Clinical Commander

Back to dossier
cardio.cardio-pulmonary.group2-ph.chronic.v1PRODUCTION
cardio.cardio-pulmonary.group2-ph.chronic.v1

Pulmonary hypertension due to left heart disease (Group 2 PH, cross-system)

cardiologychronicadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

PH suspected with a left-heart driver — frame as Group 2 (not Group 1/3/4)

Inputs
1
Actions
0
Advance rule
Set
Advance when

left-heart driver + Group-2 hypothesis framed

Patient inputs (10)

HFpEF/Group-2 prevalence; transplant candidacy

Detect inappropriate PAH-specific therapy in Group 2 PH

HFrEF vs HFpEF/HFmrEF vs valvular vs LA disease — the driver to treat

PAWP >15 mmHg defines post-capillary (Group 2) PH

PVR ≤2 WU (Ipc-PH) vs >2 WU (Cpc-PH) — phenotype + prognosis

Functional class; transplant evaluation

HF GDMT dosing; RHC contrast

Comorbid lung disease → combined Group 2+3 PH

RV strain/dysfunction — severity + transplant implications

LHD severity + monitoring; supports Group 2 over Group 1

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

Severity triggers (9)

9 need judgement
  • informationalsevereno_pah_drugs_in_group2
    Group 2 PH — PAH-specific therapy (ERA/PDE5i/prostacyclin/riociguat) is NOT indicated and is HARMFUL (pulmonary edema); deprescribe if started, treat the LHD instead — 2022 ESC/ERS PH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecpc_ph_branch
    Combined post-/pre-capillary PH (PAWP >15 + PVR >2 WU) — worse prognosis; optimise LHD then PH-expert centre (PAH drugs only in trial/specialist context) — 2022 ESC/ERS PH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevalvular_group2_branch
    Severe AS/MS/MR-driven Group 2 PH — valve intervention often substantially reverses PH — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransplant_pvr_branch
    Heart-transplant evaluation with elevated PVR — vasoreactivity testing; fixed high PVR may require combined strategy / contraindicate isolated heart transplant — 2022 ESC/ERS PH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehfpef_group2_branch
    HFpEF/HFmrEF-driven Group 2 PH — treat HFpEF (SGLT2i + finerenone; comorbidity-directed); commonest contemporary Group 2 cause — 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehfref_group2_branch
    HFrEF-driven Group 2 PH — 4-pillar GDMT lowers filling pressures and post-capillary PH — 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecombined_group2_3_branch
    HFpEF + significant lung disease (combined Group 2+3 PH) — co-manage both; avoid attributing solely to one; PAH drugs still not routinely indicated — 2022 ESC/ERS PH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepvr_reversibility_branch
    Reassess PVR/PASP after LHD optimisation — substantial reversibility is expected; persistent elevation despite optimised LHD prompts re-phenotyping — 2022 ESC/ERS PH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesecondary_tr_branch
    Chronic Group 2 PH causing secondary tricuspid regurgitation / RV failure — co-manage TR + RV — 2020 ACC/AHA VHD
    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

Group 2 PH — treat the left heart disease, NO PAH-specific drugs (2022 ESC/ERS PH; 2022 AHA/ACC/HFSA HF)
axis: group2_ph_treat_lhd_no_pah_drugsstep 1 - Step 1 — Confirm post-capillary (Group 2) + phenotype Ipc vs Cpc; enforce no-PAH-drug guardrail
Selected step "Step 1 — Confirm post-capillary (Group 2) + phenotype Ipc vs Cpc; enforce no-PAH-drug guardrail" — PH with a left-heart driver
  • do NOT initiate PAH-specific therapy (ERA/PDE5i/prostacyclin/riociguat) in Group 2 PH
    first line
    safety_guardrail
    triggers: group2_ph_confirmed_or_suspected
    2022 ESC/ERS PH — PAH drugs in Group 2 PH are not beneficial and can cause pulmonary edema/harm; deprescribe if inappropriately started

outpatient playbook — drug actions (3)

  1. 1. stop/avoid PAH-specific drugs
    n/a • n/a • n/a
    trigger: Group 2 PH (2022 ESC/ERS PH)
    PAH drugs are harmful here
  2. 2. phenotype-specific HF GDMT + decongestion
    per HF phenotype • PO • per drug
    trigger: HF-driven Group 2 PH (2022 ACC/AHA HF)
    Lower filling pressures = treat the PH
  3. 3. valve intervention if valvular driver
    procedure • surgical/transcatheter • n/a
    trigger: Severe left-sided valve disease (2020 ACC/AHA VHD)
    Often reverses Group 2 PH

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Echo: elevated PASP/RV strain with HFrEF/HFpEF/valve/LA disease; Worsening dyspnea in known left heart disease; Rising NT-proBNP with PH features + left heart disease.

