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cardio.hfpef.core.v1

Heart failure with preserved EF (HFpEF, LVEF ≥50)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Phenotype-specific split from cardio.hf.core.v1 (chronic parent, DEPTH-PASS-2 done — cross-referenced, not edited) — HFpEF only (LVEF ≥50). HFmrEF (41–49) routes to cardio.hfmref.core.v1. Disease-modifying set: SGLT2i first-line for ALL (DM-independent, 2023 ESC FU Class I) + finerenone preferred MRA (FINEARTS-HF) + semaglutide/tirzepatide if BMI ≥30 (STEP-HFpEF/SUMMIT); spironolactone = TOPCAT-Americas-only fallback; mandatory amyloid screen gates the pharmacologic axis. Critical sibling differentiation from HCM and ATTR/AL amyloid — both treatable mimics requiring different therapy. 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 (18 verified PMIDs — 14 live-verified via PubMed MCP + 4 parent-canon — with effect sizes + 95% CI + retrieval-dated 2026-05-16; dose-effect anchors w/ HFH HR + KCCQ/weight delta + time-to-effect; RxCUI log; Consensus→PubMed/WebSearch fallback logged; pre-test priors w/ H2FPEF/HFA-PEFF cohort sources; T_test≈5%/T_treat≈60%; cross-dossier routing to cardio.hf/hfmref/htn/acute-hf.core.v1); (2) rebuilt cardio.hfpef.core.v1 ros+differentials+finding-lrs seed files mirroring htn shapes (15 differentials w/ cohort-anchored priors incl. amyloid/HCM/constrictive/valvular/PH mimics + obese/hypertensive/CAD/AF/amyloid phenotype sub-partition, 15 ROS, 41 LR rows = 24 LR+/26 LR−, 5 conditional-dependency rules incl. H2FPEF-composite-not-component-multiplied + NT-proBNP|obesity/AF); (3) 2nd regimen axis hfpef_phenotype_amyloid_matrix (drug × phenotype × amyloid-screen gating as data); axis 1 hfpef_stepwise rebuilt as 5-step RegimenStep ladder; (4) RxCUI bug fixed: finerenone 2168780→2562811 (canonical DrugEffectProfile registry, validator IN:OK); all other CUIs validated OK (sac/val 1656339 MIN:OK accepted-annotation); (5) content refresh to 2022 AHA/ACC + 2023 ESC FU: SGLT2i first-line all HFpEF, finerenone preferred MRA, GLP-1/tirzepatide obese phenotype, MRA per TOPCAT-Americas, mandatory amyloid screen; stale/fabricated PMIDs fixed (35379504/35379507→35363499+35379503, 39264738→39225278, 37622663→37622681, 36027571→36027570, 39536361→39555826; removed NEAT/IMPACT/COPERNICUS/POINT/REDUCE non-HFpEF cruft); design_brief path repointed; evidence.pmids 14→19; status PLANNED→PRODUCTION. Calculator gaps: H2FPEF, HFA-PEFF, MAGGIC not yet in clinical-tools-registry.ts — flagged for the orphan-calculator sweep (owned by UI-fix terminal, not this depth shard). DEPTH-PASS-3 2026-05-26 (lane-E): +NMA (Song Postgrad Med J 2024 SGLT2i/GLP-1RA/DPP4i hypoglycemic-class NMA in HF — SGLT2i first-ranked for HHF) +Cochrane (Long 2019 CD003331 exercise-based CR for HF) +USPSTF (HF screening NOT a USPSTF topic — explicitly flagged; HTN A-2021 + obesity B-2018 are the dominant HFpEF prevention hooks given hypertensive-HFpEF + obese-cardiometabolic-HFpEF phenotypes) +ICER (Cohen JAMA Cardiol 2023 SGLT2i HFpEF $141,200/QALY — HFpEF-specific; Davis/McEwan EJHF 2024 dapa £6,470/QALY UK NHS retains CE in HFpEF; Bhatt JAMA Cardiol 2023 sac/val HFpEF subset $127,172/QALY informing PARAGON Class IIb framing; Kazi Circulation 2020 tafamidis ATTR-CM $880k/QALY; Lau Int J Cardiol 2023 universal ATTR-CM screening $919k/QALY) +Pauker-Kassirer decision thresholds explicit (T_test≈1% for PYP/monoclonal-screen given ATTR-ACT mortality benefit; T_treat≈0.95 for high-confidence ATTR-CM + tafamidis but T_treat≈0.30 for intermediate-confidence given $880k/QALY economic-harm dominance; mandatory amyloid mimic gate before HFpEF axis commit); side-car at cardio.hfpef.core.v1._depth-pass-3.md. Zero schema churn; 8 new PMIDs live-verified via PubMed MCP 2026-05-26. Finerenone/semaglutide/tirzepatide HFpEF-specific CE flagged for W2 ICER cache backfill rather than fabricated.

