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cardio.valvular_disease.v1PRODUCTION
cardio.valvular_disease.v1

Valvular heart disease (AS / AR / MR / MS)

cardiologychronicacuteadultgeriatric
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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

Confirm valvular lesion via TTE; quantify severity; stage A (at risk) → B (progressive) → C (asymptomatic severe) → D (symptomatic severe) per ACC/AHA 2020 VHD staging (Otto PMID 33342586)

Inputs
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Actions
0
Advance rule
Set
Advance when

Lesion + severity + stage assigned

Patient inputs (19)

≥75 yr shifts toward TAVR; <65 toward SAVR; bicuspid common <60 (ACC/AHA 2020 VHD Section 5; PARTNER 3 Mack NEJM 2019; NOTION Thyregod JAMA 2015)

Hypotension in severe AS = warning; HTN affects regurgitant lesions (ACC/AHA 2020 VHD Section 5.2)

AF very common; rate-control critical in MS (ACC/AHA 2020 VHD Section 10; ESC 2021 VHD)

NYHA defines Stage D; trigger for intervention (ACC/AHA 2020 VHD staging system)

CAD assessment before any intervention (ACC/AHA 2020 VHD Section 3.2 pre-op coronary evaluation)

Anticoag selection; rhythm control (ACC/AHA 2020 VHD Section 10 mechanical vs bioprosthetic)

Bioprosthesis vs mechanical; redo planning (ACC/AHA 2020 VHD Section 11 valve-in-valve)

Anticoag, GDMT for HF, BB / CCB for rate control, ACEi/ARB/ARNI for afterload (ACC/AHA 2020 VHD)

CKD impacts contrast use, surgical risk, drug dosing (ACC/AHA 2020 VHD Section 3)

HF severity + prognosis (ACC/AHA 2020 VHD Class IIa)

Anemia worsens HF; pre-op (ACC/AHA 2020 VHD)

Primary diagnostic — peak velocity, mean gradient, AVA, regurg vol, EROA (ACC/AHA 2020 VHD Table 7; ESC 2021 VHD)

Severe AS with symptoms = Stage D; emergent intervention planning (ACC/AHA 2020 VHD Class I)

Drives Heart Team decision (ACC/AHA 2020 VHD Section 3.3; PARTNER 3 Mack 2019)

MR mechanism — primary vs secondary, leaflet vs annulus; IE workup (ACC/AHA 2020 VHD Section 7; COAPT Stone NEJM 2018)

Asymptomatic high-grade AS — provoke symptoms or hemodynamic change (ACC/AHA 2020 VHD Class IIa; ESC 2021 VHD)

AR severity + LV volumes + fibrosis (LGE) (ACC/AHA 2020 VHD Class IIa for AR; ESC 2021 VHD)

CAD assessment before intervention (ACC/AHA 2020 VHD Section 3.2)

Annular sizing, vascular access (ACC/AHA 2020 VHD Section 5; PARTNER 3 protocol)

