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cardio.hf.core.v1

Heart failure (chronic, GDMT titration)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

HFpEF and HFrEF currently share this dossier. Per inventory gap list, splitting into cardio.hfref.core.v1 and cardio.hfpef.core.v1 is a planned next step so each pillar can have its own evidence + regimen axis. Calculator gaps: MAGGIC, ADHERE, NEWS2 are not yet in clinical-tools-registry.ts — add before promoting to PRODUCTION. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template mirrored on cardio.htn.core.v1) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (24 verified PMIDs, named trials + effect sizes + 95% CI, retrieval-dated 2026-05-16, Consensus→PubMed-primary fallback logged; design_brief field repointed to src/lib/dossiers/cardio.hf.core.v1._design-brief.md); (2) cardio.hf.core.v1 ros+differentials+finding-lrs seed files DEEPENED in place (12 differentials w/ cohort-anchored priors incl. HFmrEF + ATTR + look-alikes, 14 ROS, 38 LR rows = 22 LR+/16 LR−, 3 conditional-dependency rules — NT-proBNP|obesity/AF/age, H2FPEF|EF, S3/JVD co-congestion — T_test≈5%/T_treat≈60%); (3) regimen axes refactored to 2 phenotypic axes: gdmt_4_pillar_hfref now a 4-step RAPID-SIMULTANEOUS-initiation ladder (STRONG-HF + 2024 ACC Consensus) and new hf_phenotype_comorbidity_matrix encoding drug × EF-band × comorbidity (CKD/AF/T2DM/iron/low-BP/ATTR) gating as DATA; (4) RxCUI bugs fixed vs canonical DrugEffectProfile registry (rxnav:validate run live): sacubitril/valsartan 1656340→1656339, metoprolol-succ 866427→221124, finerenone 2168780→2562811, metolazone 4109→6916; setting_playbook drug_action rxcui placeholders repointed; (5) 2026-guideline content refresh: 6 stale/fabricated evidence PMIDs corrected (FINEARTS-HF 39264738→39225278 [was a vanadium-chemistry paper], STEP-HFpEF 37622663→37622681, DELIVER 36027571→36027570, COPERNICUS 11386262→11386263, MERIT-HF 10377659→10376614, guideline 35379504→35363499/35379503), 2 SUSPECTED_FABRICATION PMIDs (29766750/23900119) removed, vericiguat (VICTORIA) + ATTR-CM (ATTR-ACT) + finerenone-HFpEF + SGLT2i-across-full-EF folded in; evidence.pmids 23→26 verified; last_reconciled 2026-05-13→2026-05-16. PRODUCTION blockers remaining: some triggers ("LVEF<=40", "K<5.0") are plain-English and not yet machine-evaluable; vericiguat RxCUI corrected 2557097→2475830 (RxNorm vericiguat ingredient, RxNav-verified 2026-05-24) and tirzepatide-SUMMIT PMID corrected 39536361 [was a 3-membered-ring medicinal-chemistry paper]→39555826 (NEJM 2025, esummary-verified 2026-05-24); vericiguat still has no DrugEffectProfile (non-profile, flagged); MAGGIC/ADHERE calculator registry gap unchanged (owned by registry terminal, not this depth shard). DEPTH-PASS-3 2026-05-26 (lane-E): +NMA (Vaduganathan Lancet 2020 cross-trial comprehensive-disease-modifying HFrEF HR 0.38 0.30–0.47; Kotecha Lancet 2014 BB IPD HF+sinus vs HF+AF; Taylor 2019 EXTRAMATCH II exercise-CR IPD) +Cochrane (Long 2019 CD003331 exercise-based CR for HF) +USPSTF (HF screening explicitly NOT a USPSTF topic; HTN A-2021 + obesity B-2018 + statin B-2022 + smoking A-2021 hooks) +ICER (Bhatt JAMA Cardiol 2023 sac/val $76,852/QALY; Davis/McEwan EJHF 2024 dapa £6,470/QALY UK NHS; Cohen JAMA Cardiol 2023 SGLT2i HFpEF $141,200/QALY) +Pauker-Kassirer decision thresholds explicit (T_test≈5%/T_treat≈60% diagnostic; T_treat raised for ATTR-CM tafamidis on economic-harm grounds); side-car at cardio.hf.core.v1._depth-pass-3.md. Zero schema churn; 8 new PMIDs live-verified via PubMed MCP 2026-05-26. Three prompt-supplied PMIDs rejected (26747508/33871957/36925878 — wrong articles by live verification) and replaced with the correct authors' actual papers.

Entry points (5)

  • symptom
    Dyspnea on exertion / orthopnea / PND
    dyspnea
  • symptom
    Lower-extremity edema
    lower_extremity_edema
  • lab_abnormality
    NT-proBNP elevated
    nt_probnp_elevated
  • imaging
    Echo LVEF reduced/borderline
    echo_lvef_reduced
  • problem_list
    Existing HF on problem list (titration visit)
    heart_failure

