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cardio.geriatric-frailty-hf.chronic.v1PRODUCTION
cardio.geriatric-frailty-hf.chronic.v1

Heart failure in the frail older adult (chronic, sub-population)

cardiologychronicgeriatricadult
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

HF phenotype + frailty severity + patient goals — set disease-modifying vs symptom-focused frame

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phenotype + frailty + goals framed

Patient inputs (10)

Older-adult HF management + prognosis framing

Polypharmacy + STOPP/START deprescribing targets

HFpEF (predominant in elderly) vs HFrEF/HFmrEF — GDMT intensity

Clinical Frailty Scale — drives disease-modifying vs symptom-focused intensity

Function + patient goals (what Matters) → care intensity

Orthostatic hypotension gates RAS/BB titration + diuretic dosing

eGFR limits GDMT; over-diuresis pre-renal/falls

Renal drug dosing

Cognitive impairment → adherence aids, caregiver, regimen simplification

Falls risk modifies BP target + drug choices

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

Severity triggers (9)

9 need judgement
  • informationalsevereiatrogenic_overtreatment_harm
    Symptomatic hypotension / pre-renal AKI / falls attributable to HF over-treatment (excess diuretic/RAS/BB) in a frail elder — DE-ESCALATE/deprescribe, do not intensify — STOPP/START; 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_frailty_goals_branch
    Severe frailty / limited prognosis / comfort-aligned goals — symptom-focused care, deprescribe disease-modifying when no longer aligned, palliative integration — 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereorthostasis_falls_branch
    Orthostatic hypotension / recurrent falls — individualise BP target, check orthostatic BP before RAS/BB titration, reduce over-diuresis, midodrine if HF therapy otherwise limited — geriatric practice
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepolypharmacy_stopp_start_branch
    High polypharmacy burden — systematic STOPP/START review; stop NSAIDs/anticholinergics/QT-prolongers/redundant agents; simplify dosing — STOPP/START
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecognitive_impairment_branch
    Cognitive impairment — regimen simplification, adherence aids (blister packs/once-daily), caregiver involvement; reassess ability to self-manage — 4M
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesarcopenia_rehab_branch
    Sarcopenia/cachexia + functional decline — nutrition optimisation + tailored physical rehabilitation (REHAB-HF model) — Kitzman NEJM 2021
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehfpef_predominant_elderly_branch
    HFpEF-predominant frail elderly — SGLT2i favored (best tolerated, DELIVER frailty subgroup); finerenone as tolerated; comorbidity-directed — 2023 ESC HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_renal_limiting_branch
    CKD/renal limiting GDMT — SGLT2i to eGFR 20, cautious RAS/MRA with K/renal monitoring; avoid over-diuresis pre-renal AKI — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaf_anticoagulation_balance_branch
    AF in frail elder — stroke vs falls/bleeding balance; do not withhold AC for falls alone (number-needed-to-harm favors AC); HAS-BLED guides modifiable-risk reduction — ESC 2024 AF
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Frail-elder HF — tolerability-weighted GDMT + deprescribing + goals (2022 AHA/ACC/HFSA HF; STOPP/START; REHAB-HF)
axis: geriatric_hf_tolerability_weighted_and_deprescribestep 1 - Step 1 — Frailty + goals assessment sets the care frame
Selected step "Step 1 — Frailty + goals assessment sets the care frame" — HF in a frail older adult
  • Clinical Frailty Scale + goals-of-care (what Matters) + prognosis framing
    first line
    assessment
    triggers: frail_older_adult_HF
    Frailty + goals determine disease-modifying vs symptom-focused intensity before any drug decision (2022 ACC/AHA HF; 4M)

outpatient playbook — drug actions (4)

  1. 1. SGLT2i first (best tolerated)
    dapagliflozin/empagliflozin 10 mg • PO • daily
    trigger: Frail HF, eGFR ≥20 (DELIVER frailty subgroup)
    Prognostic benefit with minimal titration/hypotension burden
  2. 2. cautious low-dose RAS/BB/MRA if tolerated
    low start, slow titration • PO • per drug
    trigger: HFrEF tolerating BP/renal/orthostasis (2022 ACC/AHA HF)
    Individualised, monitor falls/hypotension
  3. 3. deprescribe (STOPP) + simplify
    taper/stop • n/a • n/a
    trigger: Polypharmacy / harm > benefit (STOPP/START)
    Reduce falls/AKI/anticholinergic burden
  4. 4. symptom-priority diuretic + rehab + palliative
    lowest effective loop; REHAB-HF • PO/rehab • per need
    trigger: Severe frailty / comfort goals (REHAB-HF)
    Function + symptom + goals-concordant care

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Heart failure in a frail older adult (HFpEF-predominant); GDMT intolerance / symptomatic hypotension / falls on HF meds; High polypharmacy burden with HF regimen.

Objective

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

Assessment

**Heart failure in the frail older adult (chronic, sub-population)** (cardio.geriatric-frailty-hf.chronic.v1).
Phenotype framing: HF phenotype; frailty/competing-morbidity-driven vs cardiac-driven symptoms
Scope: HF phenotype + frailty severity + patient goals — set disease-modifying vs symptom-focused frame

No severity triggers fired against current inputs.

