Clinical Commander

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cardio.htn.core.v1

Hypertension (chronic management)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

4-tier 2025 AHA stepwise ladder (CCB/RAASi/thiazide → dual → triple → MRA) authored with RxCUIs sourced from cardio.htn.core.v1.atoms.treatment.ts; outpatient + transition setting playbooks; home BP action plan (green/yellow/red); 6 severity triggers including resistant HTN, hyperK on RAASi, pregnancy switch, AKI after RAASi, hypertensive urgency vs emergency. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template dossier) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (16 verified PMIDs, named trials + effect sizes + 95% CI, retrieval-dated, Consensus→WebSearch fallback logged); (2) cardio.htn.core.v1 ros+differentials+finding-lrs seed files (11 differentials w/ cohort-anchored priors, 15 ROS, 27 LR rows = 24 LR+/27 LR−, 3 conditional-dependency rules, T_test≈1%/T_treat≈10%); (3) 2nd regimen axis htn_comorbidity_phenotype (drug × comorbidity gating as data); (4) RxCUI bugs fixed: carvedilol 3443→20352, labetalol 6918→6185, metoprolol-succ 6918→221124, validated vs DrugEffectProfile registry; (5) 2025-guideline content refresh: wrong guideline PMID 38316810→40811516/40811497, PREVENT ≥7.5% initiation fork, Stage-2 SPC, PA-screen-all-stage2/resistant-regardless-of-K+, renal denervation Class IIa→IIb, "hypertensive urgency"→"severe hypertension", K⁺-salt-substitute; evidence.pmids 6→19. PREVENT calculator (race-free, replaces Pooled Cohort) referenced in manifest; not yet a clinical-tools-registry entry — flagged for P0 orphan-calculator sweep (owned by UI-fix terminal, not this depth shard). Renal denervation (Class IIb, 2025 AHA/ACC HBP) referral path is not yet a clinical-tool entry; deferred (procedure-referral, non-pharmacologic). DEPTH-PASS-3 2026-05-26 (lane-E): +Cochrane CD001841 (Wright 2018 first-line HTN drugs) +NMA (Tian Cardiovasc Res 2024 resistant-HTN spironolactone-ranked-#1; BPLTTC IPD-MA Lancet 2021 across-baseline-BP 5mmHg→10%CV; Wang JACC-Adv 2025 LDC-SPC) +USPSTF hooks (HTN screening Grade A 2021; statin B 2022; ASA C/D 2022; obesity B 2018; tobacco A 2021) +ICER (Bress NEJM 2017 SPRINT ~\$28k/QALY) +Pauker-Kassirer thresholds explicit (T_test 1% / T_treat 10% per Pauker-Kassirer 1980; PREVENT 7.5% pharmacotherapy gate); side-car at cardio.htn.core.v1._depth-pass-3.md. Initial-pass cited 4 fabricated/wrong-article PMIDs from memory (28828993/35772420/33833084/28316313) and one mislabeled-but-real (33933205); remediated 2026-05-26 against live PubMed-MCP metadata — only verified PMIDs ship.

Entry points (4)

  • vital_abnormality
    Office BP ≥130/80 (US) or ≥140/90 (ESC) — confirmed
    office_bp_elevated
  • vital_abnormality
    Home / ABPM elevated per ACC/AHA 2017 §5
    home_or_abpm_elevated
  • problem_list
    Known HTN — titration / monitoring visit per ACC/AHA 2017 §9
    known_htn_visit
  • problem_list
    Resistant HTN ≥3 meds with diuretic per ACC/AHA 2017 §9.1
    resistant_htn

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    AHA/ACC 2017 §7.1 PREVENT calculator + drug class tolerability
  • sbprequired
    vital • used at CONTEXT
    Treatment target driver per ACC/AHA 2017 Class I; SPRINT (Wright NEJM 2015)
  • dbprequired
    vital • used at CONTEXT
    Diastolic component per ACC/AHA 2017 §4 staging criteria
  • creatininerequired
    lab • used at CONTEXT
    eGFR for ACEi/ARB titration per KDIGO 2021; CKD modifier
  • potassiumrequired
    lab • used at CONTEXT
    Baseline before ACEi/ARB/MRA per ACC/AHA 2017 §8; spironolactone for resistant HTN (PATHWAY-2, Williams Lancet 2015)
  • a1c
    lab • used at INITIAL_WORKUP
    DM target <130/80 per ADA 2026; ACEi/ARB preference per ACC/AHA 2017 Class I
  • urine_acr
    lab • used at INITIAL_WORKUP
    CKD/HTN overlap → ACEi/ARB Class I per KDIGO 2021
  • lipids
    lab • used at INITIAL_WORKUP
    Concurrent ASCVD risk → AHA/ACC PREVENT calculator 2023
  • tsh
    lab • used at INITIAL_WORKUP
    Hyperthyroidism reversible HTN driver per ESC/ESH 2023 §8.2 secondary causes
  • ecg
    imaging • used at INITIAL_WORKUP
    LVH, arrhythmia screen in HTN end-organ per ACC/AHA 2017 Class I
  • osa_symptoms
    history • used at CONTEXT
    OSA reversible HTN driver per ESC/ESH 2023 §8.2 — STOP-BANG screening
  • pregnancy
    history • used at CONTEXT
    Pregnancy → labetalol/methyldopa/nifedipine ER per ACOG 2019; AVOID ACEi/ARB (ACC/AHA 2017 Class III)
  • current_meds
    medication • used at CONTEXT
    Drug-induced HTN (NSAID, decongestants, COCs, stimulants) per ESC/ESH 2023 Table 21; existing regimen