Objective

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

Assessment

**Pulmonary hypertension due to left heart disease (Group 2 PH, cross-system)** (cardio.cardio-pulmonary.group2-ph.chronic.v1).
Phenotype framing: Group 2 vs Group 1/3/4; Ipc-PH vs Cpc-PH; combined Group 2+3
Scope: PH suspected with a left-heart driver — frame as Group 2 (not Group 1/3/4)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Group 2 PH — treat the left heart disease, NO PAH-specific drugs (2022 ESC/ERS PH; 2022 AHA/ACC/HFSA HF)** — step "Step 1 — Confirm post-capillary (Group 2) + phenotype Ipc vs Cpc; enforce no-PAH-drug guardrail".
1. do NOT initiate PAH-specific therapy (ERA/PDE5i/prostacyclin/riociguat) in Group 2 PH (safety_guardrail, first line) — 2022 ESC/ERS PH — PAH drugs in Group 2 PH are not beneficial and can cause pulmonary edema/harm; deprescribe if inappropriately started

Setting playbook (outpatient) — Confirm Group 2 (RHC Ipc/Cpc), treat the LHD, enforce no-PAH-drug guardrail, reassess PVR reversibility (2022 ESC/ERS PH; 2022 ACC/AHA HF)
2. stop/avoid PAH-specific drugs n/a n/a n/a — Group 2 PH (2022 ESC/ERS PH) (PAH drugs are harmful here)
3. phenotype-specific HF GDMT + decongestion per HF phenotype PO per drug — HF-driven Group 2 PH (2022 ACC/AHA HF) (Lower filling pressures = treat the PH)
4. valve intervention if valvular driver procedure surgical/transcatheter n/a — Severe left-sided valve disease (2020 ACC/AHA VHD) (Often reverses Group 2 PH)

Non-pharmacologic actions:
- HF/valve clinic management of the driver — 2022 ACC/AHA HF
- PH-expert-centre referral for persistent Cpc-PH / transplant PVR assessment — 2022 ESC/ERS PH
- Combined Group 2+3 → co-manage lung disease — 2022 ESC/ERS PH

AVOID / contraindication checks:
- PAH specific drugs NOT indicated and HARMFUL in Group 2 PH — 2022 ESC/ERS PH
- Treat the left heart disease this is the Group 2 PH therapy — 2022 ESC/ERS PH
- RHC required to distinguish Ipc vs Cpc and exclude Group 1 3 4 — 2022 ESC/ERS PH
- Fixed elevated PVR affects heart transplant candidacy assess reversibility — 2022 ESC/ERS PH
- Cpc PH PAH drugs only in specialist trial context — 2022 ESC/ERS PH

Monitoring

Regimen monitoring:
- reassess PASP PVR and symptoms after LHD optimisation — 2022 ESC/ERS PH
- NT-proBNP and congestion for LHD control — 2022 ACC/AHA HF
- RV function serial echo — 2022 ESC/ERS PH
- transplant PVR vasoreactivity if evaluation — 2022 ESC/ERS PH

Setting (outpatient) monitoring:
- Reassess PASP/PVR/symptoms after LHD optimisation — 2022 ESC/ERS PH

Follow-up plan: Transplant candidacy reassessment; re-phenotype if PH persists/worsens despite LHD optimisation
- Close-out criterion: long-term plan documented

Monitoring phase: Reassess PVR/PASP + symptoms after LHD optimisation (reversibility); RV function

Disposition

Current setting: outpatient — Confirm Group 2 (RHC Ipc/Cpc), treat the LHD, enforce no-PAH-drug guardrail, reassess PVR reversibility (2022 ESC/ERS PH; 2022 ACC/AHA HF)

Disposition criteria:
- Ipc-PH → treat LHD, routine HF/valve follow-up
- Cpc-PH → optimise LHD + PH-expert centre
- Transplant candidate → PVR vasoreactivity assessment

Escalation triggers (move to higher acuity):
- Inappropriate PAH drug found → deprescribe + reassess — 2022 ESC/ERS PH
- Persistent Cpc-PH despite optimised LHD → PH-expert centre — 2022 ESC/ERS PH
- Decompensated LHD/RV failure → acute pathway — 2022 ACC/AHA HF

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Group 2 PH — PAH-specific therapy (ERA/PDE5i/prostacyclin/riociguat) is NOT indicated and is HARMFUL (pulmonary edema); deprescribe if started, treat the LHD instead — 2022 ESC/ERS PH
- [SEVERE] Combined post-/pre-capillary PH (PAWP >15 + PVR >2 WU) — worse prognosis; optimise LHD then PH-expert centre (PAH drugs only in trial/specialist context) — 2022 ESC/ERS PH
- [SEVERE] Severe AS/MS/MR-driven Group 2 PH — valve intervention often substantially reverses PH — 2020 ACC/AHA VHD

Citations

- 2022 ESC/ERS Pulmonary Hypertension Guideline (Humbert) + 2022 AHA/ACC/HFSA HF Guideline [PMID:35379504](https://pubmed.ncbi.nlm.nih.gov/35379504/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)
- Cited evidence (PMID 36027570) [PMID:36027570](https://pubmed.ncbi.nlm.nih.gov/36027570/)
- Cited evidence (PMID 31535829) [PMID:31535829](https://pubmed.ncbi.nlm.nih.gov/31535829/)
- Cited evidence (PMID 39225278) [PMID:39225278](https://pubmed.ncbi.nlm.nih.gov/39225278/)

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