This handout is for acute hf — chemotherapy / cancer therapy-induced cardiomyopathy (ctrcd). Your care team identified this based on: patient on active anthracycline / her2 inhibitor / tki / ici therapy presenting with new dyspnea or lvef drop.
Other reasons your team may use this plan: surveillance echo: lvef drop ≥10% to <50% or gls decline >15% from baseline during cancer therapy (ctrcd per esc cardio-onc 2022); serial troponin elevation during cancer therapy — early ctrcd biomarker; ici myocarditis screening; ici patient with chest pain + arrhythmia + heart block + concomitant myositis or myasthenia (ici myocarditis triad).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| furosemide | 40-80 mg IV bolus then 5-10 mg/h infusion | IV | as scheduled | DOSE PMID 21366472 high-dose IV bolus arm |
| carvedilol | 3.125 mg PO BID titrate | PO | BID | OVERCOME PMID 23083779 cardioprotection in cancer therapy; CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262; ESC cardio-onc 2022 (PMID 36017575) Class I |
| enalapril | 2.5 mg PO BID titrate | PO | BID | Cardinale 2015 PMID 25956652 — enalapril cardioprotection in anthracycline CMP; full LVEF recovery in 42% if started early; ESC cardio-onc 2022 |
| sacubitril-valsartan | 24/26 mg PO BID titrate | PO | BID | PIONEER-HF PMID 30403955; SCOT preliminary data supports ARNI in cancer therapy CMP; ESC cardio-onc 2022 Class IIa |
| spironolactone | 12.5-25 mg PO daily | PO | daily | RALES PMID 10471456; ESC cardio-onc 2022 Class I; PROACT trial (cardio-onc spironolactone) preliminary support |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356; emerging evidence in CTRCD (ERASE-AF cardio-onc subgroups); ESC cardio-onc 2022 Class IIa |
| methylprednisolone | 1 g IV daily ×3-5 d then taper | IV | daily | Mahmood JACC 2018 PMID 29567210 — high-dose steroid is FIRST-LINE for ICI myocarditis; delay = death; treat empirically while workup proceeds |
| IVIG (immunoglobulin G) | 2 g/kg IV divided over 2-5 days | IV | as scheduled | ICI myocarditis steroid-refractory salvage; ESMO + NCCN guidelines support |
| abatacept | 10 mg/kg IV q2 weeks | IV | q2 weeks | Salem et al. case series — abatacept (CTLA-4 Ig) reverses ICI myocarditis by inhibiting T-cell activation; preferred over infliximab in HF (no TNF-α inhibition risk) |
| infliximab | 5 mg/kg IV | IV | one dose then reassess | TNF-α inhibitor for refractory ICI myocarditis; CAUTION: can worsen HF; AVOID if EF severely reduced; abatacept generally preferred |
| dexrazoxane | 500 mg/m² IV 30 min before each anthracycline dose (10:1 dexrazoxane:doxorubicin ratio) | IV | with each anthracycline cycle | Cardioprotection in patients receiving cumulative anthracycline >300 mg/m²; reduces CTRCD incidence (Lipshultz NEJM 2010) |
| normal saline 0.9% | 500 mL IV bolus over 30 min if hypovolemic | IV | as needed | Many cancer patients are hypovolemic from poor PO intake / vomiting; cautious bolus before diuretic if uncertain volume status |
Plan: CTRCD subtype-aware ADHF — GDMT 4-pillar (Cardinale 2015 PMID 25956652) + high-dose steroid for ICI myocarditis (Mahmood JACC 2018 PMID 29567210) + cancer-therapy continuation decision
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardio-oncology clinic at 2 weeks, 6 weeks, 3 months, 6 months; serial echo with GLS for heart pumping strength (LVEF) recovery; cancer-therapy continuation decision re-evaluated each visit; survivorship clinic for late-effect screening if anthracycline (lifelong); ICD evaluation if heart pumping strength (LVEF) persistently <35% on full the four foundational heart-failure medications
Guideline: ESC cardio-oncology 2022 + 2022 ACC/AHA HF + Cardinale 2015 enalapril cardioprotection + Mahmood ICI myocarditis JACC 2018