Clinical Commander

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cardio.valvular_disease.v1

Valvular heart disease (AS / AR / MR / MS)

cardiologychronicacuteadultgeriatricoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

NEW dossier — no manifest / atoms / package on disk yet (manifest field intentionally empty). NEXT STEPS: (1) author manifest at prisma/seed/manifests/cardio.valvular_disease.v1.ts; (2) RxCUI validation for furosemide, lisinopril, valsartan, sacubitril/valsartan, metoprolol, carvedilol, amlodipine, warfarin, apixaban, amoxicillin, clindamycin; (3) calculator gaps — STS Risk, Euro-SCORE, Heart Team risk integrator absent. AS / AR / MR / MS staging (A-D) + Heart Team referral threshold + TAVR vs SAVR decisions explicit. Sibling differentiation from cardio.hfref.core.v1 + cardio.afib.core.v1 documents secondary MR and anticoagulation routing.

Entry points (5)

  • symptom
    New systolic or diastolic murmur on examination (ACC/AHA 2020 VHD Otto Section 3)
    murmur_on_exam
  • symptom
    Syncope, angina, or HF in patient with AS (ACC/AHA 2020 VHD Stage D criteria)
    symptoms_of_AS_triad
  • symptom
    Acute severe MR / AR with pulmonary edema or shock (ACC/AHA 2020 VHD Section 7–8)
    acute_severe_MR_or_AR
  • imaging
    Incidental valvular finding on imaging (ACC/AHA 2020 VHD Stage A-B evaluation)
    incidental_valve_finding
  • history
    Rheumatic heart disease or prior valve intervention surveillance (ACC/AHA 2020 VHD; ESC 2021 VHD)
    rheumatic_or_prior_valve_disease

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    ≥75 yr shifts toward TAVR; <65 toward SAVR; bicuspid common <60 (ACC/AHA 2020 VHD Section 5; PARTNER 3 Mack NEJM 2019; NOTION Thyregod JAMA 2015)
  • sbprequired
    vital • used at CONTEXT
    Hypotension in severe AS = warning; HTN affects regurgitant lesions (ACC/AHA 2020 VHD Section 5.2)
  • hrrequired
    vital • used at CONTEXT
    AF very common; rate-control critical in MS (ACC/AHA 2020 VHD Section 10; ESC 2021 VHD)
  • symptom_status_nyharequired
    symptom • used at CONTEXT
    NYHA defines Stage D; trigger for intervention (ACC/AHA 2020 VHD staging system)
  • syncope_or_angina_exertionalrequired
    symptom • used at RED_FLAGS
    Severe AS with symptoms = Stage D; emergent intervention planning (ACC/AHA 2020 VHD Class I)
  • cad_or_prior_pci_or_cabgrequired
    history • used at CONTEXT
    CAD assessment before any intervention (ACC/AHA 2020 VHD Section 3.2 pre-op coronary evaluation)
  • atrial_fibrillationrequired
    history • used at CONTEXT
    Anticoag selection; rhythm control (ACC/AHA 2020 VHD Section 10 mechanical vs bioprosthetic)
  • prior_valve_surgery_or_TAVRrequired
    history • used at CONTEXT
    Bioprosthesis vs mechanical; redo planning (ACC/AHA 2020 VHD Section 11 valve-in-valve)
  • frailty_assessmentrequired
    history • used at RISK_STRATIFICATION
    Drives Heart Team decision (ACC/AHA 2020 VHD Section 3.3; PARTNER 3 Mack 2019)
  • current_medsrequired
    medication • used at CONTEXT
    Anticoag, GDMT for HF, BB / CCB for rate control, ACEi/ARB/ARNI for afterload (ACC/AHA 2020 VHD)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    CKD impacts contrast use, surgical risk, drug dosing (ACC/AHA 2020 VHD Section 3)
  • bnp_or_ntprobnprequired
    lab • used at INITIAL_WORKUP
    HF severity + prognosis (ACC/AHA 2020 VHD Class IIa)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Anemia worsens HF; pre-op (ACC/AHA 2020 VHD)
  • tte_severity_gradingrequired
    imaging • used at INITIAL_WORKUP
    Primary diagnostic — peak velocity, mean gradient, AVA, regurg vol, EROA (ACC/AHA 2020 VHD Table 7; ESC 2021 VHD)
  • tee_for_mechanism
    imaging • used at BRANCHING_WORKUP
    MR mechanism — primary vs secondary, leaflet vs annulus; IE workup (ACC/AHA 2020 VHD Section 7; COAPT Stone NEJM 2018)
  • exercise_echo
    imaging • used at BRANCHING_WORKUP
    Asymptomatic high-grade AS — provoke symptoms or hemodynamic change (ACC/AHA 2020 VHD Class IIa; ESC 2021 VHD)
  • cardiac_mri
    imaging • used at BRANCHING_WORKUP
    AR severity + LV volumes + fibrosis (LGE) (ACC/AHA 2020 VHD Class IIa for AR; ESC 2021 VHD)
  • cardiac_cath
    imaging • used at BRANCHING_WORKUP
    CAD assessment before intervention (ACC/AHA 2020 VHD Section 3.2)
  • ct_tavr_planning
    imaging • used at BRANCHING_WORKUP
    Annular sizing, vascular access (ACC/AHA 2020 VHD Section 5; PARTNER 3 protocol)

