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cardio.aortic_stenosis.v1PRODUCTION
cardio.aortic_stenosis.v1

Aortic stenosis (calcific + bicuspid + rheumatic; high-gradient & low-flow/low-gradient)

cardiologychronicacuteadultgeriatric
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12/12 authored

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

Current phase

Frame

Detailed

Confirm AS by TTE; classify severity (mild/moderate/severe) AND flow-state strata (high-gradient vs classical-LFLG low-EF vs paradoxical-LFLG preserved-EF vs normal-flow-low-gradient) using AVA + stroke-volume-index, NOT gradient alone (2020 ACC/AHA VHD §3.2.2, PMID 33342586)

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Severity + flow strata assigned

Patient inputs (16)

TAVR vs SAVR + prosthesis selection — TAVR favoured ≥65–80 y per 2020 ACC/AHA VHD §3.2.4 (PMID 33342586)

Hypotension/shock = critical-AS warning; afterload-dependent (2020 ACC/AHA VHD)

Tachycardia + bradycardia both worsen fixed-obstruction supply–demand (2020 ACC/AHA VHD)

Pulmonary congestion in decompensated AS (2020 ACC/AHA VHD)

STS/EuroSCORE + Heart-Team weighting + futility screen (2020 ACC/AHA VHD §3.2.4)

AVOID vasodilators/nitrates/ACEi-ARB in critical AS; reconcile anticoagulant for post-AVR plan (2020 ACC/AHA VHD)

LV-strain marker — markedly ↑ BNP is an asymptomatic-severe early-intervention trigger (2020 ACC/AHA VHD §3.2.3)

Contrast risk + SAVR-vs-TAVR weighting + post-AVR AC dosing (CKD-EPI 2021)

Anemia worsens symptoms; pre-procedure baseline; Heyde GI-bleed screen (2020 ACC/AHA VHD)

ASCVD comorbidity ONLY — statin does NOT slow AS (SEAS 18765433 / ASTRONOMER 20048204 / SALTIRE 15944423)

Vmax, mean gradient, AVA, dimensionless index, stroke-volume-index, EF — AVA+flow not gradient alone (2020 ACC/AHA VHD §3.2.2)

LVH, conduction delay, baseline before TAVR PPM risk, AF (2020 ACC/AHA VHD)

Cardiomegaly, pulmonary congestion, valve calcification (2020 ACC/AHA VHD)

CAD assessment pre-intervention (2020 ACC/AHA VHD §3.2.4)

Annular dimensions, calcium pattern, bicuspid morphology, vascular access (2020 ACC/AHA VHD)

Classical low-flow/low-gradient AS — true-vs-pseudo-severe by flow reserve; valid only with reduced baseline EF (2020 ACC/AHA VHD §3.2.2)

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningcritical_AS_hypotension
    Hypotension or shock in critical AS (2020 ACC/AHA VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_severe_AS
    Severe AS (Vmax ≥4 m/s, MG ≥40 mmHg, AVA ≤1.0 cm²) with exertional syncope / angina / HF (2020 ACC/AHA VHD §3.2.4)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereasymptomatic_severe_AS_with_LV_dysfunction
    Severe AS with EF <50% with no other cause (2020 ACC/AHA VHD §3.2.4)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretavr_av_block_requiring_PPM
    New high-grade AV block post-TAVR (2020 ACC/AHA VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparavalvular_leak_post_AVR
    Moderate–severe paravalvular regurgitation post-TAVR/SAVR (2020 ACC/AHA VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateearly_tavr_recovery_avatar_criteria
    Asymptomatic severe AS, preserved EF, with EARLY-TAVR eligibility OR very-severe (Vmax ≥5/MG ≥60) OR rapid progression OR abnormal exercise test OR markedly ↑ BNP
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelow_flow_low_gradient_AS
    AVA ≤1.0 cm² with mean gradient <40 mmHg — classical (EF<50%, SVi<35) or paradoxical (EF≥50%, SVi<35) (2020 ACC/AHA VHD §3.2.2)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

AS severity/symptom-staged management ladder (2020 ACC/AHA VHD §3.2; EARLY-TAVR/RECOVERY/AVATAR era)
axis: as_severity_symptom_staged_managementstep 1 - Stage A/B — mild/moderate AS: surveillance only, NO disease-modifying drug
Selected step "Stage A/B — mild/moderate AS: surveillance only, NO disease-modifying drug" — Vmax <4 m/s, mean gradient <40 mmHg, AVA >1.0 cm² (mild Vmax 2.0–2.9 / moderate 3.0–3.9) — asymptomatic
  • clinical surveillance (no AS-directed pharmacotherapy)
    first line
    watchful_waiting
    triggers: mild_AS, moderate_AS, asymptomatic
    No drug slows AS: SEAS AVR HR 1.00 (0.84–1.18) PMID 18765433; ASTRONOMER annualised peak-gradient rise 6.3 vs 6.1 mmHg/y P=0.83 PMID 20048204; SALTIRE no effect PMID 15944423. Surveillance TTE q1–2 y (moderate) per 2020 ACC/AHA VHD §3.2.5
  • atorvastatin
    comorbidity specific
    statin_high_intensity
    40–80 mg • PO • once daily
    triggers: ASCVD_comorbidity, aortic_sclerosis_CV_risk
    For independent ASCVD risk ONLY — does NOT slow AS (SEAS ischaemic-event HR 0.78 (0.63–0.97) reflects ASCVD benefit, AS-event HR 1.00; PMID 18765433)
    rxcui 83367

outpatient playbook — drug actions (4)

