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cardio.hf-improved.core.v1PRODUCTION
cardio.hf-improved.core.v1

Heart failure with improved EF (HFimpEF — recovered, prior LVEF ≤40)

cardiologychronicadult
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm HFimpEF: documented prior LVEF ≤40 + ≥10-pt rise + current >40. If never ≤40 → cardio.hfmref.core.v1; if currently ≤40 → cardio.hfref.core.v1

Inputs
2
Actions
0
Advance rule
Set
Advance when

recovered-EF definition met

Patient inputs (13)

Tachycardia-mediated/PPCM/alcohol/myocarditis/chemo recovery — drives surveillance + counseling

GDMT tolerability + drug dosing

Continued RAS/ARNi/BB tolerability monitoring

BB titration; rhythm (tachycardia-mediated CM recovery)

eGFR for continued SGLT2i/MRA/RAS dosing

Continued MRA/RAS safety monitoring

Confirm full GDMT in place; detect inappropriate de-escalation

HFimpEF requires documented historical LVEF ≤40 — defines this engine vs de-novo HFmrEF

Current LVEF >40 with ≥10-pt rise = recovered phenotype

Symptom status — asymptomatic does NOT license de-escalation (TRED-HF)

Genetic DCM (LMNA/FLNC/DSP/RBM20) → ICD by genotype independent of recovered EF

Residual elevation predicts relapse; surveillance + withdrawal monitoring

Residual fibrosis predicts incomplete recovery + relapse/SCD risk

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

Severity triggers (9)

9 need judgement
  • informationalsevereinappropriate_gdmt_deescalation
    Disease-modifying GDMT pillar stopped/reduced because "EF normalised" — highest-yield preventable relapse — TRED-HF Lancet 2019
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererelapse_to_hfref
    EF falls ≤40 or symptomatic relapse on surveillance — ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereperipartum_cm_recovered
    Recovered PPCM — counsel on subsequent-pregnancy recurrence; contraindicate pregnancy if LVEF not fully recovered (<50–55%) — IPAC; ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverearrhythmogenic_genotype
    LMNA/FLNC/DSP/RBM20 carrier — SCD risk is genotype-driven and independent of EF recovery; ICD per genotype risk model — HRS; ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_recovered_hf
    Pregnancy/planning in recovered HF — STOP RAS/SGLT2i/MRA; switch to BB ± hydralazine/nitrate; high antepartum relapse risk; cardio-obstetric team — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetachycardia_mediated_recovered
    Original driver was AF/SVT/frequent PVCs — ablate/treat arrhythmia; relapse risk persists if arrhythmia recurs — ESC 2024 AF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechemo_cardiotoxicity_recovered
    Recovered chemo/anthracycline/HER2 cardiotoxicity — continue cardioprotection; cardio-oncology surveillance; re-challenge decisions multidisciplinary — ESC Cardio-Oncology 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_continued_gdmt
    CKD — continue SGLT2i to eGFR 20, MRA with K monitoring, RAS per tolerability — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatealcohol_toxin_recovered
    Alcoholic / toxin (cocaine/methamphetamine) CM recovered — abstinence is essential; relapse follows resumption — ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

HFimpEF — continue 4-pillar HFrEF GDMT indefinitely (2022 AHA/ACC/HFSA; TRED-HF)
axis: hfimpef_continue_gdmtstep 1 - Pillar 1 — RAS inhibition (ARNi preferred) — CONTINUE at achieved dose
Selected step "Pillar 1 — RAS inhibition (ARNi preferred) — CONTINUE at achieved dose" — Recovered EF on prior HFrEF GDMT; do not stop
  • sacubitril/valsartan
    first line
    ARNi
    continue achieved dose • PO • BID (max: 97/103 mg BID)
    triggers: recovered_EF_on_ARNi
    TRED-HF Lancet 2019 — withdrawal in recovered DCM → ~44% relapse at 6 mo; 2022 ACC/AHA Class 1 continue
    rxcui 1656339
  • lisinopril
    contraindication substitute
    ACEi
    continue achieved dose • PO • once daily (max: 40 mg/day)
    triggers: ARNi_intolerant
    Continue foundational RAS blockade — do not de-escalate (TRED-HF)
    rxcui 29046
  • losartan
    contraindication substitute
    ARB
    continue achieved dose • PO • once daily (max: 150 mg/day)
    triggers: ACEi_cough_or_angioedema
    ARB if ACEi/ARNi intolerant — continue (TRED-HF)
    rxcui 52175

outpatient playbook — drug actions (5)

