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cardio.mitral_stenosis.v1PRODUCTION
cardio.mitral_stenosis.v1

Mitral stenosis (rheumatic + degenerative)

cardiologychronicacuteadultpregnancygeriatric
Hard-required inputs
0 / 14
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm MS via TTE; assign severity — mean gradient, MVA, PASP (ACC/AHA 2020 VHD Table 11); rheumatic vs MAC; Wilkins score for PMBV candidacy

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Advance rule
Set
Advance when

Severity + etiology confirmed

Patient inputs (16)

Rheumatic (younger) vs MAC (older — ACC/AHA 2020 VHD); pregnancy considerations

Pregnancy markedly worsens MS — risk-stratify (ESC 2021 VHD / ACC/AHA 2020)

Hemodynamic stability (ACC/AHA 2020 VHD)

Tachycardia shortens diastolic filling — worsens gradient (ACC/AHA 2020 VHD)

Rheumatic fever / endemic exposure (ACC/AHA 2020 VHD / ESC 2021)

Diuretic, BB, AC reconciliation (ACC/AHA 2020 VHD)

HF severity / response (ACC/AHA 2020 VHD)

Anemia worsens MS symptoms (ACC/AHA 2020 VHD)

Diuretic + AC dosing (ACC/AHA 2020 VHD)

Hyperthyroid worsens MS — tachycardia shortens diastolic filling (ACC/AHA 2020 VHD)

Mean gradient, MVA (planimetry, PHT), PASP, Wilkins score (ACC/AHA 2020 VHD Table 11)

LA enlargement, cephalisation, Kerley B lines (ACC/AHA 2020 VHD)

AF, P-mitrale, RVH, RAD (ACC/AHA 2020 VHD)

Pulmonary congestion marker (ACC/AHA 2020 VHD)

Mandatory before PMBV or cardioversion (ACC/AHA 2020 VHD Class I)

Warfarin monitoring if rheumatic AF (INVICTUS NEJM 2022)

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningmechanical_valve_thrombosis
    Mechanical mitral valve thrombosis suspected — hemolysis, new HF, embolism (ACC/AHA 2020 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_ms_symptomatic (ACC/AHA 2022)
    Severe MS (mean gradient ≥10 mmHg, MVA ≤1.5 cm2) with NYHA III-IV symptoms (ACC/AHA 2020 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_severe_MS (ACC/AHA 2022)
    Pregnant patient with severe MS or symptomatic moderate MS (ESC 2021 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_AF_in_MS
    New AF in mitral stenosis (ACC/AHA 2020 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehemoptysis_in_MS
    Hemoptysis from elevated LA pressure in MS (ACC/AHA 2020 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereLAA_thrombus_on_TEE
    LAA thrombus on pre-PMBV TEE (ACC/AHA 2020 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepulmonary_htn_PASP_gt_50
    PASP >50 mmHg on TTE (ACC/AHA 2020 VHD)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Rate control + decongestion in MS (ACC/AHA 2022)
axis: ms_rate_decongestion
Selected axis "Rate control + decongestion in MS (ACC/AHA 2022)" by default fallback (first axis)
  • metoprolol_succinate
    first line
    beta_blocker
    25–50 mg • PO • once daily
    triggers: symptomatic_MS, AF_with_RVR
    Lengthen diastole — ACC/AHA 2020 VHD Class I; AVOID HR <50
    rxcui 866427
  • atenolol
    second line
    beta_blocker
    25–50 mg • PO • once daily
    triggers: BB_alternative
    Pregnancy: avoid atenolol — use metoprolol/labetalol if pregnant (ESC 2021 VHD)
    rxcui 1202
  • diltiazem
    second line
    non_DHP_CCB
    120–360 mg/day • PO • daily / divided
    triggers: BB_intolerant, EF_normal
    Alternative AVN slowing (ACC/AHA 2020 VHD); avoid if EF <40%
    rxcui 3443
  • verapamil
    second line
    non_DHP_CCB
    120–480 mg/day • PO • daily / divided
    triggers: BB_intolerant, EF_normal
    Alternative AVN slowing (ACC/AHA 2020 VHD); avoid if EF <40%
    rxcui 11170
  • digoxin
    add on
    cardiac_glycoside
    0.125–0.25 mg • PO • daily
    triggers: HF_with_AF, BB_CCB_inadequate
    Adjunctive AVN slowing (ACC/AHA 2020 VHD); renal dosing required
    rxcui 3407
  • furosemide
    first line
    loop_diuretic
    20–40 mg • PO/IV • once daily / BID
    triggers: pulmonary_congestion
    Decongestion; symptom relief; NOT valve-modifying (ACC/AHA 2020 VHD Class I)
    rxcui 4603
  • torsemide
    second line
    loop_diuretic
    10–20 mg • PO • daily
    triggers: furosemide_inadequate_absorption
    Better PO bioavailability vs furosemide (ACC/AHA 2020 VHD)
    rxcui 38413

