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cardio.geriatric-frailty-hf.chronic.v1

Heart failure in the frail older adult (chronic, sub-population)

cardiologychronicgeriatricadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Frail-elder HF chronic — tolerability-weighted GDMT (SGLT2i favored, DELIVER frailty subgroup) + STOPP/START deprescribing + orthostasis/falls mitigation + REHAB-HF rehab/nutrition + goals-of-care/palliative integration; deprescribe when harm > benefit. Completes the explicit STEP 3 list (sub-population variants). Manifest points at existing sibling cardio.acute-hf.core.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (tolerability-weighted + deprescribe + goals axis + workups + calculators + panels), test_files, 5-PMID evidence object (REHAB-HF/STOPP-START referenced by name — evidence-gap, not fabricated), chronic phases all present. Drug RxCUIs reused from RxNav-validated cardio dossiers (dapagliflozin 1488564, sacubitril/valsartan 1656340, bisoprolol 19484, spironolactone 9997, finerenone 2627043, furosemide 4603, midodrine 36117); assessment/deprescribe/rehab/palliative non_pharm; SNOMED deferred. 9 trigger/special-pop branches: iatrogenic-overtreatment (not-to-miss), severe-frailty goals, polypharmacy STOPP/START, orthostasis/falls, cognitive-impairment, sarcopenia/rehab, HFpEF-predominant, CKD-limiting, AF-AC-balance.

Entry points (5)

  • problem_list
    Heart failure in a frail older adult (HFpEF-predominant)
    hf_in_frail_elder
  • symptom
    GDMT intolerance / symptomatic hypotension / falls on HF meds
    gdmt_intolerance_hypotension
  • medication
    High polypharmacy burden with HF regimen
    polypharmacy_burden
  • symptom
    Recurrent falls / orthostatic hypotension
    falls_orthostasis
  • history
    Goals-of-care / palliative review in advanced HF + frailty
    goals_of_care_review

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older-adult HF management + prognosis framing
  • hf_phenotyperequired
    imaging • used at FRAME
    HFpEF (predominant in elderly) vs HFrEF/HFmrEF — GDMT intensity
  • frailty_severityrequired
    history • used at RISK_STRATIFICATION
    Clinical Frailty Scale — drives disease-modifying vs symptom-focused intensity
  • current_medsrequired
    medication • used at CONTEXT
    Polypharmacy + STOPP/START deprescribing targets
  • orthostatic_bprequired
    vital • used at TREATMENT
    Orthostatic hypotension gates RAS/BB titration + diuretic dosing
  • renal_functionrequired
    lab • used at TREATMENT
    eGFR limits GDMT; over-diuresis pre-renal/falls
  • cognitive_status
    history • used at CONTEXT
    Cognitive impairment → adherence aids, caregiver, regimen simplification
  • falls_history
    history • used at RISK_STRATIFICATION
    Falls risk modifies BP target + drug choices
  • functional_status_goalsrequired
    symptom • used at RISK_STRATIFICATION
    Function + patient goals (what Matters) → care intensity
  • creatininerequired
    lab • used at TREATMENT
    Renal drug dosing

12-phase flow (12)

  1. 1FRAME
    HF phenotype + frailty severity + patient goals — set disease-modifying vs symptom-focused frame
    inputs: hf_phenotype
    advance: phenotype + frailty + goals framed
  2. 2ENTRY
    HF in frail elder, GDMT intolerance, polypharmacy, falls/orthostasis, goals review
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Multimorbidity, cognition, function, caregiver/SDOH, medication burden
    inputs: current_meds, cognitive_status
    advance: geriatric context complete
  4. 4RED_FLAGS
    Decompensation; iatrogenic harm — symptomatic hypotension/AKI/falls from over-treatment
    inputs: orthostatic_bp, renal_function
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed/iatrogenic harm addressed
  5. 5INITIAL_WORKUP
    Echo phenotype, BMP, orthostatic BP, frailty + cognition screen
    inputs: orthostatic_bp, renal_function
    actions: panel.cardiac, panel.renal
    advance: phenotype + frailty + safety metrics documented
  6. 6BRANCHING_WORKUP
    Clinical Frailty Scale, nutrition/sarcopenia, polypharmacy (STOPP/START) review, prognosis estimation
    inputs: frailty_severity
    actions: preop_cardiac
    advance: frailty + polypharmacy + prognosis characterised
  7. 7DIFFERENTIAL
    HF phenotype; frailty/competing-morbidity-driven vs cardiac-driven symptoms
    inputs: hf_phenotype, frailty_severity
    advance: symptom attribution + phenotype assigned
  8. 8RISK_STRATIFICATION
    Frailty + prognosis + goals → disease-modifying vs symptom-focused intensity
    inputs: frailty_severity, functional_status_goals
    advance: care intensity + goals tier assigned
  9. 9TREATMENT
    Tolerability-weighted GDMT (SGLT2i favored) + STOPP/START deprescribing + orthostasis/falls mitigation + nutrition/REHAB-HF rehab + goals-aligned palliative integration
    inputs: orthostatic_bp, renal_function, current_meds
    advance: tolerability-weighted plan + deprescribing + goals alignment documented
  10. 10DISPOSITION
    Geriatric-cardiology co-management; palliative referral when goals-aligned
    inputs: functional_status_goals
    actions: preop_cardiac
    advance: co-management/palliative plan set
  11. 11MONITORING
    Orthostatic BP, renal/K, falls, function, medication burden — de-escalate if harm > benefit
    inputs: orthostatic_bp, renal_function
    actions: panel.renal
    advance: monitoring cadence documented
  12. 12FOLLOWUP
    Periodic goals-of-care re-evaluation; caregiver support; re-phenotype if HF changes
    inputs: functional_status_goals
    advance: goals re-evaluation + caregiver plan documented