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cardio.achd-coarctation.chronic.v1PRODUCTION
cardio.achd-coarctation.chronic.v1

Adult aortic coarctation (native + repaired, chronic ACHD)

cardiologychronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Native vs repaired coarctation; BAV/ascending-aorta involvement

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coarctation context framed

Patient inputs (11)

Discrete vs long-segment + repair-site aneurysm — modality (stent vs surgery)

Adult intervention modality (stent) + lifelong surveillance

Native vs repaired (re-coarctation/aneurysm) — different surveillance + intervention

Resting gradient + exercise HTN — hemodynamic significance

Peak-to-peak ≥20 mmHg = intervention threshold

Residual/exercise HTN — drives lifelong aggressive control

Contrast for CTA/MRA; antihypertensive dosing

One-time intracranial MRA berry-aneurysm screening

BAV (50–85%) + ascending aortopathy co-management

mWHO risk; dissection/HTN risk; avoid ACEi/ARB → labetalol

Symptomatic significance + LV burden

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Severity triggers (9)

9 need judgement
  • informationallife_threateningrepair_site_aneurysm_branch
    Repair-site aneurysm/pseudoaneurysm (esp. post-patch/Dacron) — covered stent or surgery; expansion/rupture = emergency — 2020 ESC ACHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresignificant_coarctation_intervention
    Peak-to-peak gradient ≥20 mmHg, OR <20 mmHg + significant anatomic narrowing + HTN/LVH/collaterals, OR re-coarctation — stent/surgical intervention — 2018 AHA/ACC ACHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereresidual_htn_lifelong_branch
    Persistent/residual or exercise-induced HTN even after successful repair — aggressive lifelong multi-agent control (drives premature CV death) — 2018 AHA/ACC ACHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebav_ascending_aortopathy_branch
    Associated bicuspid aortic valve (50–85%) + ascending aortopathy — valve + ascending-aorta surveillance; aortic surgery at ACHD/BAV thresholds — 2022 ACC/AHA Aortic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereintracranial_aneurysm_branch
    Coarctation increased intracranial berry-aneurysm prevalence — one-time MRA screen; neurosurgical referral if positive — 2018 AHA/ACC ACHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverere_coarctation_branch
    Re-coarctation (recurrent gradient/HTN post-repair) — re-intervention (stent preferred in adults) — 2018 AHA/ACC ACHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy with coarctation — HTN + dissection risk (esp. unrepaired/aneurysm); mWHO II–IV by anatomy; avoid ACEi/ARB → labetalol; cardio-obstetric — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepremature_cv_prevention_branch
    Coarctation patients have premature CAD/stroke risk — aggressive global CV-risk-factor optimization (lipids, glucose, smoking, BP) — 2018 AHA/ACC ACHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — minimise contrast (CTA/MRA); renal-adjust antihypertensives — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Coarctation — intervention + lifelong HTN control + surveillance (2018 AHA/ACC ACHD; 2020 ESC ACHD; 2022 ACC/AHA Aortic)
axis: coarctation_intervention_and_lifelong_htnstep 1 - Step 1 — Assess hemodynamic significance + anatomy
Selected step "Step 1 — Assess hemodynamic significance + anatomy" — Native or repaired coarctation

outpatient playbook — drug actions (3)

  1. 1. stent/surgical intervention if significant
    procedure • transcatheter/surgical • n/a
    trigger: Gradient ≥20 mmHg or significant narrowing + HTN (2018 AHA/ACC ACHD)
    Relieve obstruction; HTN often persists
  2. 2. aggressive multi-agent HTN control
    losartan 50–100 mg + metoprolol ± amlodipine ± chlorthalidone • PO • daily/BID
    trigger: Residual/exercise HTN (2018 AHA/ACC ACHD)
    Residual HTN drives premature CV death
  3. 3. labetalol if pregnant
    100–200 mg BID–TID • PO • BID–TID
    trigger: Pregnancy (ESC 2018)
    Avoid ACEi/ARB in pregnancy

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Upper-extremity HTN with arm-leg BP gradient / radio-femoral delay; Aortic narrowing on echo/CTA/MRA (native or re-coarctation); Repaired coarctation — surveillance visit.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Adult aortic coarctation (native + repaired, chronic ACHD)** (cardio.achd-coarctation.chronic.v1).
Phenotype framing: Significant vs non-significant; native vs re-coarctation vs repair-site pseudoaneurysm
Scope: Native vs repaired coarctation; BAV/ascending-aorta involvement

No severity triggers fired against current inputs.

Plan

Regimen axis: **Coarctation — intervention + lifelong HTN control + surveillance (2018 AHA/ACC ACHD; 2020 ESC ACHD; 2022 ACC/AHA Aortic)** — step "Step 1 — Assess hemodynamic significance + anatomy".

