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cardio.hf-improved.core.v1

Heart failure with improved EF (HFimpEF — recovered, prior LVEF ≤40)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Recovered-EF (HFimpEF) phenotype split from cardio.hf.core.v1. Defining rule: continue full HFrEF 4-pillar GDMT indefinitely (TRED-HF — ~44% relapse on phased withdrawal). Distinct from de-novo HFmrEF (cardio.hfmref.core.v1) — decided by documented prior LVEF ≤40. Manifest points at existing sibling cardio.acute-hf.core.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (continue-GDMT regimen axis + workups + panels + calculators), test_files, 16-PMID evidence object, and chronic phases all present. INTEGRATED (not PRODUCTION): GDMT RxCUIs reused from RxNav-validated cardio.hfref.core.v1; procedure entries (ablation, ICD) marked non_pharm. 9 special-population / relapse severity triggers including inappropriate de-escalation, relapse-to-HFrEF, tachycardia-mediated, recovered PPCM, arrhythmogenic genotype, chemo-cardiotoxicity, CKD, pregnancy, alcohol/toxin.

Entry points (5)

  • imaging
    Echo LVEF now >40 with documented prior ≤40 (≥10-pt rise)
    echo_lvef_improved
  • problem_list
    Known recovered-EF HF — surveillance visit
    hfimpef_existing
  • history
    Prior HFrEF, asymptomatic on GDMT — recovery query
    prior_hfref_on_gdmt
  • symptom
    Patient asks to stop HF meds because "EF is normal"
    patient_requests_med_stop
  • history
    Recent HF admission with subsequent EF recovery
    recent_hf_admission

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    GDMT tolerability + drug dosing
  • prior_lvefrequired
    imaging • used at FRAME
    HFimpEF requires documented historical LVEF ≤40 — defines this engine vs de-novo HFmrEF
  • current_lvefrequired
    imaging • used at FRAME
    Current LVEF >40 with ≥10-pt rise = recovered phenotype
  • sbprequired
    vital • used at CONTEXT
    Continued RAS/ARNi/BB tolerability monitoring
  • hrrequired
    vital • used at CONTEXT
    BB titration; rhythm (tachycardia-mediated CM recovery)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for continued SGLT2i/MRA/RAS dosing
  • potassiumrequired
    lab • used at CONTEXT
    Continued MRA/RAS safety monitoring
  • nt_probnp
    lab • used at RISK_STRATIFICATION
    Residual elevation predicts relapse; surveillance + withdrawal monitoring
  • cmr_lge
    imaging • used at RISK_STRATIFICATION
    Residual fibrosis predicts incomplete recovery + relapse/SCD risk
  • original_cm_etiologyrequired
    history • used at BRANCHING_WORKUP
    Tachycardia-mediated/PPCM/alcohol/myocarditis/chemo recovery — drives surveillance + counseling
  • familial_dcm
    history • used at BRANCHING_WORKUP
    Genetic DCM (LMNA/FLNC/DSP/RBM20) → ICD by genotype independent of recovered EF
  • current_medsrequired
    medication • used at CONTEXT
    Confirm full GDMT in place; detect inappropriate de-escalation
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptom status — asymptomatic does NOT license de-escalation (TRED-HF)

12-phase flow (12)

  1. 1FRAME
    Confirm HFimpEF: documented prior LVEF ≤40 + ≥10-pt rise + current >40. If never ≤40 → cardio.hfmref.core.v1; if currently ≤40 → cardio.hfref.core.v1
    inputs: prior_lvef, current_lvef
    advance: recovered-EF definition met
  2. 2ENTRY
    Surveillance visit, recovery on echo, or patient request to stop meds
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Original etiology, current GDMT regimen, comorbidities, genetics
    inputs: sbp, hr, creatinine, potassium, current_meds
    advance: regimen + comorbidity context complete
  4. 4RED_FLAGS
    Decompensation, hyperK/AKI on continued GDMT, symptomatic relapse
    inputs: creatinine, potassium
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    NT-proBNP, BMP, echo with GLS, ECG; CMR for residual LGE
    inputs: nt_probnp
    actions: panel.cardiac, panel.renal
    advance: recovery completeness assessed
  6. 6BRANCHING_WORKUP
    Identify the reversible cause that drove recovery (tachycardia-mediated, PPCM, alcohol/toxin, myocarditis, stress, thyroid, chemo); genetic testing for familial DCM
    inputs: original_cm_etiology, familial_dcm
    actions: afib_new_onset
    advance: etiology + genetic risk characterised
  7. 7DIFFERENTIAL
    HFimpEF vs de-novo HFmrEF vs HFpEF vs still-≤40 (incomplete recovery)
    inputs: prior_lvef, current_lvef
    advance: recovered phenotype confirmed
  8. 8RISK_STRATIFICATION
    Relapse/SCD risk: residual LGE, abnormal GLS, NT-proBNP, arrhythmogenic genotype; ICD by genotype independent of EF
    inputs: nyha_class, cmr_lge
    advance: relapse + SCD risk documented
  9. 9TREATMENT
    CONTINUE all 4 GDMT pillars indefinitely at achieved doses; treat persisting cause; do NOT de-escalate (TRED-HF)
    inputs: current_meds, sbp, creatinine, potassium
    advance: full GDMT confirmed continued; etiology-directed plan set
  10. 10DISPOSITION
    Lifelong cardiology follow-up; advanced-HF referral on relapse
    inputs: nyha_class
    actions: preop_cardiac
    advance: follow-up plan set
  11. 11MONITORING
    Serial echo + NT-proBNP; if any shared-decision de-escalation attempted → TRED-HF intensive surveillance (echo+NP at 1/3/6 mo, reverse at first relapse sign)
    inputs: creatinine, potassium, nt_probnp
    actions: panel.renal
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Re-route to HFrEF if EF falls ≤40; genetic + pregnancy counseling where relevant
    inputs: current_lvef
    advance: follow-up + counseling scheduled