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Age cutoffs for ARNi vs ACEi tolerability + dose adjustment — ACC/AHA 2022
  • sbprequired
    vital • used at CONTEXT
    GDMT initiation requires SBP ≥ 100 mmHg — ACC/AHA 2022; titration requires monitoring for hypotension
  • hrrequired
    vital • used at CONTEXT
    Beta-blocker titration target HR; ivabradine candidacy ≥ 70 bpm sinus — ACC/AHA 2022
  • creatininerequired
    lab • used at CONTEXT
    eGFR for SGLT2i (≥20 — DAPA-HF 2019), ACEi/ARB initiation, MRA monitoring — ACC/AHA 2022
  • potassiumrequired
    lab • used at CONTEXT
    MRA contraindicated K > 5.0 (RALES, Pitt NEJM 1999); baseline before ACEi/ARB/MRA — ACC/AHA 2022
  • lvefrequired
    imaging • used at DIFFERENTIAL
    Branches HFrEF (≤40) / HFmrEF (41–49) / HFpEF (≥50) — ACC/AHA 2022 universal definition; drives 4-pillar regimen choice
  • nt_probnp
    lab • used at INITIAL_WORKUP
    Diagnostic confirmation + monitoring; age-adjusted thresholds — ACC/AHA 2022 Class I
  • tsh
    lab • used at INITIAL_WORKUP
    Hyper/hypothyroidism as reversible HF cause/aggravator — ACC/AHA 2022 §4.3
  • iron_panel
    lab • used at INITIAL_WORKUP
    IV iron in HFrEF + iron deficiency (FAIR-HF/CONFIRM-HF/AFFIRM-AHF)
  • a1c
    lab • used at INITIAL_WORKUP
    Diabetes co-prevalence drives SGLT2i + GLP-1 selection; HFpEF + obesity → semaglutide/tirzepatide (STEP-HFpEF, Kosiborod NEJM 2023)
  • past_mi
    history • used at CONTEXT
    Ischemic vs non-ischemic etiology branches workup — ACC/AHA 2022 §4.1
  • atrial_fibrillation
    history • used at CONTEXT
    Rate vs rhythm strategy; anticoagulation — ACC/AHA 2022 §7.3.7
  • ckd
    history • used at CONTEXT
    CKD stage gates SGLT2i, ACEi/ARB titration, MRA risk — KDIGO 2021 + ACC/AHA 2022
  • dm2
    history • used at CONTEXT
    Dual cardiorenal indication — favors SGLT2i (DAPA-HF 2019) + GLP-1 — ADA 2026
  • current_meds
    medication • used at CONTEXT
    Detect existing GDMT components for titration vs initiation; flag NSAIDs/CCB-non-DHP — ACC/AHA 2022 §7.3
  • ecg
    imaging • used at INITIAL_WORKUP
    QRS ≥150ms LBBB → CRT candidacy — ACC/AHA 2022 §7.5; AF rhythm; ischemic Q-waves
  • nyha_class
    symptom • used at RISK_STRATIFICATION
    NYHA II-IV classification drives device + advanced therapy thresholds — ACC/AHA 2022 §3

12-phase flow (12)

  1. 1FRAME
    Confirm chronic HF scope — exclude acute decompensation that should route to cardio.acute-hf.core.v1 — ACC/AHA 2022 §3
    inputs: nyha_class
    advance: patient is hemodynamically stable and not in acute pulmonary edema
  2. 2ENTRY
    Recognize triggering symptom, lab, or imaging finding and capture patient identity
    inputs: age
    advance: one entry trigger present and basic demographics captured
  3. 3CONTEXT
    Capture vitals, key comorbidities (CKD, DM, AF, prior MI), allergies, current GDMT components
    inputs: sbp, hr, creatinine, potassium, past_mi, atrial_fibrillation, ckd, dm2, current_meds
    advance: all hard_required vitals/labs and comorbidity screen complete
  4. 4RED_FLAGS
    Screen for acute decompensation, cardiogenic shock, hyperkalemia, AKI on CKD — ACC/AHA 2022 §10
    inputs: sbp, creatinine, potassium
    actions: cardiogenic_shock
    advance: no red flags or red flags routed to acute pathway
  5. 5INITIAL_WORKUP
    BNP/NT-proBNP, BMP, TSH, iron panel, A1c, ECG, echo (if not on file) — ACC/AHA 2022 §4
    inputs: nt_probnp, tsh, iron_panel, a1c, ecg
    actions: panel.cardiac, panel.renal, panel.thyroid
    advance: baseline labs returned; LVEF documented
  6. 6BRANCHING_WORKUP
    Etiology workup if newly diagnosed: ischemic vs non-ischemic, valvular, infiltrative — ACC/AHA 2022 §4.1
    inputs: lvef, past_mi
    actions: workup.le_edema
    advance: etiology established or referred for further imaging (cardiac MRI, cath)
  7. 7DIFFERENTIAL
    Phenotype as HFrEF (≤40) / HFmrEF (41–49) / HFpEF (≥50) / HF-improved — ACC/AHA 2022 universal definition
    inputs: lvef
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    NYHA class, MAGGIC/Seattle/ADHERE risk; CRT/ICD eligibility check — ACC/AHA 2022 §7.5
    inputs: nyha_class
    advance: NYHA documented; high-risk flag triggered if applicable
  9. 9TREATMENT
    Build/titrate 4-pillar GDMT for HFrEF (ACC/AHA 2022 Class I) or SGLT2i + diuretic + finerenone for HFpEF (DELIVER 2022, FINEARTS-HF 2024); treat reversible drivers
    inputs: lvef, sbp, hr, creatinine, potassium, dm2, ckd
    advance: every applicable pillar prescribed at lowest tolerated dose with monitoring plan
  10. 10DISPOSITION
    Titration visit cadence; refer to advanced HF if stage D triggers met — ACC/AHA 2022 §8
    inputs: nyha_class
    advance: next visit interval set; advanced HF referral made if NYHA IV / inotrope-dep / VAD candidacy
  11. 11MONITORING
    BMP within 1–2 weeks of GDMT change, then at each titration — ACC/AHA 2022; weight + symptom diary; iron repletion check (FAIR-HF 2009)
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring plan documented and patient educated
  12. 12FOLLOWUP
    Visit cadence by NYHA + recent titration; cardiac rehab referral; vaccination check (flu, pneumococcal, COVID) — ACC/AHA 2022 §7.3.8
    advance: follow-up scheduled and patient given return precautions