Chronic secondary (functional) mitral regurgitation
Encounter flow
12/12 authoredCanonical 12-phase frame with authored status for this dossier.
Frame
Confirm functional mechanism (normal leaflets); if primary/leaflet → cardio.mitral-regurgitation.primary-chronic.v1; classify ischemic vs non-ischemic vs atrial
functional chronic mechanism confirmed
Patient inputs (13)
Must confirm MAXIMAL GDMT before MR is called refractory
Functional (normal leaflets, tethering) vs primary determines the entire pathway
EROA/RegVol → ACC/AHA stage; severe ≥0.40 cm² (adverse ≥0.20)
TEER candidacy + surgical risk + frailty
COAPT phenotype LVEF 20–50%; the ventricle is the disease
COAPT LVESD ≤70 mm; large LV = MITRA-FR (disproportionate) phenotype
NYHA II–IV on maximal GDMT = TEER eligibility
GDMT + AC + contrast dosing
MRA/RAS up-titration safety in GDMT-first strategy
QRS ≥150 ms LBBB → CRT, which itself reduces functional MR
Ischemic → revascularization/viability; non-ischemic → DCM workup
Atrial functional MR — rhythm control + treat AF
EROA/LVEDV proportionality (Grayburn) — proportionate vs disproportionate MR
* = hard-required. Engine cannot meaningfully run until these are filled.
Severity triggers (9)
- informationallife_threateningend_stage_branchEnd-stage HF with refractory severe functional MR despite all therapy — advanced HF / transplant / durable MCS — 2022 ACC/AHA HFTrigger could not be auto-evaluated — needs clinician judgement.
- informationalseverecoapt_phenotype_eligibleNYHA II–IV severe 2°MR on maximal GDMT; LVEF 20–50%; LVESD ≤70 mm; proportionate MR — TEER Class IIa — COAPTTrigger could not be auto-evaluated — needs clinician judgement.
- informationalseveredisproportionate_mr_mitrafrLarge LV (LVEDV high relative to EROA — disproportionate / MITRA-FR phenotype) — TEER benefit uncertain; prioritise advanced HF evaluation — MITRA-FR Obadia NEJM 2018Trigger could not be auto-evaluated — needs clinician judgement.
- informationalseverepregnancy_special_popPregnancy/planning — STOP RAS/SGLT2i/MRA; BB ± hydralazine/nitrate; cardio-obstetric; functional MR worsens with volume load — ESC 2018 PregnancyTrigger could not be auto-evaluated — needs clinician judgement.
- informationalmoderategdmt_not_maximalSevere functional MR labelled "refractory" without documented maximal GDMT — most common error; optimise GDMT before any device — COAPT; 2020 ACC/AHA VHDTrigger could not be auto-evaluated — needs clinician judgement.
- informationalmoderateischemic_etiology_branchIschemic functional MR — revascularization + viability assessment; surgical MV at CABG (CTSN — replacement more durable) — 2020 ACC/AHA VHDTrigger could not be auto-evaluated — needs clinician judgement.
- informationalmoderateatrial_functional_mr_branchAtrial functional MR (AF/HFpEF, LA + annular dilatation, normal LV) — rhythm control + treat AF/HFpEF; emerging annuloplasty/TEER data — ESC 2024 AFTrigger could not be auto-evaluated — needs clinician judgement.
- informationalmoderatecrt_candidate_branchLVEF ≤35 + LBBB QRS ≥150 ms on GDMT — CRT itself reduces functional MR; implant before TEER decision — 2022 ACC/AHA HFTrigger could not be auto-evaluated — needs clinician judgement.
- informationalmoderateckd_special_popCKD — GDMT dose-gating (SGLT2i ≥20, MRA K monitoring), contrast + AC adjustment — KDIGO 2024Trigger could not be auto-evaluated — needs clinician judgement.
Workflow calculators
Run this disease's risk and dosing calculators inline.