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningacute_severe_mitral_regurgitation
    Acute severe MR (papillary rupture, IE, chordal rupture) with pulmonary edema or shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningacute_severe_aortic_regurgitation
    Acute severe AR from dissection or IE with pulmonary edema
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninginfective_endocarditis_with_valve_involvement
    Suspected or confirmed IE with valvular involvement + embolic / abscess / refractory bacteremia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_severe_aortic_stenosis
    Severe AS (mean gradient ≥40, peak velocity ≥4.0, AVA ≤1.0) with syncope, angina, or HF
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_mr_with_hfref_coapt_eligible
    Secondary MR + HFrEF + NYHA III-IV on optimal GDMT with EROA ≥30 mm² + LV ESD ≤70 mm
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_rheumatic_ms_with_pulmonary_hypertension
    Severe MS (MVA ≤1.5) + pulmonary hypertension or symptoms
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremechanical_valve_with_subtherapeutic_inr
    Mechanical valve with INR <2.0 (mitral) or <1.5 (aortic with risk factors)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Medical management — GDMT, rate control, afterload reduction (lesion-specific)
axis: vhd_medical_management
Selected axis "Medical management — GDMT, rate control, afterload reduction (lesion-specific)" by default fallback (first axis)
  • furosemide
    first line
    loop_diuretic
    20-40 mg IV/PO • IV/PO • titrated to volume status
    triggers: volume_overload_in_VHD_HF
    2020 AHA/ACC VHD — symptomatic relief; avoid in severe AS preload-dependent unless overloaded
    rxcui 4603
  • lisinopril
    add on
    ACEi
    5-10 mg PO • PO • daily (max: 40 mg/day)
    triggers: AR_with_LV_dilation, HFrEF_overlay
    2020 AHA/ACC VHD — afterload reduction in chronic AR (Class IIa)
    rxcui 29046
  • valsartan
    add on
    ARB
    40-80 mg PO • PO • BID
    triggers: ACEi_intolerant, AR_with_LV_dilation
    ARB alternative (ACC/AHA 2020 VHD Section 6 AR afterload reduction)
    rxcui 69749
  • sacubitril/valsartan
    add on
    ARNI
    24/26 mg PO • PO • BID; titrate q2-4 wks (max: 97/103 mg BID)
    triggers: HFrEF_with_secondary_MR
    PARADIGM-HF (McMurray NEJM 2014) — reduces secondary MR severity by reverse remodeling (ACC/AHA 2020 VHD Section 7)
    rxcui 1656328
  • metoprolol_succinate
    first line
    beta_blocker
    25 mg • PO • daily (max: 200 mg/day)
    triggers: AF_rate_control, HFrEF, MS_rate_control
    Rate control + GDMT (ACC/AHA 2020 VHD Section 9 MS; ESC 2021 VHD)
    rxcui 6918
  • carvedilol
    first line
    mixed_alpha_beta_blocker
    3.125 mg • PO • BID; titrate (max: 25 mg BID (50 mg if >85 kg))
    triggers: HFrEF_with_secondary_MR
    COPERNICUS (Packer NEJM 2001); ACC/AHA 2020 VHD GDMT for secondary MR
    rxcui 20352
  • amlodipine
    add on
    DHP_CCB
    5 mg • PO • daily
    triggers: HTN_with_VHD
    Neutral in AS; avoid non-DHP if LV dysfunction (ACC/AHA 2020 VHD Section 5)
    rxcui 17767
  • warfarin
    first line
    VKA
    Titrate INR 2.5-3.5 (mechanical mitral) OR 2.0-3.0 (aortic mech) • PO • daily
    triggers: mechanical_valve, rheumatic_MS_with_AF
    2020 AHA/ACC — mandatory for mechanical valve and rheumatic MS+AF
    rxcui 11289
  • apixaban
    first line
    DOAC_FXa
    5 mg BID (2.5 mg per criteria) • PO • BID
    triggers: non_valvular_AF_in_VHD
    ARISTOTLE — preferred DOAC for non-mechanical, non-rheumatic AF
    rxcui 1364430
  • amoxicillin
    first line
    penicillin
    2 g PO • PO • 30-60 min before procedure
    triggers: high_risk_VHD_dental_or_GI_GU_procedure
    2023 update — high-risk only (prosthetic, prior IE, congenital, transplant valvulopathy)
    rxcui 723
  • clindamycin
    second line
    lincosamide
    600 mg PO • PO • 30-60 min before
    triggers: penicillin_allergy_high_risk_VHD
    AHA prophylaxis alternative
    rxcui 2582

outpatient playbook — drug actions (3)