12-phase flow (12)

  1. 1FRAME
    Confirm valvular lesion via TTE; quantify severity; stage A (at risk) → B (progressive) → C (asymptomatic severe) → D (symptomatic severe) per ACC/AHA 2020 VHD staging (Otto PMID 33342586)
    inputs: tte_severity_grading
    advance: Lesion + severity + stage assigned
  2. 2ENTRY
    New murmur, exertional symptoms, surveillance imaging, rheumatic history (ACC/AHA 2020 VHD Section 3)
    inputs: age
    advance: Entry pattern recognized
  3. 3CONTEXT
    Symptom status, NYHA, BP, HR, LV function, CAD, AF, anticoag, prior interventions, frailty (ACC/AHA 2020 VHD Section 3; ESC 2021 VHD)
    inputs: symptom_status_nyha, cad_or_prior_pci_or_cabg, atrial_fibrillation, frailty_assessment, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Symptomatic severe AS (syncope/angina/HF), acute severe MR (papillary rupture, IE), acute severe AR (dissection, IE), decompensated HF (ACC/AHA 2020 VHD Stage D Class I intervention)
    inputs: syncope_or_angina_exertional
    actions: workup.acute_valvular_emergency, workup.endocarditis
    advance: Acute red flags addressed
  5. 5INITIAL_WORKUP
    ECG, TTE for severity (ACC/AHA 2020 VHD Table 7), BMP/CBC, BNP (ACC/AHA 2020 VHD Class IIa)
    inputs: tte_severity_grading, creatinine_egfr, bnp_or_ntprobnp, cbc
    actions: panel.cardiac, panel.cbc, panel.renal, workup.acute_valvular_emergency
    advance: Workup returned
  6. 6BRANCHING_WORKUP
    TEE for MR mechanism (ACC/AHA 2020 VHD Section 7); exercise echo for asymptomatic high-grade (ESC 2021 VHD Class IIa); cardiac MRI for AR/fibrosis; cardiac cath for CAD pre-op; CT-TAVR planning (PARTNER 3 protocol); frailty
    inputs: tee_for_mechanism, exercise_echo, cardiac_mri, cardiac_cath, ct_tavr_planning
    actions: workup.endocarditis, workup.acs_pathway
    advance: Branching workup completed
  7. 7DIFFERENTIAL
    AS (degenerative / bicuspid / rheumatic / radiation) / AR (root vs leaflet) / MR (primary vs secondary) / MS (rheumatic) / mixed; sclerosis vs stenosis (ACC/AHA 2020 VHD Section 4; ESC 2021 VHD)
    advance: Diagnosis classified
  8. 8RISK_STRATIFICATION
    STS Risk + Euro-SCORE + Heart Team integration; CKD, frailty, age (ACC/AHA 2020 VHD Section 3.3; PARTNER 3 Mack NEJM 2019 PMID 30883058; Evolut Low Risk Popma NEJM 2019 PMID 30883053)
    inputs: frailty_assessment
    advance: Surgical risk class assigned
  9. 9TREATMENT
    GDMT for HF; avoid nitrates/vasodilators in severe AS; gentle ACEi/ARB/ARNI in AR; SAVR vs TAVR per Heart Team (ACC/AHA 2020 VHD Section 5; PARTNER 3; NOTION Thyregod JAMA 2015); MitraClip/TEER for COAPT-eligible secondary MR (Stone NEJM 2018 PMID 30222302); surgical mitral repair for primary MR (ACC/AHA 2020 VHD Section 7); balloon valvotomy for rheumatic MS (ACC/AHA 2020 VHD Section 9); warfarin for mechanical valve; DOAC for non-mechanical AF; selective IE prophylaxis high-risk only (2023 focused update)
    inputs: symptom_status_nyha
    advance: GDMT + intervention plan + anticoag plan documented
  10. 10DISPOSITION
    Heart Team referral; outpatient stepwise; admit for acute decompensation, IE, decompensated HF (ACC/AHA 2020 VHD Section 3)
    advance: Disposition documented
  11. 11MONITORING
    TTE annual for moderate, q6 mo for severe asymptomatic (ACC/AHA 2020 VHD Table 4); INR for warfarin; renal function for ARNI/diuretic; symptom diary (ESC 2021 VHD)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Cardiology / structural / cardiothoracic surgery; cardiac rehab post-procedure; vaccinations; dental clearance pre-procedure (ACC/AHA 2020 VHD; 2023 focused update IE prophylaxis)
    advance: Referrals + plans scheduled