  1. 1. continue ARNi/ACEi/ARB
    achieved dose • PO • per drug
    trigger: Recovered EF on RAS (TRED-HF)
    Withdrawal → ~44% relapse at 6 mo (TRED-HF Lancet 2019)
  2. 2. continue carvedilol/metoprolol succ/bisoprolol
    achieved dose • PO • per drug
    trigger: Recovered EF on BB (TRED-HF)
    Continue — part of the withdrawn regimen that relapsed (TRED-HF)
  3. 3. continue spironolactone/eplerenone
    achieved dose • PO • daily
    trigger: K ≤5.0, eGFR ≥30 (RALES/EMPHASIS-HF)
    Continue MRA (TRED-HF)
  4. 4. continue dapagliflozin/empagliflozin
    10 mg • PO • daily
    trigger: eGFR ≥20 (DAPA-HF/EMPEROR-Reduced)
    Continue SGLT2i across EF spectrum (ESC 2023)
  5. 5. loop diuretic — taper only if truly euvolemic
    lowest effective • PO • daily/PRN
    trigger: Euvolemic, no congestion
    Diuretic is the only pillar that may be reduced — disease-modifying pillars are not (TRED-HF)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Echo LVEF now >40 with documented prior ≤40 (≥10-pt rise); Known recovered-EF HF — surveillance visit; Prior HFrEF, asymptomatic on GDMT — recovery query.

Objective

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

Assessment

**Heart failure with improved EF (HFimpEF — recovered, prior LVEF ≤40)** (cardio.hf-improved.core.v1).
Phenotype framing: HFimpEF vs de-novo HFmrEF vs HFpEF vs still-≤40 (incomplete recovery)
Scope: Confirm HFimpEF: documented prior LVEF ≤40 + ≥10-pt rise + current >40. If never ≤40 → cardio.hfmref.core.v1; if currently ≤40 → cardio.hfref.core.v1

No severity triggers fired against current inputs.

Plan

Regimen axis: **HFimpEF — continue 4-pillar HFrEF GDMT indefinitely (2022 AHA/ACC/HFSA; TRED-HF)** — step "Pillar 1 — RAS inhibition (ARNi preferred) — CONTINUE at achieved dose".
1. sacubitril/valsartan continue achieved dose PO BID (ARNi, first line) — TRED-HF Lancet 2019 — withdrawal in recovered DCM → ~44% relapse at 6 mo; 2022 ACC/AHA Class 1 continue
2. lisinopril continue achieved dose PO once daily (ACEi, contraindication substitute) — Continue foundational RAS blockade — do not de-escalate (TRED-HF)
3. losartan continue achieved dose PO once daily (ARB, contraindication substitute) — ARB if ACEi/ARNi intolerant — continue (TRED-HF)

Setting playbook (outpatient) — Confirm recovered-EF phenotype, continue full GDMT indefinitely, characterise relapse/SCD risk, treat persisting cause (2022 AHA/ACC/HFSA; TRED-HF)
4. continue ARNi/ACEi/ARB achieved dose PO per drug — Recovered EF on RAS (TRED-HF) (Withdrawal → ~44% relapse at 6 mo (TRED-HF Lancet 2019))
5. continue carvedilol/metoprolol succ/bisoprolol achieved dose PO per drug — Recovered EF on BB (TRED-HF) (Continue — part of the withdrawn regimen that relapsed (TRED-HF))
6. continue spironolactone/eplerenone achieved dose PO daily — K ≤5.0, eGFR ≥30 (RALES/EMPHASIS-HF) (Continue MRA (TRED-HF))
7. continue dapagliflozin/empagliflozin 10 mg PO daily — eGFR ≥20 (DAPA-HF/EMPEROR-Reduced) (Continue SGLT2i across EF spectrum (ESC 2023))
8. loop diuretic — taper only if truly euvolemic lowest effective PO daily/PRN — Euvolemic, no congestion (Diuretic is the only pillar that may be reduced — disease-modifying pillars are not (TRED-HF))

Non-pharmacologic actions:
- Etiology-directed: arrhythmia ablation (tachycardia-mediated), abstinence (alcohol/toxin), cardio-oncology continuation (chemo)
- Genetic counseling + cascade screening for familial DCM — ACC/AHA 2022; HRS
- Pregnancy counseling in recovered PPCM — recurrence risk, contraindicate pregnancy if not fully recovered
- Cardiac rehab + vaccinations — ACC/AHA 2022

AVOID / contraindication checks:
- Do not withdraw disease modifying GDMT in recovered DCM — TRED HF Halliday Lancet 2019
- Hyperkalemia mra block if K gt 5.0 — RALES; ACC/AHA 2022
- Aki rasi pause if Cr rise gt 30pct — ACC/AHA 2022
- Arni acei arb sglt2i mra block in pregnancy — switch to BB ± hydralazine/nitrate
- Do not decommission ICD on EF recovery if arrhythmogenic genotype — HRS; ACC/AHA 2022

