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cardio.hfref.core.v1

Heart failure with reduced EF (HFrEF, LVEF ≤40)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Phenotype-specific split from cardio.hf.core.v1 — HFrEF only (LVEF ≤40); EF-band neighbours route to cardio.hfmref.core.v1 / cardio.hfpef.core.v1. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template-mirrored on cardio.htn.core.v1; reuses same-session live-verified GDMT anchors from cardio.hf.core.v1) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (25 verified PMIDs, named trials + effect sizes + 95% CI, retrieval-dated 2026-05-16, Consensus→PubMed/parent-reuse fallback logged; dose-effect anchors w/ all-cause-mortality + HHF HR + time-to-effect + target dose; RxCUI log; pre-test priors w/ cohort sources; T_test≈5%/T_treat≈60%; cross-dossier routing); (2) cardio.hfref.core.v1 differentials+ros+finding-lrs seed files DEEPENED in place — 11 differentials (HFrEF-aetiology partition: ischaemic/idiopathic-DCM/hypertensive/valvular/tachy-mediated/toxic/peripartum/infiltrative/myocarditis + MECE HFmrEF & HF-recovered boundaries) w/ cohort-anchored priors (PMID), 13 ROS, 33 LR rows = 17 LR+/16 LR−, 2 conditional-dependency rules (NT-proBNP|age/AF/BMI; QRS-CRT-benefit|LBBB-morphology); (3) 2nd regimen axis hfref_phenotype_comorbidity_device_matrix (drug & device × phenotype gating as DATA: ischaemic/non-ischaemic, CRT/ICD by QRS/EF/LBBB/NYHA, AF, CKD/hyperK, low-BP, iron-deficiency, persistent-symptoms); (4) RxCUI bugs fixed vs DrugEffectProfile registry: sacubitril/valsartan 1656340→1656339, metoprolol-succ 866427→221124, metolazone 4109→6916, lisinopril 18867→29046 (carvedilol 20352 / bisoprolol 19484 / spironolactone 9997 / dapagliflozin 1488564 / empagliflozin 1545653 / ivabradine 1649480 / vericiguat 2475830 confirmed correct); (5) content refresh to 2022 AHA/ACC/HFSA + 2023 ESC FU: rapid simultaneous 4-pillar per STRONG-HF, device criteria by EF/QRS/NYHA, vericiguat for worsening HFrEF, IV iron for symptomatic FE-deficiency, GALACTIC-HF logged neutral/not-adopted; evidence.pmids 26→28 with stale/fabricated removed (35379504/38743075/11386262/10377659/29766750/23900119) and dual-pub guideline pair + 2024 ACC ECDP corrected. Calculator gaps: MAGGIC, Seattle HF Model, ADHERE not yet in clinical-tools-registry.ts — flagged for orphan-calculator sweep (owned by UI-fix terminal, not this depth shard). Vericiguat + IV iron carry no DrugEffectProfile in this worktree — RxNorm ingredient CUIs annotated non-pharm/non-profile, anchored to VICTORIA/AFFIRM-AHF PMIDs (not hand-authored therapeutic claims). 96-fail rxnav registry baseline OUT OF SCOPE per task. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA (Vaduganathan Lancet 2020 comprehensive-disease-modifying HFrEF cross-trial HR 0.38 0.30–0.47 — canonical HFrEF NMA-equivalent; Kotecha Lancet 2014 BB IPD HF+sinus HR 0.73 vs HF+AF HR 0.97 p_interaction=0.002; Taylor 2019 EXTRAMATCH II exercise-CR IPD) +Cochrane (Long 2019 CD003331 exercise-based CR for HF) +USPSTF (HF screening NOT a USPSTF topic — explicitly flagged; HTN A-2021 + statin B-2022 + smoking A-2021 + alcohol B-2018 hooks for HFrEF aetiology prevention) +ICER (Bhatt JAMA Cardiol 2023 sac/val HFrEF subset $59,614/QALY at EF ≤50 — high value; Davis/McEwan EJHF 2024 dapa £6,470/QALY UK NHS — dominant in HFrEF + poor renal subgroups) +CONSENSUS 1987 ACEi-in-HF foundational anchor +Pauker-Kassirer decision thresholds explicit (T_test≈5%/T_treat≈60% diagnostic; non-ischemic ICD T_treat raised in GDMT/CRT era per DANISH; CRT-benefit LR conditional on LBBB+QRS≥150); side-car at cardio.hfref.core.v1._depth-pass-3.md. Zero schema churn; 8 new PMIDs live-verified via PubMed MCP 2026-05-26.