outpatient playbook — drug actions (3)

  1. 1. metoprolol succinate (ACC/AHA 2022)
    25–50 mg daily (ACC/AHA 2022) • PO • daily
    trigger: Symptomatic MS or AF (ACC/AHA 2022)
    Lengthen diastolic filling (ACC/AHA 2020 VHD Class I)
  2. 2. furosemide
    20–40 mg daily (ACC/AHA 2022) • PO • daily
    trigger: Congestive symptoms (ACC/AHA 2022)
    Decongestion (ACC/AHA 2020 VHD Class I)
  3. 3. warfarin
    INR 2–3 • PO • daily
    trigger: Rheumatic MS + AF or prior embolism (ACC/AHA 2022)
    INVICTUS NEJM 2022 — warfarin superior to rivaroxaban in rheumatic VHD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Progressive dyspnea on exertion / orthopnea / PND (ACC/AHA 2020 VHD Stage D symptom); Hemoptysis — bronchial vein rupture from elevated LA pressure (ACC/AHA 2020 VHD); Palpitations or new AF (ACC/AHA 2020 — AF nearly universal in moderate-severe MS).

Objective

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

Assessment

**Mitral stenosis (rheumatic + degenerative)** (cardio.mitral_stenosis.v1).
Phenotype framing: Rheumatic vs MAC vs congenital (parachute / supravalvular ring) vs cor triatriatum vs LA myxoma mimicking MS (ACC/AHA 2020 VHD)
Scope: Confirm MS via TTE; assign severity — mean gradient, MVA, PASP (ACC/AHA 2020 VHD Table 11); rheumatic vs MAC; Wilkins score for PMBV candidacy

No severity triggers fired against current inputs.

Plan

Regimen axis: **Rate control + decongestion in MS (ACC/AHA 2022)**.
1. metoprolol_succinate 25–50 mg PO once daily (beta_blocker, first line) — Lengthen diastole — ACC/AHA 2020 VHD Class I; AVOID HR <50
2. atenolol 25–50 mg PO once daily (beta_blocker, second line) — Pregnancy: avoid atenolol — use metoprolol/labetalol if pregnant (ESC 2021 VHD)
3. diltiazem 120–360 mg/day PO daily / divided (non_DHP_CCB, second line) — Alternative AVN slowing (ACC/AHA 2020 VHD); avoid if EF <40%
4. verapamil 120–480 mg/day PO daily / divided (non_DHP_CCB, second line) — Alternative AVN slowing (ACC/AHA 2020 VHD); avoid if EF <40%
5. digoxin 0.125–0.25 mg PO daily (cardiac_glycoside, add on) — Adjunctive AVN slowing (ACC/AHA 2020 VHD); renal dosing required
6. furosemide 20–40 mg PO/IV once daily / BID (loop_diuretic, first line) — Decongestion; symptom relief; NOT valve-modifying (ACC/AHA 2020 VHD Class I)
7. torsemide 10–20 mg PO daily (loop_diuretic, second line) — Better PO bioavailability vs furosemide (ACC/AHA 2020 VHD)

