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cardio.cardio-pulmonary.group2-ph.chronic.v1

Pulmonary hypertension due to left heart disease (Group 2 PH, cross-system)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Group 2 PH (PH due to left heart disease) — RHC phenotyping (Ipc vs Cpc); dominant not-to-miss: PAH-specific drugs NOT indicated/HARMFUL — treat the LHD (phenotype-specific HF GDMT / valve intervention / decongestion) + reassess PVR reversibility; RHC informs transplant PVR candidacy. Manifest points at existing sibling cardio.acute-hf.core.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (treat-LHD + no-PAH-drug-guardrail axis + workups + calculators + panels), test_files, 5-PMID evidence object (2022 ESC/ERS PH referenced by name — evidence-gap, not fabricated), chronic phases all present. HF-GDMT drug RxCUIs reused from RxNav-validated cardio dossiers (dapagliflozin 1488564, empagliflozin 1545653, sacubitril/valsartan 1656340, finerenone 2627043, carvedilol 20352, spironolactone 9997, furosemide 4603); valve-intervention/referral/guardrail non_pharm; SNOMED deferred. 9 trigger/special-pop branches: no-PAH-drugs (not-to-miss), Cpc-PH, HFpEF-Group2, valvular-Group2, HFrEF-Group2, combined-Group2+3, transplant-PVR, PVR-reversibility, secondary-TR.

Entry points (5)

  • imaging
    Echo: elevated PASP/RV strain with HFrEF/HFpEF/valve/LA disease
    echo_ph_with_lhd
  • symptom
    Worsening dyspnea in known left heart disease
    dyspnea_with_known_lhd
  • lab_abnormality
    Rising NT-proBNP with PH features + left heart disease
    rising_np_with_lhd
  • history
    RHC showing post-capillary (PAWP >15) PH
    ph_on_rhc_postcapillary
  • medication
    PAH-specific drug prescribed in suspected Group 2 PH
    inappropriate_pah_drug_in_group2

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    HFpEF/Group-2 prevalence; transplant candidacy
  • left_heart_disease_typerequired
    imaging • used at FRAME
    HFrEF vs HFpEF/HFmrEF vs valvular vs LA disease — the driver to treat
  • pawprequired
    imaging • used at RISK_STRATIFICATION
    PAWP >15 mmHg defines post-capillary (Group 2) PH
  • pvrrequired
    imaging • used at RISK_STRATIFICATION
    PVR ≤2 WU (Ipc-PH) vs >2 WU (Cpc-PH) — phenotype + prognosis
  • rv_function
    imaging • used at INITIAL_WORKUP
    RV strain/dysfunction — severity + transplant implications
  • natriuretic_peptide
    lab • used at INITIAL_WORKUP
    LHD severity + monitoring; supports Group 2 over Group 1
  • lung_disease
    history • used at CONTEXT
    Comorbid lung disease → combined Group 2+3 PH
  • current_medsrequired
    medication • used at CONTEXT
    Detect inappropriate PAH-specific therapy in Group 2 PH
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Functional class; transplant evaluation
  • creatininerequired
    lab • used at TREATMENT
    HF GDMT dosing; RHC contrast

12-phase flow (12)

  1. 1FRAME
    PH suspected with a left-heart driver — frame as Group 2 (not Group 1/3/4)
    inputs: left_heart_disease_type
    advance: left-heart driver + Group-2 hypothesis framed
  2. 2ENTRY
    PH on echo + LHD, dyspnea, rising NP, post-capillary RHC, inappropriate PAH drug
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    HF phenotype, valve lesion, LA disease, comorbid lung disease, current meds
    inputs: lung_disease, current_meds
    advance: driver + comorbidity context complete
  4. 4RED_FLAGS
    Decompensated LHD, RV failure
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    Echo (LHD + PASP + RV), NT-proBNP, ECG
    inputs: rv_function, natriuretic_peptide
    actions: panel.cardiac
    advance: LHD + PH severity documented
  6. 6BRANCHING_WORKUP
    Right-heart catheterisation (PAWP/PVR/TPG → Ipc vs Cpc); exclude superimposed Group 1/3/4
    inputs: pawp, pvr
    actions: preop_cardiac
    advance: post-capillary confirmed + Ipc/Cpc phenotyped
  7. 7DIFFERENTIAL
    Group 2 vs Group 1/3/4; Ipc-PH vs Cpc-PH; combined Group 2+3
    inputs: pawp, pvr, lung_disease
    advance: PH group + phenotype assigned
  8. 8RISK_STRATIFICATION
    Cpc-PH = worse prognosis; fixed/elevated PVR → heart-transplant candidacy implications
    inputs: pvr, nyha_class
    advance: phenotype + prognosis + transplant implication assigned
  9. 9TREATMENT
    Optimise the LHD (phenotype-specific HF GDMT / valve intervention / decongestion); do NOT use PAH-specific drugs; reassess PVR reversibility
    inputs: left_heart_disease_type, creatinine
    advance: LHD-optimisation plan + no-PAH-drug guardrail documented
  10. 10DISPOSITION
    HF/valve clinic; PH-expert centre for Cpc-PH / transplant candidacy
    inputs: pvr
    actions: preop_cardiac
    advance: referral plan set
  11. 11MONITORING
    Reassess PVR/PASP + symptoms after LHD optimisation (reversibility); RV function
    inputs: pvr, natriuretic_peptide
    actions: panel.cardiac
    advance: reversibility-reassessment cadence documented
  12. 12FOLLOWUP
    Transplant candidacy reassessment; re-phenotype if PH persists/worsens despite LHD optimisation
    inputs: pvr
    advance: long-term plan documented