5INITIAL_WORKUP
    STAT CT-PA + bedside echo (RV strain) + ECG (AFL + RV strain pattern) + troponin + NT-proBNP + BMP + CBC + coags + lactate; Wells/Geneva score documented but CT-PA is definitive in this composite presentation
    inputs: cta_pe, echo_rv_strain, ecg_12_lead, troponin, nt_probnp, creatinine_egfr, platelets_inr_ptt
    actions: acs_pathway, panel.cardiac, panel.coag, panel.renal
    advance: PE severity tier assigned + AFL morphology confirmed
  6. 6BRANCHING_WORKUP
    TTE bubble study for PFO (paradoxical embolism risk if right-to-left shunt + PE); LE Doppler for residual DVT; CT chest with HRCT if alternative pulmonary pathology suspected; route concomitant AF detection to cardio.afib.core.v1; TEE pre-cardioversion if AFL persistent + AC <3 wk
    inputs: pfo_history_or_paradoxical_embolism_signs
    actions: afib_new_onset
    advance: branch resolved
  7. 7DIFFERENTIAL
    AFL+PE vs AFL alone with sinus tachycardia mimicking PE; PE alone with secondary AF/flutter; ACS with arrhythmia (acs_pathway routing); pneumonia/COPD exacerbation with concurrent AFL
    advance: differential resolved
  8. 8RISK_STRATIFICATION
    PE severity tier (massive: SBP <90; sub-massive: normotensive + RV strain + troponin/BNP elevation; low-risk: normotensive + no RV strain) — ESC 2019 (PMID 31504429); CHA2DS2-VASc for AFL; HAS-BLED for AC + thrombolysis bleed risk
    inputs: cha2ds2_vasc_factors, bleeding_history
    actions: calc.cha2ds2vasc, calc.has_bled
    advance: tier documented
  9. 9TREATMENT
    Massive PE → systemic tPA 100 mg over 2 h (or 0.5 mg/kg over 15 min if cardiac arrest) + UFH bridge; sub-massive PE → CDT/EKOS per OPTALYSE-PE if center available, else AC alone with close monitoring; low-risk PE → DOAC alone (apixaban 10 mg BID × 7 d → 5 mg BID; or rivaroxaban 15 mg BID × 21 d → 20 mg daily). AFL rate control with REDUCED-DOSE BB (metoprolol 2.5–5 mg IV initially, watch for RV failure worsening; AVOID full doses if SBP <100 or echo RV failure) or low-dose diltiazem; AVOID full AVN blockade — RV needs preload + chronotropy. AC: DOAC at full PE-treatment dose covers both AFL stroke + PE; lifelong if AFL persistent. Avoid systemic thrombolysis in AFL alone — only for massive PE.
    inputs: sbp, creatinine_egfr, lactate
    advance: PE-tier-specific reperfusion + RV-protective rate control + dual-indication AC documented
  10. 10DISPOSITION
    Massive/sub-massive PE → ICU; AFL with stable PE → step-down telemetry; CDT/EKOS → IR/cath lab post-procedure ICU; coordinate with PE Response Team (PERT) where available
    advance: disposition documented
  11. 11MONITORING
    Telemetry continuous for AFL + arrhythmia; serial troponin/NT-proBNP for RV strain trend; daily echo for first 48 h post-thrombolysis; BMP + creatinine for DOAC dose; SpO2 + work of breathing; PE follow-up echo at 3 mo for chronic thromboembolic pulmonary hypertension (CTEPH) screen
    inputs: ecg_12_lead
    advance: monitoring orders documented
  12. 12FOLLOWUP
    Pulmonology + cardiology + EP for AFL ablation candidacy; 3-mo follow-up echo for CTEPH screen (~3% incidence post-PE); thrombophilia workup if unprovoked PE + age <50; lifelong DOAC if AFL persistent or unprovoked PE; CTI ablation for typical AFL; pulmonary rehab
    advance: follow-up booked + secondary prevention plan