Entry points (6)

  • imaging
    Echo LVEF ≥50 with diastolic dysfunction
    echo_lvef_ge_50
  • lab_abnormality
    NT-proBNP elevated with preserved LVEF
    nt_probnp_elevated_preserved_ef
  • symptom
    Exertional dyspnea / orthopnea / fatigue
    dyspnea_exertional
  • symptom
    Lower-extremity edema
    lower_extremity_edema
  • problem_list
    Known HFpEF — disease-modifying titration visit
    hfpef_existing
  • history
    Recent HF hospitalisation (HFpEF transition)
    recent_hf_admission

Required inputs (20)

  • agerequired
    demographic • used at CONTEXT
    Age + frailty informs target dose + tolerability
  • sbprequired
    vital • used at CONTEXT
    HTN is dominant driver; titration target
  • hrrequired
    vital • used at CONTEXT
    AF rate-control coexists in ~60%
  • weightrequired
    vital • used at CONTEXT
    BMI gates GLP-1 / tirzepatide; weight diary for congestion
  • bmirequired
    vital • used at CONTEXT
    BMI ≥30 unlocks semaglutide / tirzepatide as disease-modifying
  • creatininerequired
    lab • used at CONTEXT
    eGFR for SGLT2i (≥20) and finerenone (≥25)
  • potassiumrequired
    lab • used at CONTEXT
    Finerenone contraindicated K >5.0
  • lvefrequired
    imaging • used at DIFFERENTIAL
    HFpEF gate (LVEF ≥50); HFmrEF (41–49) routes to HFrEF dossier
  • nt_probnp
    lab • used at INITIAL_WORKUP
    Diagnostic confirmation; H2FPEF / HFA-PEFF score input
  • a1c
    lab • used at INITIAL_WORKUP
    DM dose-modifier for SGLT2i + GLP-1 selection
  • iron_panel
    lab • used at INITIAL_WORKUP
    IV iron for symptom benefit in HFpEF + iron deficiency
  • tsh
    lab • used at INITIAL_WORKUP
    Hyper/hypothyroidism reversible aggravator
  • ecg
    imaging • used at INITIAL_WORKUP
    AF + LVH detection; LBBB ≥150 ms is uncommon in HFpEF
  • hypertensionrequired
    history • used at CONTEXT
    Dominant HFpEF driver; uncontrolled HTN must be addressed
  • dm2
    history • used at CONTEXT
    Comorbid DM + HFpEF strengthens SGLT2i + GLP-1 indication
  • atrial_fibrillation
    history • used at CONTEXT
    AF ablation may improve HFpEF symptoms (CABANA subgroups)
  • osa
    history • used at CONTEXT
    OSA is reversible HFpEF aggravator
  • amyloidosis_red_flags
    history • used at BRANCHING_WORKUP
    ATTR-CM red flags (carpal tunnel, lumbar stenosis, low-flow low-gradient AS, autonomic features) → PYP scan
  • current_meds
    medication • used at CONTEXT
    Detect existing HF meds; flag NSAIDs / non-DHP CCB / negative inotropes
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    NYHA II–IV drives advanced therapy thresholds

12-phase flow (12)

  1. 1FRAME
    Confirm chronic HFpEF — exclude acute decompensation routing to cardio.acute-hf.core.v1
    inputs: nyha_class
    advance: patient hemodynamically stable
  2. 2ENTRY
    Recognise triggering symptom, lab, or LVEF
    inputs: age
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, BMI, comorbidities (HTN, DM, AF, OSA, CKD), allergies, meds
    inputs: sbp, hr, weight, bmi, creatinine, potassium, hypertension, dm2, atrial_fibrillation, osa, current_meds
    advance: context complete
  4. 4RED_FLAGS
    Acute decompensation, hypertensive emergency, AKI on CKD (ACC/AHA 2022 HF §10)
    inputs: sbp, creatinine, potassium
    actions: acute_pulm_edema, htn_emergency
    advance: no red flags or routed
  5. 5INITIAL_WORKUP
    NT-proBNP, BMP, A1c, iron panel, TSH, ECG, echo (E/e′, LA size, RV)
    inputs: nt_probnp, a1c, iron_panel, tsh, ecg
    actions: panel.cardiac, panel.renal, panel.thyroid, panel.iron, panel.glucose_a1c
    advance: baseline labs returned; LVEF + diastolic markers documented
  6. 6BRANCHING_WORKUP
    Rule out HFpEF mimics: cardiac amyloidosis (PYP scan + light-chain testing), HCM (LV ≥15 mm), constrictive pericarditis, valvular HD; secondary HTN if uncontrolled
    inputs: amyloidosis_red_flags
    actions: hcm_diagnosis, secondary_htn, le_edema, afib_new_onset
    advance: mimics excluded or specific phenotype identified
  7. 7DIFFERENTIAL
    Confirm HFpEF (LVEF ≥50) vs HFmrEF / HCM / amyloid / constrictive (ACC/AHA 2022 HF §3; ESC 2021)
    inputs: lvef
    advance: phenotype confirmed as HFpEF
  8. 8RISK_STRATIFICATION
    NYHA class, H2FPEF score (Reddy Circulation 2018), HFA-PEFF score (Pieske EHJ 2019), MAGGIC; eligibility for disease-modifying therapy
    inputs: nyha_class, bmi, a1c
    advance: risk class documented
  9. 9TREATMENT
    SGLT2i (Class I) + finerenone (FINEARTS-HF) + semaglutide/tirzepatide if BMI ≥30; tight HTN control (<130/80); AF rate/rhythm; loop diuretic for congestion; AVOID nitrates unless angina
    inputs: lvef, sbp, creatinine, potassium, bmi, dm2
    advance: each applicable agent prescribed at lowest tolerated dose with monitoring plan
  10. 10DISPOSITION
    Titration cadence; refer advanced HF / amyloid clinic if Stage D / amyloid
    inputs: nyha_class
    advance: next visit set; specialty referral made if indicated
  11. 11MONITORING
    BMP within 2 wks of finerenone start; weight diary; A1c q3m if DM
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Visit cadence by NYHA + recent titration; vaccinations; cardiac rehab
    advance: follow-up scheduled