Recommended regimen
Secondary MR — GDMT-first ladder then TEER (COAPT; 2020 ACC/AHA VHD; 2022 AHA/ACC/HFSA HF)- sacubitril/valsartanfirst lineARNi24/26→97/103 mg • PO • BIDtriggers: LVEF<=40, SBP>=100PARADIGM-HF — reverse remodeling reduces functional MR; GDMT precedes any device decision (2022 ACC/AHA HF; 2020 VHD)rxcui 1656340
- carvedilolfirst linebeta_blocker3.125→25 mg • PO • BIDtriggers: LVEF<=40Evidence-based BB — reverse remodeling reduces MR (2022 ACC/AHA HF)rxcui 20352
- spironolactonefirst lineMRA12.5–25 mg • PO • once dailytriggers: LVEF<=40, K<=5.0RALES — MRA component of GDMT (2022 ACC/AHA HF)rxcui 9997
- dapagliflozinfirst lineSGLT2i10 mg • PO • once dailytriggers: eGFR>=20DAPA-HF — SGLT2i pillar; benefit across the EF spectrum (2022 ACC/AHA HF)rxcui 1488564
outpatient playbook — drug actions (3)
- 1. maximise 4-pillar GDMTper HFrEF protocol • PO • per drugtrigger: Secondary MR with HFrEF (2022 ACC/AHA HF)Reverse remodeling reduces functional MR — first-line
- 2. CRT if QRS criteriadevice • device • n/atrigger: LVEF ≤35 + LBBB ≥150 ms on GDMT (2022 ACC/AHA HF)CRT reduces functional MR before TEER
- 3. TEER referralprocedure • transcatheter • n/atrigger: COAPT phenotype, GDMT-refractory (COAPT)COAPT — HF hosp + mortality benefit Class IIa
Auto-drafted A&P note
outpatientSubjective
- Possible entry pathways: Echo: significant MR with structurally normal leaflets + LV dilatation/tethering; HFrEF/HFpEF with significant secondary MR; Worsening dyspnea despite GDMT.
Objective
- No vitals, labs, or imaging entered for this encounter.
Assessment
**Chronic secondary (functional) mitral regurgitation** (cardio.mitral-regurgitation.secondary-chronic.v1). Phenotype framing: Secondary vs primary vs mixed; proportionate (COAPT) vs disproportionate (MITRA-FR) MR Scope: Confirm functional mechanism (normal leaflets); if primary/leaflet → cardio.mitral-regurgitation.primary-chronic.v1; classify ischemic vs non-ischemic vs atrial No severity triggers fired against current inputs.
Plan
Regimen axis: **Secondary MR — GDMT-first ladder then TEER (COAPT; 2020 ACC/AHA VHD; 2022 AHA/ACC/HFSA HF)** — step "Step 1 — Maximise 4-pillar GDMT (reverse remodeling reduces functional MR)". 1. sacubitril/valsartan 24/26→97/103 mg PO BID (ARNi, first line) — PARADIGM-HF — reverse remodeling reduces functional MR; GDMT precedes any device decision (2022 ACC/AHA HF; 2020 VHD) 2. carvedilol 3.125→25 mg PO BID (beta_blocker, first line) — Evidence-based BB — reverse remodeling reduces MR (2022 ACC/AHA HF) 3. spironolactone 12.5–25 mg PO once daily (MRA, first line) — RALES — MRA component of GDMT (2022 ACC/AHA HF) 4. dapagliflozin 10 mg PO once daily (SGLT2i, first line) — DAPA-HF — SGLT2i pillar; benefit across the EF spectrum (2022 ACC/AHA HF) Setting playbook (outpatient) — Maximise GDMT ± CRT, reassess MR at 3–6 mo, refer COAPT-like refractory severe MR for TEER (2020 ACC/AHA VHD; 2022 ACC/AHA HF) 5. maximise 4-pillar GDMT per HFrEF protocol PO per drug — Secondary MR with HFrEF (2022 ACC/AHA HF) (Reverse remodeling reduces functional MR — first-line) 6. CRT if QRS criteria device device n/a — LVEF ≤35 + LBBB ≥150 ms on GDMT (2022 ACC/AHA HF) (CRT reduces functional MR before TEER) 7. TEER referral procedure transcatheter n/a — COAPT phenotype, GDMT-refractory (COAPT) (COAPT — HF hosp + mortality benefit Class IIa) Non-pharmacologic actions: - Structural heart-team evaluation when MR persists severe + symptomatic on max GDMT — 2020 ACC/AHA VHD - Revascularization decision in ischemic 2°MR — 2020 ACC/AHA VHD - Advanced HF / transplant / MCS evaluation if end-stage or disproportionate MR — 2022 ACC/AHA HF AVOID / contraindication checks: - Do not offer TEER before maximal GDMT trial — COAPT; 2020 ACC/AHA VHD - TEER uncertain benefit in disproportionate large LV MR — MITRA FR Obadia NEJM 2018 - Isolated surgery for secondary MR limited survival benefit — 2020 ACC/AHA VHD - Hyperkalemia mra block if K gt 5.0 — RALES - Gdmt pregnancy contraindications RAS SGLT2i MRA — switch to BB ± hydralazine/nitrate
Monitoring
Regimen monitoring: - TTE reassess MR after 3-6mo maximal GDMT — 2020 ACC/AHA VHD; 2022 ACC/AHA HF - BMP during GDMT titration — 2022 ACC/AHA HF - serial LVEF LVESD for COAPT eligibility — COAPT - post-TEER TTE baseline then annually — 2020 ACC/AHA VHD - NT-proBNP trend — 2022 ACC/AHA HF Setting (outpatient) monitoring: - TTE at 3–6 mo after GDMT optimisation — 2020 ACC/AHA VHD - BMP during titration; NT-proBNP trend — 2022 ACC/AHA HF Follow-up plan: Co-manage with HFrEF engine; transplant/MCS if end-stage - Close-out criterion: follow-up + escalation triggers documented Monitoring phase: TTE after 3–6 mo GDMT optimisation; serial reassessment of MR + LV
Disposition
Current setting: outpatient — Maximise GDMT ± CRT, reassess MR at 3–6 mo, refer COAPT-like refractory severe MR for TEER (2020 ACC/AHA VHD; 2022 ACC/AHA HF) Disposition criteria: - MR improves on GDMT → continue HF surveillance (co-manage HFrEF engine) - GDMT-refractory COAPT-like → TEER - End-stage → transplant/MCS evaluation Escalation triggers (move to higher acuity): - Persistent severe symptomatic MR on max GDMT ± CRT → TEER referral — COAPT - Decompensation/shock → ED + acute HF/shock pathway — 2022 ACC/AHA HF - End-stage / disproportionate MR → advanced HF — 2022 ACC/AHA HF
Earlier-Return Triggers
Return-precaution thresholds (watch for): - [LIFE_THREATENING] End-stage HF with refractory severe functional MR despite all therapy — advanced HF / transplant / durable MCS — 2022 ACC/AHA HF - [SEVERE] NYHA II–IV severe 2°MR on maximal GDMT; LVEF 20–50%; LVESD ≤70 mm; proportionate MR — TEER Class IIa — COAPT - [SEVERE] Large LV (LVEDV high relative to EROA — disproportionate / MITRA-FR phenotype) — TEER benefit uncertain; prioritise advanced HF evaluation — MITRA-FR Obadia NEJM 2018
Citations
- 2020 ACC/AHA VHD Guideline + 2021 ESC/EACTS VHD Guideline + 2022 AHA/ACC/HFSA HF Guideline [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 35379504) [PMID:35379504](https://pubmed.ncbi.nlm.nih.gov/35379504/) - Cited evidence (PMID 30280640) [PMID:30280640](https://pubmed.ncbi.nlm.nih.gov/30280640/) - Cited evidence (PMID 30145927) [PMID:30145927](https://pubmed.ncbi.nlm.nih.gov/30145927/) Last reconciled with current guidelines: 2026-05-16.
- 2020 ACC/AHA VHD Guideline + 2021 ESC/EACTS VHD Guideline + 2022 AHA/ACC/HFSA HF Guideline — PMID:33332149
- Cited evidence (PMID 34453165) — PMID:34453165
- Cited evidence (PMID 35379504) — PMID:35379504
- Cited evidence (PMID 30280640) — PMID:30280640
- Cited evidence (PMID 30145927) — PMID:30145927