12-phase flow (9)

  1. 1FRAME
    Outpatient HTN per ACC/AHA 2017; acute crisis (>180/120 + end-organ) routes to hypertensive-emergency engine
    inputs: sbp, dbp
    advance: patient is in chronic management context per ACC/AHA 2017 §4
  2. 2ENTRY
    Confirmation via repeat office, home, or ABPM per ACC/AHA 2017 Recommendation §5 (white-coat / masked HTN)
    inputs: age, sbp
    advance: BP elevation confirmed per ACC/AHA 2017 §5
  3. 3CONTEXT
    Comorbid DM, CKD, HF, ASCVD, OSA; pregnancy; current meds; lifestyle per ACC/AHA 2017 §6
    inputs: sbp, dbp, creatinine, potassium, osa_symptoms, pregnancy, current_meds
    advance: context complete per ACC/AHA 2017 §6
  4. 4INITIAL_WORKUP
    BMP, lipids, A1c, urine ACR, TSH, ECG; consider PA screen if stage 2 / resistant per 2025 AHA
    inputs: a1c, urine_acr, lipids, tsh, ecg
    actions: panel.renal, panel.lipid, panel.glucose_a1c, panel.thyroid
    advance: baseline workup documented per ACC/AHA 2017 §6
  5. 5BRANCHING_WORKUP
    Secondary HTN Bayesian screen (PA, pheo, renovascular, OSA, CKD, Cushing, coarctation, drug-induced). 2025 AHA/ACC HBP: screen for primary aldosteronism in ALL stage-2 OR resistant HTN regardless of serum potassium (ARR ≥30 with PAC ≥10, PRA <1 → confirmatory). LR chain + T_test≈1%/T_treat≈10% per cardio.htn.core.v1.finding-lrs.ts
    actions: secondary_htn
    advance: secondary causes screened/ruled out per 2025 AHA/ACC HBP (PMID 40811516)
  6. 6RISK_STRATIFICATION
    AHA/ACC PREVENT 10-yr CVD risk (replaces Pooled Cohort, 2025 AHA/ACC HBP) → pharmacologic-initiation fork: PREVENT ≥7.5% → treat at BP ≥130/80; PREVENT <7.5% → 3–6 mo lifestyle then treat if still ≥130/80. SPRINT HR 0.75 (0.64–0.89), BPROAD HR 0.79 (0.69–0.90) anchor the <120 intensive target. Resistant HTN classification; HMOD check
    inputs: age, sbp, dbp
    advance: PREVENT risk class + treatment-threshold fork documented per 2025 AHA/ACC HBP (PMID 40811516)
  7. 7TREATMENT
    Lifestyle (DASH, Na <1500 mg, exercise, weight, alcohol); ACEi or ARB or thiazide (chlorthalidone preferred) or DHP-CCB; combo therapy preferred at start; resistant → spironolactone; renal denervation Class 2a (2025 AHA); pregnancy → labetalol/methyldopa/nifedipine ER
    inputs: sbp, creatinine, potassium
    advance: BP at goal-tolerated dose with monitoring plan per ACC/AHA 2017 §8
  8. 8MONITORING
    Home BP series per ACC/AHA 2017 §5; BMP at 1–2 wks after ACEi/ARB/diuretic change; lipid + A1c per ASCVD plan
    inputs: creatinine, potassium
    actions: panel.renal
    advance: monitoring cadence documented per ACC/AHA 2017 §9
  9. 9FOLLOWUP
    Visit cadence by control + comorbidity per ACC/AHA 2017 §9; ASCVD prevention bundle
    advance: follow-up scheduled per ACC/AHA 2017 §9