Monitoring

Regimen monitoring:
- echo q6-12mo for relapse — ACC/AHA 2022
- NT-proBNP q3-6mo residual elevation predicts relapse — TRED-HF Lancet 2019
- if withdrawal attempted echo and NP at 1 3 6mo reverse at first relapse — TRED-HF protocol
- BMP with any GDMT change — ACC/AHA 2022
- genetic counseling and cascade if familial DCM — ACC/AHA 2022; HRS

Setting (outpatient) monitoring:
- Echo q6–12 mo for relapse — ACC/AHA 2022
- NT-proBNP q3–6 mo — TRED-HF
- BMP with any GDMT change — ACC/AHA 2022

Follow-up plan: Re-route to HFrEF if EF falls ≤40; genetic + pregnancy counseling where relevant
- Close-out criterion: follow-up + counseling scheduled

Monitoring phase: Serial echo + NT-proBNP; if any shared-decision de-escalation attempted → TRED-HF intensive surveillance (echo+NP at 1/3/6 mo, reverse at first relapse sign)

Disposition

Current setting: outpatient — Confirm recovered-EF phenotype, continue full GDMT indefinitely, characterise relapse/SCD risk, treat persisting cause (2022 AHA/ACC/HFSA; TRED-HF)

Disposition criteria:
- Stable recovered EF on full GDMT → lifelong q6–12 mo cardiology follow-up
- Relapse → HFrEF pathway + advanced-HF consideration

Escalation triggers (move to higher acuity):
- EF falls ≤40 or symptomatic relapse → route cardio.hfref.core.v1 + re-optimise — ACC/AHA 2022
- Arrhythmogenic genotype → EP referral for ICD regardless of recovered EF — HRS

Patient Action Plan

**Recovered-EF HF action plan — do NOT stop heart meds (ACC/AHA 2022; TRED-HF)**
Personalised values: dry_weight_kg, home_diuretic, baseline_NYHA, gdmt_regimen.

**Stable — recovered EF, on full GDMT — ACC/AHA 2022** (green):
Triggers:
- No new dyspnea, edema, or weight gain — ACC/AHA 2022
- Taking all 4 heart-failure medicines daily — TRED-HF
Actions:
- Keep taking ALL heart-failure medicines even though the heart pump looks normal — TRED-HF
- Daily weight; sodium <2 g/day — ACC/AHA 2022
- Keep echo + lab + genetics appointments — ACC/AHA 2022

**Caution — early relapse signs — ACC/AHA 2022** (yellow):
Triggers:
- Weight up 2 kg in 3 days — ACC/AHA 2022
- New ankle swelling or reduced exercise tolerance — ACC/AHA 2022
- Missed several doses of heart-failure medicine — TRED-HF
Actions:
- Resume any missed medicines immediately — TRED-HF
- Take prescribed rescue diuretic dose — ACC/AHA 2022
- Call HF clinic within 24–48 h for echo/NT-proBNP — TRED-HF
Contact provider when:
- Symptoms persist after 48 h — ACC/AHA 2022
- Any thought of stopping medicines — discuss first, do not stop — TRED-HF

**Medical alert — symptomatic relapse — ACC/AHA 2022** (red):
Triggers:
- Severe breathlessness at rest or lying flat — ACC/AHA 2022
- Chest pain, fainting, or near-fainting — ACC/AHA 2022
Actions:
- Call 911 / emergency services immediately — ACC/AHA 2022
- Bring medication list — ACC/AHA 2022
Contact provider when:
- Any red-zone symptom — go to ED now — ACC/AHA 2022

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Disease-modifying GDMT pillar stopped/reduced because "EF normalised" — highest-yield preventable relapse — TRED-HF Lancet 2019
- [SEVERE] EF falls ≤40 or symptomatic relapse on surveillance — ACC/AHA 2022
- [SEVERE] Recovered PPCM — counsel on subsequent-pregnancy recurrence; contraindicate pregnancy if LVEF not fully recovered (<50–55%) — IPAC; ESC 2018 Pregnancy

Citations

- 2022 AHA/ACC/HFSA HF Guideline + 2023 ESC Focused Update on HF + 2021 Universal Definition of HF (Bozkurt) [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 33663906) [PMID:33663906](https://pubmed.ncbi.nlm.nih.gov/33663906/)
- Cited evidence (PMID 30429050) [PMID:30429050](https://pubmed.ncbi.nlm.nih.gov/30429050/)
- Cited evidence (PMID 26293760) [PMID:26293760](https://pubmed.ncbi.nlm.nih.gov/26293760/)

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