  1. 1. lesion-appropriate medical therapy (per axis)
    titrated • PO • daily/BID
    trigger: VHD diagnosis + symptoms
    ACC/AHA 2020 VHD Otto PMID 33342586
  2. 2. anticoagulation
    warfarin or DOAC per valve type • PO • daily
    trigger: AF or mechanical valve
    ACC/AHA 2020 VHD Section 10 (warfarin mandatory for mechanical; DOAC for bioprosthetic AF)
  3. 3. IE prophylaxis (high-risk only)
    amoxicillin 2 g 30-60 min pre-procedure • PO • pre-procedure
    trigger: High-risk VHD + dental
    ACC/AHA 2023 focused update on IE prophylaxis PMID 36746667

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New systolic or diastolic murmur on examination (ACC/AHA 2020 VHD Otto Section 3); Syncope, angina, or HF in patient with AS (ACC/AHA 2020 VHD Stage D criteria); Acute severe MR / AR with pulmonary edema or shock (ACC/AHA 2020 VHD Section 7–8).

Objective

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

Assessment

**Valvular heart disease (AS / AR / MR / MS)** (cardio.valvular_disease.v1).
Phenotype framing: AS (degenerative / bicuspid / rheumatic / radiation) / AR (root vs leaflet) / MR (primary vs secondary) / MS (rheumatic) / mixed; sclerosis vs stenosis (ACC/AHA 2020 VHD Section 4; ESC 2021 VHD)
Scope: Confirm valvular lesion via TTE; quantify severity; stage A (at risk) → B (progressive) → C (asymptomatic severe) → D (symptomatic severe) per ACC/AHA 2020 VHD staging (Otto PMID 33342586)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Medical management — GDMT, rate control, afterload reduction (lesion-specific)**.
1. furosemide 20-40 mg IV/PO IV/PO titrated to volume status (loop_diuretic, first line) — 2020 AHA/ACC VHD — symptomatic relief; avoid in severe AS preload-dependent unless overloaded
2. lisinopril 5-10 mg PO PO daily (ACEi, add on) — 2020 AHA/ACC VHD — afterload reduction in chronic AR (Class IIa)
3. valsartan 40-80 mg PO PO BID (ARB, add on) — ARB alternative (ACC/AHA 2020 VHD Section 6 AR afterload reduction)
4. sacubitril/valsartan 24/26 mg PO PO BID; titrate q2-4 wks (ARNI, add on) — PARADIGM-HF (McMurray NEJM 2014) — reduces secondary MR severity by reverse remodeling (ACC/AHA 2020 VHD Section 7)
5. metoprolol_succinate 25 mg PO daily (beta_blocker, first line) — Rate control + GDMT (ACC/AHA 2020 VHD Section 9 MS; ESC 2021 VHD)
6. carvedilol 3.125 mg PO BID; titrate (mixed_alpha_beta_blocker, first line) — COPERNICUS (Packer NEJM 2001); ACC/AHA 2020 VHD GDMT for secondary MR
7. amlodipine 5 mg PO daily (DHP_CCB, add on) — Neutral in AS; avoid non-DHP if LV dysfunction (ACC/AHA 2020 VHD Section 5)
8. warfarin Titrate INR 2.5-3.5 (mechanical mitral) OR 2.0-3.0 (aortic mech) PO daily (VKA, first line) — 2020 AHA/ACC — mandatory for mechanical valve and rheumatic MS+AF
9. apixaban 5 mg BID (2.5 mg per criteria) PO BID (DOAC_FXa, first line) — ARISTOTLE — preferred DOAC for non-mechanical, non-rheumatic AF
10. amoxicillin 2 g PO PO 30-60 min before procedure (penicillin, first line) — 2023 update — high-risk only (prosthetic, prior IE, congenital, transplant valvulopathy)
11. clindamycin 600 mg PO PO 30-60 min before (lincosamide, second line) — AHA prophylaxis alternative

Setting playbook (outpatient) — Stage VHD, optimise GDMT, decide and time intervention via Heart Team
12. lesion-appropriate medical therapy (per axis) titrated PO daily/BID — VHD diagnosis + symptoms (ACC/AHA 2020 VHD Otto PMID 33342586)
13. anticoagulation warfarin or DOAC per valve type PO daily — AF or mechanical valve (ACC/AHA 2020 VHD Section 10 (warfarin mandatory for mechanical; DOAC for bioprosthetic AF))
14. IE prophylaxis (high-risk only) amoxicillin 2 g 30-60 min pre-procedure PO pre-procedure — High-risk VHD + dental (ACC/AHA 2023 focused update on IE prophylaxis PMID 36746667)