  1. 1. NO AS-directed drug — surveillance
    n/a • n/a • n/a
    trigger: Mild/moderate or trigger-negative asymptomatic severe
    No drug slows AS — SEAS/ASTRONOMER/SALTIRE negative (PMID 18765433/20048204/15944423)
  2. 2. atorvastatin
    rxcui 83367
    40–80 mg • PO • daily
    trigger: Independent ASCVD comorbidity only
    ASCVD prevention — does NOT slow AS (SEAS AS-event HR 1.00; PMID 18765433)
  3. 3. furosemide (cautious)
    rxcui 4603
    20–40 mg • PO • daily
    trigger: Congestive symptoms in severe AS awaiting AVR
    Cautious decongestion bridge — preload-dependent (2020 ACC/AHA VHD)
  4. 4. metoprolol succinate (cautious, small dose)
    rxcui 221124
    12.5–25 mg • PO • daily
    trigger: AF rate control or angina with preserved EF
    Small doses; avoid bradycardia/negative inotropy in fixed obstruction (2020 ACC/AHA VHD)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Classic AS triad — exertional syncope, angina, or HF (2020 ACC/AHA VHD §3.2); Progressive dyspnea on exertion in known AS (2020 ACC/AHA VHD §3.2); Late-peaking systolic ejection murmur with diminished/absent A2 (Etchells JAMA 1997 PMID 9032164).

Objective

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

Assessment

**Aortic stenosis (calcific + bicuspid + rheumatic; high-gradient & low-flow/low-gradient)** (cardio.aortic_stenosis.v1).
Phenotype framing: Valvular AS vs HOCM dynamic LVOT vs sub/supravalvular AS vs aortic sclerosis vs MR vs AR vs flow/pulmonic-stenosis murmur; assign severity & flow strata (Etchells JAMA 1997 PMID 9032164)
Scope: Confirm AS by TTE; classify severity (mild/moderate/severe) AND flow-state strata (high-gradient vs classical-LFLG low-EF vs paradoxical-LFLG preserved-EF vs normal-flow-low-gradient) using AVA + stroke-volume-index, NOT gradient alone (2020 ACC/AHA VHD §3.2.2, PMID 33342586)

No severity triggers fired against current inputs.

Plan

Regimen axis: **AS severity/symptom-staged management ladder (2020 ACC/AHA VHD §3.2; EARLY-TAVR/RECOVERY/AVATAR era)** — step "Stage A/B — mild/moderate AS: surveillance only, NO disease-modifying drug".
1. clinical surveillance (no AS-directed pharmacotherapy) (watchful_waiting, first line) — No drug slows AS: SEAS AVR HR 1.00 (0.84–1.18) PMID 18765433; ASTRONOMER annualised peak-gradient rise 6.3 vs 6.1 mmHg/y P=0.83 PMID 20048204; SALTIRE no effect PMID 15944423. Surveillance TTE q1–2 y (moderate) per 2020 ACC/AHA VHD §3.2.5
2. atorvastatin 40–80 mg PO once daily (statin_high_intensity, comorbidity specific) — For independent ASCVD risk ONLY — does NOT slow AS (SEAS ischaemic-event HR 0.78 (0.63–0.97) reflects ASCVD benefit, AS-event HR 1.00; PMID 18765433)

Setting playbook (outpatient) — Severity + flow-state grading, asymptomatic-severe trigger surveillance, Heart-Team referral timing, peri-procedural pharmacology only (2020 ACC/AHA VHD §3.2)
3. NO AS-directed drug — surveillance n/a n/a n/a — Mild/moderate or trigger-negative asymptomatic severe (No drug slows AS — SEAS/ASTRONOMER/SALTIRE negative (PMID 18765433/20048204/15944423))
4. atorvastatin 40–80 mg PO daily — Independent ASCVD comorbidity only (ASCVD prevention — does NOT slow AS (SEAS AS-event HR 1.00; PMID 18765433))
5. furosemide (cautious) 20–40 mg PO daily — Congestive symptoms in severe AS awaiting AVR (Cautious decongestion bridge — preload-dependent (2020 ACC/AHA VHD))
6. metoprolol succinate (cautious, small dose) 12.5–25 mg PO daily — AF rate control or angina with preserved EF (Small doses; avoid bradycardia/negative inotropy in fixed obstruction (2020 ACC/AHA VHD))

