cardio.aortic-regurgitation.chronic.v1PRODUCTION

cardio.aortic-regurgitation.chronic.v1

Chronic aortic regurgitation

cardiologychronicadult

Hard-required inputs

0 / 9

Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm chronic AR; if acute severe AR (dissection/endocarditis) → emergency route cardio.aortic-dissection.core.v1 / IE engine

Inputs

Actions

Advance rule

Set

Advance when

chronic AR confirmed

Patient inputs (11)

age*demographic • CONTEXT

Surgical risk + bicuspid/syndromic aortopathy probability

ar_acuity*imaging • FRAME

not present

Chronic (compensated dilated LV) vs acute (small non-compliant LV, shock) — acute routes out

ar_severity*imaging • INITIAL_WORKUP

not present

VC/RF/EROA/flow-reversal → ACC/AHA stage

lvef*imaging • RISK_STRATIFICATION

not present

LVEF ≤55% in severe AR = Class I AVR (stage C2)

lvesd*imaging • RISK_STRATIFICATION

not present

LVESD >50 mm (or >25 mm/m² indexed) = Class IIa AVR

aortic_diameter*imaging • RISK_STRATIFICATION

not present

Root/ascending diameter drives aortic replacement independent of valve

nyha_class*symptom • RISK_STRATIFICATION

Symptomatic severe AR (stage D) = Class I AVR

sbp*vital • TREATMENT

HTN raises wall stress — BP control bridge (ACEi/ARB/DHP-CCB)

creatinine*lab • TREATMENT

Contrast for CT aorta + peri-op risk

syndromic_aortopathyhistory • CONTEXT

not present

Marfan/Loeys-Dietz/vEDS lower aortic surgical threshold + ARB/BB therapy

bicuspid_valvehistory • CONTEXT

not present

Bicuspid aortopathy lower threshold + first-degree family screening

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement

informationallife_threateningacute_ar_emergency
Acute severe AR (endocarditis leaflet destruction or aortic dissection) — small non-compliant LV → shock/flash edema — EMERGENCY surgery — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereclass_I_avr_symptomatic
Symptomatic severe chronic AR (stage D) — Class I surgical AVR — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereclass_I_avr_lv_dysfunction
Asymptomatic severe AR + LVEF ≤55% (stage C2) — Class I AVR — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresyndromic_aortopathy_branch
Marfan / Loeys-Dietz / vascular EDS — ARB + BB, earlier aortic surgery (Marfan ≥4.5–5.0 cm; Loeys-Dietz lower), genetics + cascade — 2022 ACC/AHA Aortic
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverepregnancy_special_pop
Pregnancy/planning — STOP ACEi/ARB; use BB; mWHO risk by aortic root size (root >4.5 cm Marfan = very high risk / consider pre-pregnancy repair); cardio-obstetric — ESC 2018 Pregnancy
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatelvesd_threshold_IIa
Asymptomatic severe AR + LVEF >55% + LVESD >50 mm (or >25 mm/m² indexed) — Class IIa AVR — 2020 ACC/AHA VHD
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatebicuspid_aortopathy_branch
Bicuspid aortic valve with aortopathy — lower aortic surgical threshold (≥5.0 cm with risk features); first-degree family echo screening — 2022 ACC/AHA Aortic
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateckd_special_pop
CKD — minimise iodinated contrast for aortic CT (use MR), renal-adjust peri-op meds — KDIGO 2024
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatelv_dysfunction_post_avr
Persistent LV dysfunction after AVR — co-manage as HFrEF with GDMT — 2022 ACC/AHA HF
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment

Loading…

Recommended regimen

Chronic AR — intervention timing + BP/aortopathy bridge (2020 ACC/AHA VHD; 2022 ACC/AHA Aortic)

axis: chronic_ar_intervention_and_bridgestep 1 - Stage B/C1 — asymptomatic, preserved LV, normal aorta — SURVEILLANCE

Selected step "Stage B/C1 — asymptomatic, preserved LV, normal aorta — SURVEILLANCE" — Asymptomatic, LVEF >55%, LVESD ≤50 mm, aorta below threshold

outpatient playbook — drug actions (2)

1. losartan ± amlodipine for BP/wall stress
losartan 50–100 mg • PO • daily
trigger: HTN with AR or aortopathy (2020 ACC/AHA VHD)
Afterload + aortic-growth reduction
2. metoprolol if syndromic aortopathy
25–100 mg • PO • BID
trigger: Marfan/aortic dilatation (2022 ACC/AHA Aortic)
Slows aortic dilatation; balance diastolic prolongation

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Early diastolic decrescendo murmur at LSB; Wide pulse pressure / bounding pulses; Echo: severe AR (VC >0.6 cm, RF ≥50%, EROA ≥0.30 cm², holodiastolic flow reversal).

Objective

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

Assessment

**Chronic aortic regurgitation** (cardio.aortic-regurgitation.chronic.v1).
Phenotype framing: Chronic vs acute AR; valve-driven vs aortopathy-driven; mixed AS/AR
Scope: Confirm chronic AR; if acute severe AR (dissection/endocarditis) → emergency route cardio.aortic-dissection.core.v1 / IE engine

No severity triggers fired against current inputs.