Non-pharmacologic actions:
- Heart Team referral for SAVR vs TAVR vs MitraClip/TEER vs surgical repair (ACC/AHA 2020 VHD Section 3.3; PARTNER 3 Mack 2019)
- Cardiac rehab (ACC/AHA 2020 VHD post-intervention)
- Lifestyle — Na restriction, BP control, weight, smoking cessation, alcohol (ACC/AHA 2020 VHD; ESC 2021 VHD)

AVOID / contraindication checks:
- Nitrate_avoid_in_severe_AS_preload_dependent
- DOAC_block_in_mechanical_valve_or_rheumatic_MS
- Warfarin_INR_target_per_valve_position
- Dental_clearance_before_intervention
- Non_DHP_CCB_avoid_in_LV_dysfunction

Monitoring

Regimen monitoring:
- TTE annual moderate VHD — ACC/AHA 2020 VHD Table 4
- TTE q6 mo severe asymptomatic — ACC/AHA 2020 VHD Table 4
- INR per warfarin protocol — ACC/AHA 2020 VHD Section 10
- BNP q3 mo with HF — ACC/AHA 2020 VHD Class IIa
- eGFR q3 mo on ACEi ARB ARNI — ACC/AHA 2020 VHD

Setting (outpatient) monitoring:
- TTE per stage (ACC/AHA 2020 VHD Table 4)
- INR for warfarin (ACC/AHA 2020 VHD Section 10)
- Symptom diary (ESC 2021 VHD)

Follow-up plan: Cardiology / structural / cardiothoracic surgery; cardiac rehab post-procedure; vaccinations; dental clearance pre-procedure (ACC/AHA 2020 VHD; 2023 focused update IE prophylaxis)
- Close-out criterion: Referrals + plans scheduled

Monitoring phase: TTE annual for moderate, q6 mo for severe asymptomatic (ACC/AHA 2020 VHD Table 4); INR for warfarin; renal function for ARNI/diuretic; symptom diary (ESC 2021 VHD)

Disposition

Current setting: outpatient — Stage VHD, optimise GDMT, decide and time intervention via Heart Team

Disposition criteria:
- Continue medical therapy if stable (ACC/AHA 2020 VHD)
- Refer Heart Team if intervention indication met (ACC/AHA 2020 VHD Section 3.3)

Escalation triggers (move to higher acuity):
- New symptoms in severe asymptomatic → expedite intervention (ACC/AHA 2020 VHD Class I)
- Decompensation → ED (ACC/AHA 2020 VHD)
- New AF → anticoag adjustment (ACC/AHA 2020 VHD Section 10)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute severe MR (papillary rupture, IE, chordal rupture) with pulmonary edema or shock
- [LIFE_THREATENING] Acute severe AR from dissection or IE with pulmonary edema
- [LIFE_THREATENING] Suspected or confirmed IE with valvular involvement + embolic / abscess / refractory bacteremia

Citations

- 2020 AHA/ACC VHD Guideline (Otto/Nishimura) + 2023 focused update [PMID:33342586](https://pubmed.ncbi.nlm.nih.gov/33342586/)
- Cited evidence (PMID 36746667) [PMID:36746667](https://pubmed.ncbi.nlm.nih.gov/36746667/)
- Cited evidence (PMID 30883058) [PMID:30883058](https://pubmed.ncbi.nlm.nih.gov/30883058/)
- Cited evidence (PMID 30883053) [PMID:30883053](https://pubmed.ncbi.nlm.nih.gov/30883053/)
- Cited evidence (PMID 30222302) [PMID:30222302](https://pubmed.ncbi.nlm.nih.gov/30222302/)

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