Non-pharmacologic actions:
- Heart-Team referral if symptomatic severe OR asymptomatic-severe trigger-positive (EARLY-TAVR/RECOVERY/AVATAR) (2020 ACC/AHA VHD §3.2.4)
- Avoid intense isometric/competitive exertion in severe AS (2020 ACC/AHA VHD)
- Vaccinations (influenza, pneumococcal, COVID, RSV) (AHA prevention)
- Smoking cessation; ASCVD risk-factor optimisation

AVOID / contraindication checks:
- No disease modifying drug for AS — SEAS (PMID 18765433) / ASTRONOMER (PMID 20048204) / SALTIRE (PMID 15944423) all negative; statin only for independent ASCVD
- Nitrate block in severe AS — preload dependent (2020 ACC/AHA VHD)
- ACEi ARB cautious in critical AS — afterload dependent fixed obstruction (2020 ACC/AHA VHD)
- Beta blocker cautious in LFLG low EF — negative inotropy worsens low output state (2020 ACC/AHA VHD)
- Avoid over diuresis preload dependent severe AS (2020 ACC/AHA VHD)

Monitoring

Regimen monitoring:
- TTE q3–6 mo (very-severe asymptomatic), q6–12 mo (severe asymptomatic), q1–2 y (moderate) (2020 ACC/AHA VHD §3.2.5)
- Symptom re-assessment + exercise tolerance each visit (asymptomatic severe)
- BNP/NT-proBNP trend — rising trend is an early-intervention trigger (2020 ACC/AHA VHD §3.2.3)
- BMP q24h during any diuresis (preload-dependent) (2020 ACC/AHA VHD)

Setting (outpatient) monitoring:
- TTE per severity stage (2020 ACC/AHA VHD §3.2.5)
- Symptom + exercise-tolerance diary; BNP trend

Follow-up plan: Cardiology / valve clinic; endocarditis prophylaxis after prosthetic AVR; lifestyle; vaccinations (2020 ACC/AHA VHD §3.2.5)
- Close-out criterion: Follow-up booked

Monitoring phase: TTE q3–6 mo (very-severe asymptomatic), q6–12 mo (severe asymptomatic), q1–2 y (moderate); 30-d post-AVR echo; valve durability + HALT + PPM surveillance (2020 ACC/AHA VHD §3.2.5; PARTNER 3 5-yr PMID 37874020)

Disposition

Current setting: outpatient — Severity + flow-state grading, asymptomatic-severe trigger surveillance, Heart-Team referral timing, peri-procedural pharmacology only (2020 ACC/AHA VHD §3.2)

Disposition criteria:
- Continue surveillance if trigger-negative (2020 ACC/AHA VHD §3.2.3)

Escalation triggers (move to higher acuity):
- New exertional symptom → urgent Heart-Team referral (Class I AVR) (2020 ACC/AHA VHD)
- EARLY-TAVR/RECOVERY/AVATAR trigger met (very-severe / rapid progression / abnormal exercise test / ↑BNP) → early-intervention referral
- EF <50% on surveillance echo → Class I AVR referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hypotension or shock in critical AS (2020 ACC/AHA VHD)
- [SEVERE] Severe AS (Vmax ≥4 m/s, MG ≥40 mmHg, AVA ≤1.0 cm²) with exertional syncope / angina / HF (2020 ACC/AHA VHD §3.2.4)
- [SEVERE] Severe AS with EF <50% with no other cause (2020 ACC/AHA VHD §3.2.4)

Citations

- 2020 ACC/AHA Valvular Heart Disease Guideline (current 2026; full ACC/AHA revision planned late 2026) + 2021 ESC/EACTS VHD; EARLY-TAVR-era evidence layered on [PMID:33342586](https://pubmed.ncbi.nlm.nih.gov/33342586/)
- Cited evidence (PMID 33332149) [PMID:33332149](https://pubmed.ncbi.nlm.nih.gov/33332149/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 39466903) [PMID:39466903](https://pubmed.ncbi.nlm.nih.gov/39466903/)
- Cited evidence (PMID 39641732) [PMID:39641732](https://pubmed.ncbi.nlm.nih.gov/39641732/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2020 ACC/AHA Valvular Heart Disease Guideline (current 2026; full ACC/AHA revision planned late 2026) + 2021 ESC/EACTS VHD; EARLY-TAVR-era evidence layered on — PMID:33342586
  • Cited evidence (PMID 33332149) — PMID:33332149
  • Cited evidence (PMID 34453165) — PMID:34453165
  • Cited evidence (PMID 39466903) — PMID:39466903
  • Cited evidence (PMID 39641732) — PMID:39641732