Setting playbook (outpatient) — Intervene significant coarctation, lifelong aggressive HTN control, surveil aorta/BAV/cerebral, prevent premature CV death (2018 AHA/ACC ACHD; 2022 ACC/AHA Aortic)
1. stent/surgical intervention if significant procedure transcatheter/surgical n/a — Gradient ≥20 mmHg or significant narrowing + HTN (2018 AHA/ACC ACHD) (Relieve obstruction; HTN often persists)
2. aggressive multi-agent HTN control losartan 50–100 mg + metoprolol ± amlodipine ± chlorthalidone PO daily/BID — Residual/exercise HTN (2018 AHA/ACC ACHD) (Residual HTN drives premature CV death)
3. labetalol if pregnant 100–200 mg BID–TID PO BID–TID — Pregnancy (ESC 2018) (Avoid ACEi/ARB in pregnancy)

Non-pharmacologic actions:
- ACHD centre + aortic-team referral — 2018 AHA/ACC ACHD
- One-time intracranial aneurysm screen + neurosurgery if positive — 2018 AHA/ACC ACHD
- BAV/ascending-aorta co-management — 2022 ACC/AHA Aortic
- Pregnancy + transition-of-care counseling — 2018 AHA/ACC ACHD

AVOID / contraindication checks:
- Continue aggressive HTN control even after successful repair residual HTN drives premature CV death — 2018 AHA/ACC ACHD
- Covered stent or surgery if repair site aneurysm or near atresia — 2020 ESC ACHD
- Avoid ACEi ARB in pregnancy use labetalol — ESC 2018 Pregnancy
- Co manage bicuspid aortic valve and ascending aortopathy — 2022 ACC/AHA Aortic
- One time intracranial aneurysm screen — 2018 AHA/ACC ACHD

Monitoring

Regimen monitoring:
- resting and exercise BP lifelong — 2018 AHA/ACC ACHD
- repair site and ascending aorta CTA MRA surveillance — 2018 AHA/ACC ACHD
- BAV aortic valve and root echo surveillance — 2022 ACC/AHA Aortic
- premature CAD stroke risk factor optimization — 2018 AHA/ACC ACHD

Setting (outpatient) monitoring:
- Lifelong BP (resting + exercise) + repair-site/ascending-aorta imaging — 2018 AHA/ACC ACHD

Follow-up plan: Lifelong ACHD; pregnancy + transition planning; CV-prevention (premature CAD/stroke)
- Close-out criterion: lifelong ACHD + prevention plan documented

Monitoring phase: BP (incl. exercise), repair-site + ascending-aorta CTA/MRA surveillance

Disposition

Current setting: outpatient — Intervene significant coarctation, lifelong aggressive HTN control, surveil aorta/BAV/cerebral, prevent premature CV death (2018 AHA/ACC ACHD; 2022 ACC/AHA Aortic)

Disposition criteria:
- Significant coarctation → stent/surgery + lifelong HTN control
- Repaired, controlled → periodic ACHD + aortic surveillance
- Repair-site aneurysm → covered stent/surgery

Escalation triggers (move to higher acuity):
- Dissection / repair-site aneurysm expansion → emergency aortic pathway — 2022 ACC/AHA Aortic
- Re-coarctation (recurrent gradient/HTN) → re-intervention — 2018 AHA/ACC ACHD
- Uncontrolled HTN despite multi-agent → re-assess obstruction + intensify — 2018 AHA/ACC ACHD

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Repair-site aneurysm/pseudoaneurysm (esp. post-patch/Dacron) — covered stent or surgery; expansion/rupture = emergency — 2020 ESC ACHD
- [SEVERE] Peak-to-peak gradient ≥20 mmHg, OR <20 mmHg + significant anatomic narrowing + HTN/LVH/collaterals, OR re-coarctation — stent/surgical intervention — 2018 AHA/ACC ACHD
- [SEVERE] Persistent/residual or exercise-induced HTN even after successful repair — aggressive lifelong multi-agent control (drives premature CV death) — 2018 AHA/ACC ACHD

Citations

- 2018 AHA/ACC Adult Congenital Heart Disease Guideline (Stout) + 2020 ESC Adult Congenital Heart Disease Guideline (Baumgartner) + 2022 ACC/AHA Aortic Disease Guideline (Isselbacher) [PMID:30121239](https://pubmed.ncbi.nlm.nih.gov/30121239/)
- Cited evidence (PMID 32860028) [PMID:32860028](https://pubmed.ncbi.nlm.nih.gov/32860028/)
- Cited evidence (PMID 36322642) [PMID:36322642](https://pubmed.ncbi.nlm.nih.gov/36322642/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2018 AHA/ACC Adult Congenital Heart Disease Guideline (Stout) + 2020 ESC Adult Congenital Heart Disease Guideline (Baumgartner) + 2022 ACC/AHA Aortic Disease Guideline (Isselbacher) — PMID:30121239
  • Cited evidence (PMID 32860028) — PMID:32860028
  • Cited evidence (PMID 36322642) — PMID:36322642