12-phase flow (10)

1. 1FRAME
   CTRCD = LVEF drop ≥10% to <50% OR GLS decline >15% from baseline during cancer therapy; 4 mechanisms (anthracycline cumulative; HER2 reversible; TKI HTN-mediated; ICI myocarditis fulminant); cancer prognosis informs intensity
   inputs: specific_chemo_agent_dose_and_cumulative_exposure, baseline_and_serial_echo_with_lvef_and_gls
   advance: CTRCD subtype identified
2. 2ENTRY
   Joint cardiology + oncology evaluation; bedside echo with GLS; serial troponin; ECG (heart block in ICI myocarditis is ominous)
   inputs: age, cancer_diagnosis_and_stage
   advance: cardio-oncology team activated
3. 3CONTEXT
   Cancer diagnosis + stage + prognosis; specific chemo agent + cumulative dose + planned remaining cycles; comorbidities; ECOG performance status
   inputs: creatinine
   advance: oncologic context complete
4. 4RED_FLAGS
   ICI myocarditis fulminant (heart block, ventricular arrhythmia, cardiogenic shock — ~50% mortality); cardiogenic shock from any CTRCD subtype; refractory HTN crisis from TKI; acute pulmonary edema
   inputs: sbp, troponin_serial
   actions: cardiogenic_shock
   advance: red flags screened
5. 5INITIAL_WORKUP
   Echo with strain imaging (GLS), serial troponin, NT-proBNP, BMP, CBC, ECG (block + arrhythmia), CXR, lactate; if ICI patient with suspicion of myocarditis: high-dose steroid empirically while workup proceeds (delay = death per Mahmood JACC 2018 PMID 29567210)
   inputs: baseline_and_serial_echo_with_lvef_and_gls, troponin_serial, nt_probnp
   actions: acute_pulm_edema, panel.cardiac, panel.renal
   advance: workup documented + CTRCD subtype confirmed
6. 6BRANCHING_WORKUP
   Cardiac MRI with T1/T2 mapping + LGE for ICI myocarditis vs anthracycline late effect; endomyocardial biopsy if life-threatening ICI myocarditis (lymphocytic infiltrate); coronary CTA or cath to rule out ischemic CMP confounder; concomitant irAE workup (CK, AST, ALT for myositis/hepatitis)
   inputs: cardiac_mri_with_lge_if_diagnostic_uncertainty
   advance: differential narrowed + biopsy decision made if applicable
7. 7TREATMENT
   STANDARD ADHF: IV diuretic, NIPPV, IV inotrope if shock. CTRCD-SPECIFIC: GDMT 4-pillar (carvedilol + ACEi/ARB/ARNI + MRA + SGLT2i — established in cardio-oncology per Cardinale 2015 enalapril cardioprotection PMID 25956652; SCOT preliminary supports ARNI). FOR ICI MYOCARDITIS: HIGH-DOSE methylprednisolone 1 g IV daily ×3-5 d then taper; if refractory at 24-72h: IVIG 2 g/kg, plasmapheresis, abatacept 10 mg/kg, OR infliximab 5 mg/kg (latter avoided if HF — TNF-α inhibitor HF risk). HOLD ICI permanently for grade ≥3 ICI myocarditis. FOR ANTHRACYCLINE: hold therapy if LVEF drop; cardioprotection with dexrazoxane in subsequent cycles for high-risk. FOR TRASTUZUMAB: usually reversible — pause + GDMT 6-8 weeks + recheck echo + rechallenge if LVEF recovers. CANCER-CONTINUATION DECISION: joint cardio + onc; weigh tumor response, alternative agents, HF severity.
   inputs: sbp
   actions: protocol.cardiogenic_shock
   advance: subtype-specific regimen active + cancer-continuation decision documented
8. 8DISPOSITION
   CICU if shock or fulminant ICI myocarditis; cardiology floor if stable; transfer to advanced HF center if refractory shock or transplant evaluation
   advance: unit assigned + multidisciplinary plan documented
9. 9MONITORING
   Continuous telemetry (block + VT/VF in ICI myocarditis), daily weight, hourly UOP, serial troponin q6-8h until trending down, daily BMP, daily echo until stable, repeat echo at 1-2 weeks for LVEF response
   inputs: troponin_serial, nt_probnp
   actions: panel.cardiac
   advance: monitoring + LVEF surveillance plan booked
10. 10FOLLOWUP
    Cardio-oncology clinic at 2 weeks, 6 weeks, 3 months, 6 months; serial echo with GLS for LVEF recovery; cancer-therapy continuation decision re-evaluated each visit; survivorship clinic for late-effect screening if anthracycline (lifelong); ICD evaluation if LVEF persistently <35% on full GDMT
    advance: cardio-oncology clinic + cancer-therapy plan + survivorship pathway documented