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cardio.mitral_stenosis.v1

Mitral stenosis (rheumatic + degenerative)

cardiologychronicacuteadultpregnancygeriatricoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Mitral stenosis dossier — rheumatic dominant; Wilkins ≤8 favours PMBV; warfarin (INVICTUS) for rheumatic + AF. Pregnancy markedly worsens — pre-conception assessment + multi-disciplinary care. AF nearly universal in moderate-severe MS — rate-control and AC are core. Open: manifest, atoms, problem-package, RxCUI verification, engine-specific tests; Wilkins / pregnancy-NYHA calculator gaps.

Entry points (5)

  • symptom
    Progressive dyspnea on exertion / orthopnea / PND (ACC/AHA 2020 VHD Stage D symptom)
    dyspnea_exertion
  • symptom
    Hemoptysis — bronchial vein rupture from elevated LA pressure (ACC/AHA 2020 VHD)
    hemoptysis
  • symptom
    Palpitations or new AF (ACC/AHA 2020 — AF nearly universal in moderate-severe MS)
    palpitations_or_AF
  • imaging
    Opening snap + low-pitched diastolic rumble at apex (ACC/AHA 2020 VHD)
    opening_snap_diastolic_rumble
  • history
    Pregnancy planning or pregnant patient with known MS (ESC 2021 VHD — pregnancy markedly worsens MS)
    pregnancy_planning_or_pregnant_with_MS

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Rheumatic (younger) vs MAC (older — ACC/AHA 2020 VHD); pregnancy considerations
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Pregnancy markedly worsens MS — risk-stratify (ESC 2021 VHD / ACC/AHA 2020)
  • sbprequired
    vital • used at CONTEXT
    Hemodynamic stability (ACC/AHA 2020 VHD)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia shortens diastolic filling — worsens gradient (ACC/AHA 2020 VHD)
  • spo2required
    vital • used at RED_FLAGS
    Pulmonary congestion marker (ACC/AHA 2020 VHD)
  • bnp_or_ntprobnprequired
    lab • used at INITIAL_WORKUP
    HF severity / response (ACC/AHA 2020 VHD)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Anemia worsens MS symptoms (ACC/AHA 2020 VHD)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Diuretic + AC dosing (ACC/AHA 2020 VHD)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hyperthyroid worsens MS — tachycardia shortens diastolic filling (ACC/AHA 2020 VHD)
  • inr
    lab • used at TREATMENT
    Warfarin monitoring if rheumatic AF (INVICTUS NEJM 2022)
  • tte_severity_gradingrequired
    imaging • used at INITIAL_WORKUP
    Mean gradient, MVA (planimetry, PHT), PASP, Wilkins score (ACC/AHA 2020 VHD Table 11)
  • tee_for_LAA_thrombus
    imaging • used at BRANCHING_WORKUP
    Mandatory before PMBV or cardioversion (ACC/AHA 2020 VHD Class I)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    LA enlargement, cephalisation, Kerley B lines (ACC/AHA 2020 VHD)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    AF, P-mitrale, RVH, RAD (ACC/AHA 2020 VHD)
  • rheumatic_historyrequired
    history • used at CONTEXT
    Rheumatic fever / endemic exposure (ACC/AHA 2020 VHD / ESC 2021)
  • current_medsrequired
    medication • used at CONTEXT
    Diuretic, BB, AC reconciliation (ACC/AHA 2020 VHD)

12-phase flow (12)

  1. 1FRAME
    Confirm MS via TTE; assign severity — mean gradient, MVA, PASP (ACC/AHA 2020 VHD Table 11); rheumatic vs MAC; Wilkins score for PMBV candidacy
    inputs: tte_severity_grading
    advance: Severity + etiology confirmed
  2. 2ENTRY
    Dyspnea / orthopnea / hemoptysis / palpitations / pregnancy assessment (ACC/AHA 2020 VHD Stage C-D symptoms)
    inputs: age, pregnancy_status
    advance: Engine entered
  3. 3CONTEXT
    Rheumatic exposure (ACC/AHA 2020), prior valve disease, AF, pregnancy plans (ESC 2021 VHD), comorbidities
    inputs: rheumatic_history, pregnancy_status, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Pulmonary edema, hemoptysis, AF with RVR (worsens gradient — ACC/AHA 2020), pregnancy decompensation (ESC 2021), severe PASP rise
    inputs: spo2, sbp
    actions: acute_pulm_edema, tachycardia
    advance: Stabilised or escalated
  5. 5INITIAL_WORKUP
    TTE — mean grad, MVA, Wilkins, PASP (ACC/AHA 2020 Class I); ECG, CXR, BNP, BMP, CBC, TSH, INR if on warfarin
    inputs: tte_severity_grading, ecg_12_lead, cxr, bnp_or_ntprobnp, creatinine_egfr, cbc, tsh
    actions: panel.cardiac, panel.cbc, panel.thyroid, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    TEE for LAA thrombus pre-PMBV / pre-cardioversion (ACC/AHA 2020 Class I); right-heart cath if PASP discordant (ESC 2021); stress echo for symptom-severity mismatch
    inputs: tee_for_LAA_thrombus
    advance: Branch resolved
  7. 7DIFFERENTIAL
    Rheumatic vs MAC vs congenital (parachute / supravalvular ring) vs cor triatriatum vs LA myxoma mimicking MS (ACC/AHA 2020 VHD)
    advance: Etiology assigned
  8. 8RISK_STRATIFICATION
    ACC/AHA 2020 stages A-D; Wilkins score for PMBV candidacy; pregnancy NYHA class (ESC 2021); CHA2DS2-VASc if AF
    inputs: tte_severity_grading
    actions: calc.cha2ds2vasc, calc.has_bled
    advance: Risk and severity tier documented
  9. 9TREATMENT
    Diuretic + rate control — BB / non-DHP CCB / digoxin to maximise diastolic filling (ACC/AHA 2020 Class I); PMBV for severe symptomatic Wilkins ≤8 + no LAA thrombus + no/mild MR (ACC/AHA 2020 Class I); surgical MVR for unfavourable anatomy; warfarin INR 2-3 if rheumatic + AF or prior embolism (INVICTUS NEJM 2022); IE prophylaxis only per ACC/AHA 2020 narrow indications
    inputs: hr, creatinine_egfr, tte_severity_grading
    advance: Plan documented
  10. 10DISPOSITION
    Admit if decompensated / hemoptysis / pregnancy peripartum / pre-PMBV; outpatient cardiology otherwise (ACC/AHA 2020)
    advance: Disposition documented
  11. 11MONITORING
    TTE annual (severe) or q2-3 yr (moderate) per ACC/AHA 2020; pregnancy q4-6 wks (ESC 2021); INR weekly to monthly on warfarin
    inputs: inr
    advance: Schedule documented
  12. 12FOLLOWUP
    Cardiology q3-12 mo (ACC/AHA 2020); high-volume valve surgeon if intervention (ESC 2021 — heart valve centre); OB-cardio team in pregnancy
    advance: Follow-up booked