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cardio.mitral-regurgitation.secondary-chronic.v1PRODUCTION
cardio.mitral-regurgitation.secondary-chronic.v1

Chronic secondary (functional) mitral regurgitation

cardiologychronicadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm functional mechanism (normal leaflets); if primary/leaflet → cardio.mitral-regurgitation.primary-chronic.v1; classify ischemic vs non-ischemic vs atrial

Inputs
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Advance rule
Set
Advance when

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)

9 need judgement
  • informationallife_threateningend_stage_branch
    End-stage HF with refractory severe functional MR despite all therapy — advanced HF / transplant / durable MCS — 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecoapt_phenotype_eligible
    NYHA II–IV severe 2°MR on maximal GDMT; LVEF 20–50%; LVESD ≤70 mm; proportionate MR — TEER Class IIa — COAPT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredisproportionate_mr_mitrafr
    Large LV (LVEDV high relative to EROA — disproportionate / MITRA-FR phenotype) — TEER benefit uncertain; prioritise advanced HF evaluation — MITRA-FR Obadia NEJM 2018
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy/planning — STOP RAS/SGLT2i/MRA; BB ± hydralazine/nitrate; cardio-obstetric; functional MR worsens with volume load — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategdmt_not_maximal
    Severe functional MR labelled "refractory" without documented maximal GDMT — most common error; optimise GDMT before any device — COAPT; 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateischemic_etiology_branch
    Ischemic functional MR — revascularization + viability assessment; surgical MV at CABG (CTSN — replacement more durable) — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateatrial_functional_mr_branch
    Atrial functional MR (AF/HFpEF, LA + annular dilatation, normal LV) — rhythm control + treat AF/HFpEF; emerging annuloplasty/TEER data — ESC 2024 AF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecrt_candidate_branch
    LVEF ≤35 + LBBB QRS ≥150 ms on GDMT — CRT itself reduces functional MR; implant before TEER decision — 2022 ACC/AHA HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — GDMT dose-gating (SGLT2i ≥20, MRA K monitoring), contrast + AC adjustment — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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TREATMENTrequiredDrives dose adjustment
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Recommended regimen

Secondary MR — GDMT-first ladder then TEER (COAPT; 2020 ACC/AHA VHD; 2022 AHA/ACC/HFSA HF)
axis: secondary_mr_gdmt_first_ladderstep 1 - Step 1 — Maximise 4-pillar GDMT (reverse remodeling reduces functional MR)
Selected step "Step 1 — Maximise 4-pillar GDMT (reverse remodeling reduces functional MR)" — Secondary MR with HFrEF — before MR is ever called refractory
  • sacubitril/valsartan
    first line
    ARNi
    24/26→97/103 mg • PO • BID
    triggers: LVEF<=40, SBP>=100
    PARADIGM-HF — reverse remodeling reduces functional MR; GDMT precedes any device decision (2022 ACC/AHA HF; 2020 VHD)
    rxcui 1656340
  • carvedilol
    first line
    beta_blocker
    3.125→25 mg • PO • BID
    triggers: LVEF<=40
    Evidence-based BB — reverse remodeling reduces MR (2022 ACC/AHA HF)
    rxcui 20352
  • spironolactone
    first line
    MRA
    12.5–25 mg • PO • once daily
    triggers: LVEF<=40, K<=5.0
    RALES — MRA component of GDMT (2022 ACC/AHA HF)
    rxcui 9997
  • dapagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: eGFR>=20
    DAPA-HF — SGLT2i pillar; benefit across the EF spectrum (2022 ACC/AHA HF)
    rxcui 1488564

outpatient playbook — drug actions (3)

  1. 1. maximise 4-pillar GDMT
    per HFrEF protocol • PO • per drug
    trigger: Secondary MR with HFrEF (2022 ACC/AHA HF)
    Reverse remodeling reduces functional MR — first-line
  2. 2. CRT if QRS criteria
    device • device • n/a
    trigger: LVEF ≤35 + LBBB ≥150 ms on GDMT (2022 ACC/AHA HF)
    CRT reduces functional MR before TEER
  3. 3. TEER referral
    procedure • transcatheter • n/a
    trigger: COAPT phenotype, GDMT-refractory (COAPT)
    COAPT — HF hosp + mortality benefit Class IIa

Auto-drafted A&P note

outpatient

Subjective

- 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.
References