Entry points (6)

  • imaging
    Echo LVEF ≤40 — HFrEF phenotype
    echo_lvef_le_40
  • symptom
    Dyspnea on exertion / orthopnea / PND
    dyspnea
  • symptom
    Lower-extremity edema
    lower_extremity_edema
  • lab_abnormality
    NT-proBNP elevated with reduced LVEF
    nt_probnp_elevated
  • problem_list
    Known HFrEF — GDMT titration visit
    hfref_existing
  • history
    Recent HF hospitalisation (STRONG-HF transition)
    recent_hf_admission

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Age cutoffs for ARNi vs ACEi tolerability + dose adjustment
  • sbprequired
    vital • used at CONTEXT
    GDMT initiation requires SBP ≥100 mmHg; titration requires monitoring for hypotension
  • hrrequired
    vital • used at CONTEXT
    BB titration target HR; ivabradine candidacy ≥70 bpm sinus on max BB
  • weightrequired
    vital • used at CONTEXT
    Weight diary for congestion; carvedilol dose threshold (>85 kg)
  • creatininerequired
    lab • used at CONTEXT
    eGFR for SGLT2i (≥20), ACEi/ARNi titration, MRA monitoring
  • potassiumrequired
    lab • used at CONTEXT
    MRA contraindicated K >5.0; baseline before ACEi/ARNi/MRA
  • lvefrequired
    imaging • used at DIFFERENTIAL
    HFrEF gate (LVEF ≤40); drives 4-pillar regimen
  • nt_probnp
    lab • used at INITIAL_WORKUP
    Diagnostic confirmation + monitoring; age-adjusted thresholds
  • iron_panel
    lab • used at INITIAL_WORKUP
    IV iron for symptomatic iron deficiency in HFrEF (AFFIRM-AHF PMID 33197395; IRONMAN PMID 36347265)
  • tsh
    lab • used at INITIAL_WORKUP
    Hyper/hypothyroidism as reversible HF cause/aggravator
  • a1c
    lab • used at INITIAL_WORKUP
    DM co-prevalence drives SGLT2i + GLP-1 selection
  • ecg
    imaging • used at INITIAL_WORKUP
    QRS ≥150 ms LBBB → CRT candidacy; AF rhythm; ischemic Q-waves
  • past_mi
    history • used at CONTEXT
    Ischemic vs non-ischemic etiology branches workup
  • atrial_fibrillation
    history • used at CONTEXT
    Rate vs rhythm strategy; anticoagulation
  • ckd
    history • used at CONTEXT
    CKD stage gates SGLT2i, ACEi/ARNi titration, MRA risk
  • dm2
    history • used at CONTEXT
    Dual cardiorenal indication — favors SGLT2i + GLP-1
  • current_meds
    medication • used at CONTEXT
    Detect existing GDMT components for titration vs initiation; flag NSAIDs/non-DHP CCB
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    NYHA II–IV drives device + advanced therapy thresholds

12-phase flow (12)

  1. 1FRAME
    Confirm chronic HFrEF — exclude acute decompensation that should route to cardio.acute-hf.core.v1
    inputs: nyha_class, sbp
    advance: patient is hemodynamically stable and not in acute pulmonary edema
  2. 2ENTRY
    Recognise triggering symptom, lab, or LVEF and capture identity
    inputs: age
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, comorbidities (CKD, DM, AF, prior MI), allergies, current GDMT components
    inputs: sbp, hr, weight, 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 (SCAI 2019), hyperkalemia, AKI on CKD (ACC/AHA 2022 HF §10)
    inputs: sbp, creatinine, potassium
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    BNP/NT-proBNP, BMP, TSH, iron panel, A1c, ECG, echo (if not on file)
    inputs: nt_probnp, tsh, iron_panel, a1c, ecg
    actions: panel.cardiac, panel.renal, panel.thyroid, panel.iron
    advance: baseline labs returned; LVEF documented
  6. 6BRANCHING_WORKUP
    Etiology workup if newly diagnosed: ischemic vs non-ischemic, valvular, infiltrative (cardiac MRI, cath)
    inputs: lvef, past_mi
    actions: le_edema
    advance: etiology established or referred
  7. 7DIFFERENTIAL
    Confirm HFrEF (LVEF ≤40) vs HFmrEF (41–49) vs HFpEF (≥50) vs HF-improved (ACC/AHA 2022 HF §3; ESC 2021)
    inputs: lvef
    advance: phenotype confirmed as HFrEF
  8. 8RISK_STRATIFICATION
    NYHA class, MAGGIC (Pocock 2013)/Seattle/ADHERE risk; CRT/ICD eligibility (LVEF ≤35 + LBBB ≥150 ms per ACC/AHA 2022 HF §7)
    inputs: nyha_class
    advance: NYHA documented; high-risk flag triggered if applicable
  9. 9TREATMENT
    Build/titrate 4-pillar GDMT (ARNi or ACEi/ARB + evidence-based BB + MRA + SGLT2i); ivabradine if HR ≥70 sinus on max BB; vericiguat for worsening HF; loop diuretic per congestion
    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 (q1–2 wk during STRONG-HF rapid titration); refer advanced HF if Stage D / inotrope-dependent / VAD candidacy
    inputs: nyha_class
    advance: next visit interval set; advanced-HF referral made if criteria met
  11. 11MONITORING
    BMP within 1–2 wks of GDMT change, then at each titration; weight + symptom diary; iron repletion check
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring plan documented and patient educated
  12. 12FOLLOWUP
    Visit cadence by NYHA + recent titration; cardiac rehab; vaccinations (flu, pneumococcal, COVID, RSV)
    advance: follow-up scheduled and patient given return precautions