Plan

Regimen axis: **Chronic AR — intervention timing + BP/aortopathy bridge (2020 ACC/AHA VHD; 2022 ACC/AHA Aortic)** — step "Stage B/C1 — asymptomatic, preserved LV, normal aorta — SURVEILLANCE".

Setting playbook (outpatient) — Stage AR + aorta, control BP, refer for AVR/aortic surgery at the correct trigger, screen family (2020 ACC/AHA VHD; 2022 ACC/AHA Aortic)
1. losartan ± amlodipine for BP/wall stress losartan 50–100 mg PO daily — HTN with AR or aortopathy (2020 ACC/AHA VHD) (Afterload + aortic-growth reduction)
2. metoprolol if syndromic aortopathy 25–100 mg PO BID — Marfan/aortic dilatation (2022 ACC/AHA Aortic) (Slows aortic dilatation; balance diastolic prolongation)

Non-pharmacologic actions:
- Refer for surgical AVR ± aortic replacement when Class I/IIa or aortic threshold met — 2020 ACC/AHA VHD; 2022 Aortic
- First-degree family echo screening for bicuspid valve/aortopathy — 2022 ACC/AHA Aortic
- Endocarditis prophylaxis only if prior IE or prosthetic material — 2020 ACC/AHA VHD

AVOID / contraindication checks:
- No medical therapy delays surgery in symptomatic or LV decompensated severe AR — 2020 ACC/AHA VHD
- Caution pure BB in severe AR diastolic prolongation increases regurgitation — 2020 ACC/AHA VHD
- ACEi ARB contraindicated in pregnancy switch to BB — fetotoxic RAS blockade
- Lower aortic surgical threshold in Marfan LoeysDietz bicuspid — 2022 ACC/AHA Aortic

Monitoring

Regimen monitoring:
- TTE q6-12mo severe asymptomatic — 2020 ACC/AHA VHD
- TTE q1-2yr moderate — 2020 ACC/AHA VHD
- aortic imaging CT or MR by root size and growth rate — 2022 ACC/AHA Aortic
- serial LVEF LVESD for intervention trigger — 2020 ACC/AHA VHD
- first degree family screening bicuspid or syndromic — 2022 ACC/AHA Aortic

Setting (outpatient) monitoring:
- Serial TTE + aortic imaging per severity and root size — 2020 ACC/AHA VHD; 2022 Aortic
- Symptom + BP review each visit — 2020 ACC/AHA VHD

Follow-up plan: Family screening (bicuspid/syndromic); route to HFrEF engine if LV dysfunction
- Close-out criterion: follow-up + screening + escalation triggers documented

Monitoring phase: Serial TTE + aortic imaging by severity and root size

Disposition

Current setting: outpatient — Stage AR + aorta, control BP, refer for AVR/aortic surgery at the correct trigger, screen family (2020 ACC/AHA VHD; 2022 ACC/AHA Aortic)

Disposition criteria:
- Asymptomatic non-severe, normal aorta → routine surveillance
- Class I/IIa or aortic threshold → AVR ± aortic surgery referral
- Prohibitive surgical risk + pure AR → transcatheter AR device evaluation

Escalation triggers (move to higher acuity):
- Symptoms OR LVEF ≤55% OR LVESD >50 mm (>25 mm/m²) → surgical referral now — 2020 ACC/AHA VHD
- Aortic root/ascending at threshold → aortic surgery — 2022 ACC/AHA Aortic
- Acute severe AR (dissection/IE features) → ED + emergency route — 2020 ACC/AHA VHD

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute severe AR (endocarditis leaflet destruction or aortic dissection) — small non-compliant LV → shock/flash edema — EMERGENCY surgery — 2020 ACC/AHA VHD
- [SEVERE] Symptomatic severe chronic AR (stage D) — Class I surgical AVR — 2020 ACC/AHA VHD
- [SEVERE] Asymptomatic severe AR + LVEF ≤55% (stage C2) — Class I AVR — 2020 ACC/AHA VHD

Citations

- 2020 ACC/AHA VHD Guideline + 2022 ACC/AHA Aortic Disease Guideline + 2021 ESC/EACTS VHD Guideline [PMID:33332149](https://pubmed.ncbi.nlm.nih.gov/33332149/)
- Cited evidence (PMID 36322642) [PMID:36322642](https://pubmed.ncbi.nlm.nih.gov/36322642/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 25409260) [PMID:25409260](https://pubmed.ncbi.nlm.nih.gov/25409260/)
- Cited evidence (PMID 10199862) [PMID:10199862](https://pubmed.ncbi.nlm.nih.gov/10199862/)

Last reconciled with current guidelines: 2026-05-16.

References

2020 ACC/AHA VHD Guideline + 2022 ACC/AHA Aortic Disease Guideline + 2021 ESC/EACTS VHD Guideline — PMID:33332149
Cited evidence (PMID 36322642) — PMID:36322642
Cited evidence (PMID 34453165) — PMID:34453165
Cited evidence (PMID 25409260) — PMID:25409260
Cited evidence (PMID 10199862) — PMID:10199862