Setting playbook (outpatient) — Severity grading, intervention candidacy, AC, pregnancy planning (ACC/AHA 2022)
8. metoprolol succinate (ACC/AHA 2022) 25–50 mg daily (ACC/AHA 2022) PO daily — Symptomatic MS or AF (ACC/AHA 2022) (Lengthen diastolic filling (ACC/AHA 2020 VHD Class I))
9. furosemide 20–40 mg daily (ACC/AHA 2022) PO daily — Congestive symptoms (ACC/AHA 2022) (Decongestion (ACC/AHA 2020 VHD Class I))
10. warfarin INR 2–3 PO daily — Rheumatic MS + AF or prior embolism (ACC/AHA 2022) (INVICTUS NEJM 2022 — warfarin superior to rivaroxaban in rheumatic VHD)

Non-pharmacologic actions:
- Salt restriction (ACC/AHA 2020 VHD)
- Pregnancy counseling — assess pre-conception (ESC 2021 VHD)
- Cardiology / valve surgeon referral if severe (ACC/AHA 2020 VHD Class I)
- OSA evaluation (ACC/AHA 2022)
- Vaccinations (ESC 2021 — IE prophylaxis only narrow indications)

AVOID / contraindication checks:
- Beta blocker block if decompensated HF (ACC/AHA 2022)
- Non DHP CCB block if EF lt 40 (ACC/AHA 2022)
- Digoxin renal toxicity (ACC/AHA 2022)
- Atenolol avoid pregnancy (ACC/AHA 2022)

Monitoring

Regimen monitoring:
- BMP q24h during diuresis (ACC/AHA 2022)
- HR target 60-80 (ACC/AHA 2022)
- symptom diary

Setting (outpatient) monitoring:
- TTE per severity (ACC/AHA 2022)
- INR weekly to monthly (ACC/AHA 2022)

Follow-up plan: Cardiology q3-12 mo (ACC/AHA 2020); high-volume valve surgeon if intervention (ESC 2021 — heart valve centre); OB-cardio team in pregnancy
- Close-out criterion: Follow-up booked

Monitoring phase: TTE annual (severe) or q2-3 yr (moderate) per ACC/AHA 2020; pregnancy q4-6 wks (ESC 2021); INR weekly to monthly on warfarin

Disposition

Current setting: outpatient — Severity grading, intervention candidacy, AC, pregnancy planning (ACC/AHA 2022)

Disposition criteria:
- Continue chronic management (ACC/AHA 2022)

Escalation triggers (move to higher acuity):
- NYHA worsening → intervention referral (ACC/AHA 2020 Class I)
- New AF → admit for AC + cardioversion plan (ACC/AHA 2020 VHD / INVICTUS NEJM 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Mechanical mitral valve thrombosis suspected — hemolysis, new HF, embolism (ACC/AHA 2020 VHD)
- [SEVERE] Severe MS (mean gradient ≥10 mmHg, MVA ≤1.5 cm2) with NYHA III-IV symptoms (ACC/AHA 2020 VHD)
- [SEVERE] Pregnant patient with severe MS or symptomatic moderate MS (ESC 2021 VHD)

Citations

- 2020 AHA/ACC VHD (Otto/Nishimura) + 2023 focused update; ESC/EACTS 2021 VHD; INVICTUS NEJM 2022 [PMID:33342586](https://pubmed.ncbi.nlm.nih.gov/33342586/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 36018037) [PMID:36018037](https://pubmed.ncbi.nlm.nih.gov/36018037/)
- Cited evidence (PMID 21870978) [PMID:21870978](https://pubmed.ncbi.nlm.nih.gov/21870978/)

Last reconciled with current guidelines: 2026-04-27.
References