Plan

Regimen axis: **Frail-elder HF — tolerability-weighted GDMT + deprescribing + goals (2022 AHA/ACC/HFSA HF; STOPP/START; REHAB-HF)** — step "Step 1 — Frailty + goals assessment sets the care frame".
1. Clinical Frailty Scale + goals-of-care (what Matters) + prognosis framing (assessment, first line) — Frailty + goals determine disease-modifying vs symptom-focused intensity before any drug decision (2022 ACC/AHA HF; 4M)

Setting playbook (outpatient) — Frailty/goals-aligned HF care: SGLT2i-favored tolerability-weighted GDMT, STOPP/START deprescribing, orthostasis/falls mitigation, rehab/nutrition, palliative integration (2022 AHA/ACC/HFSA HF; REHAB-HF)
2. SGLT2i first (best tolerated) dapagliflozin/empagliflozin 10 mg PO daily — Frail HF, eGFR ≥20 (DELIVER frailty subgroup) (Prognostic benefit with minimal titration/hypotension burden)
3. cautious low-dose RAS/BB/MRA if tolerated low start, slow titration PO per drug — HFrEF tolerating BP/renal/orthostasis (2022 ACC/AHA HF) (Individualised, monitor falls/hypotension)
4. deprescribe (STOPP) + simplify taper/stop n/a n/a — Polypharmacy / harm > benefit (STOPP/START) (Reduce falls/AKI/anticholinergic burden)
5. symptom-priority diuretic + rehab + palliative lowest effective loop; REHAB-HF PO/rehab per need — Severe frailty / comfort goals (REHAB-HF) (Function + symptom + goals-concordant care)

Non-pharmacologic actions:
- Geriatric-cardiology co-management + 4M framework — geriatric practice
- Tailored cardiac rehabilitation (REHAB-HF) + nutrition/sarcopenia — Kitzman NEJM 2021
- Caregiver support + SDOH; advance-care-planning + palliative referral — 2022 ACC/AHA HF

AVOID / contraindication checks:
- Deprescribe when harm exceeds benefit do not reflexively add GDMT in severe frailty — STOPP/START; 2022 ACC/AHA HF
- Check orthostatic BP before RAS BB titration in fallers — geriatric practice
- Avoid over diuresis causing pre renal AKI and falls — 2022 ACC/AHA HF
- SGLT2i is the preferred best tolerated GDMT pillar in frailty — DELIVER frailty subgroup
- Align disease modifying intensity to goals and prognosis — 2022 ACC/AHA HF

Monitoring

Regimen monitoring:
- orthostatic BP and falls after any GDMT change — geriatric practice
- renal function and K with RAS MRA — 2022 ACC/AHA HF
- medication burden and STOPP START review periodically — STOPP/START
- function frailty and cognition trajectory — 4M
- goals of care re evaluation each visit or status change — 2022 ACC/AHA HF

Setting (outpatient) monitoring:
- Orthostatic BP/falls + renal/K after changes; medication-burden review — STOPP/START
- Function/frailty/cognition + goals re-evaluation — 4M

Follow-up plan: Periodic goals-of-care re-evaluation; caregiver support; re-phenotype if HF changes
- Close-out criterion: goals re-evaluation + caregiver plan documented

Monitoring phase: Orthostatic BP, renal/K, falls, function, medication burden — de-escalate if harm > benefit

Disposition

Current setting: outpatient — Frailty/goals-aligned HF care: SGLT2i-favored tolerability-weighted GDMT, STOPP/START deprescribing, orthostasis/falls mitigation, rehab/nutrition, palliative integration (2022 AHA/ACC/HFSA HF; REHAB-HF)

Disposition criteria:
- Robust-enough + goals support → tolerability-weighted GDMT + rehab
- Severe frailty / comfort goals → symptom-focused + palliative
- Polypharmacy harm → deprescribing-led plan

Escalation triggers (move to higher acuity):
- Iatrogenic hypotension/AKI/falls from over-treatment → deprescribe/de-escalate — STOPP/START
- Decompensation → goals-concordant escalation vs comfort — 2022 ACC/AHA HF
- Advanced frailty/declining trajectory → palliative-led care — 2022 ACC/AHA HF

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Symptomatic hypotension / pre-renal AKI / falls attributable to HF over-treatment (excess diuretic/RAS/BB) in a frail elder — DE-ESCALATE/deprescribe, do not intensify — STOPP/START; 2022 ACC/AHA HF
- [SEVERE] Severe frailty / limited prognosis / comfort-aligned goals — symptom-focused care, deprescribe disease-modifying when no longer aligned, palliative integration — 2022 ACC/AHA HF
- [SEVERE] Orthostatic hypotension / recurrent falls — individualise BP target, check orthostatic BP before RAS/BB titration, reduce over-diuresis, midodrine if HF therapy otherwise limited — geriatric practice

Citations

- 2022 AHA/ACC/HFSA HF Guideline + 2023 ESC Focused Update on HF; REHAB-HF (Kitzman); STOPP/START [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