Patient handout

Acute HF — Infusion-reaction cardiotoxicity (mAb / CAR-T CRS / transfusion reaction / contrast)

PRODUCTION

1. Your condition

This handout is for acute hf — infusion-reaction cardiotoxicity (mab / car-t crs / transfusion reaction / contrast). Your care team identified this based on: new cardiac decompensation (dyspnea, chest pain, hypotension, hypoxia) during or within hours of monoclonal antibody (rituximab, infliximab, alemtuzumab, obinutuzumab) infusion — peri-infusion cardiotoxicity / crs reaction.

Other reasons your team may use this plan: car-t patient (within 14 d of infusion) with new cardiac decompensation + fever / hypoxia / hypotension — crs-mediated cardiotoxicity (cosenza jacc cardioonc 2023; alvi jacc 2019); patient with new dyspnea / hypoxia / hypotension within 6h of blood transfusion — trali vs taco vs hemolytic vs anaphylactic reaction; iv-contrast (iodinated or gadolinium) administration followed by anaphylactoid / anaphylactic reaction with cardiogenic + distributive shock pattern.

2. Your medications

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
tocilizumab	8 mg/kg IV (max 800 mg) repeat q8h up to 4 doses	IV	q8h up to 4 doses	Lee CRS PMID 24876563 + Ganatra JACC CardioOnc 2020 + ASCO/SITC CRS guidelines — anti-IL-6R first-line for CAR-T CRS grade ≥2 with end-organ involvement; reduces cardiotoxicity progression
methylprednisolone	125 mg IV (anaphylaxis or refractory CRS) or 1 mg/kg IV daily for CRS escalation	IV	as needed for anaphylaxis; q6-24h for CRS	WAO 2020 anaphylaxis + ASCO/SITC CRS — corticosteroid adjunct for anaphylaxis (after epinephrine) and refractory CRS (after tocilizumab); dexamethasone alternative 10-20 mg IV q6h
epinephrine	0.3 mg IM (1:1000) repeat q5-15 min; or 0.05-0.5 µg/kg/min IV infusion if persistent shock	IM/IV	q5-15 min IM; continuous IV if shock	WAO 2020 anaphylaxis Class I — epinephrine FIRST-LINE for anaphylaxis with cardiovascular / respiratory compromise; IM thigh preferred over SC; IV infusion if refractory hypotension
diphenhydramine	25-50 mg IV	IV	q4-6h up to 24h	WAO 2020 — H1 blockade adjunct after epinephrine; reduces urticaria + pruritus + bronchospasm contribution
famotidine	20 mg IV	IV	q12h	WAO 2020 — H2 blockade in combination with H1 superior to H1 alone for hypotension reversal
furosemide	40-80 mg IV bolus then 5-10 mg/h infusion if needed	IV	as needed	DOSE PMID 21366472 — standard ADHF diuresis; first-line for TACO; NOT helpful for TRALI (TRALI is non-cardiogenic permeability edema)
norepinephrine	0.05-0.5 µg/kg/min titrate to MAP ≥65	IV	continuous	SOAP-II PMID 20200382 — first vasopressor for refractory cardiogenic + distributive shock; useful adjunct after epinephrine for anaphylaxis with persistent hypotension
lactated Ringer crystalloid	1-2 L IV bolus over 20-30 min	IV	as needed; cautious in cardiogenic component	WAO 2020 anaphylaxis — IV crystalloid bolus for anaphylactic hypotension; cautious in concurrent cardiogenic component (TACO, CRS-CMP) — start with 250-500 mL bolus and reassess
acetaminophen	650 mg PO 30-60 min before infusion	PO	pre-infusion	Standard premedication for at-risk infusions (rituximab, paclitaxel, IV iron, gadolinium); reduces febrile reaction component
hydrocortisone	100 mg IV 30-60 min before infusion	IV	pre-infusion	Standard premedication for at-risk infusions; reduces severity of subsequent reaction
carvedilol	3.125 mg PO BID titrate	PO	BID	GDMT once stable; CAPRICORN PMID 11356436 + ESC cardio-onc 2022 PMID 36017575
sacubitril-valsartan	24/26 mg PO BID titrate	PO	BID	PIONEER-HF PMID 30403955 + ESC cardio-onc 2022 Class IIa
spironolactone	12.5-25 mg PO daily	PO	daily	RALES PMID 10471456 + ESC cardio-onc 2022 Class I
empagliflozin	10 mg PO daily	PO	daily	EMPULSE PMID 35347356 + ESC cardio-onc 2022 Class IIa

Plan: Infusion-reaction cardiotoxicity — STOP infusion + cause-specific antidote (tocilizumab CRS; epinephrine anaphylaxis; diuretic TACO; respiratory support TRALI) + supportive ADHF bundle (ASH 2024 + Lee CRS PMID 24876563 + WAO 2020 anaphylaxis + AHA cardio-onc 2022 PMID 35403432)

3. When to call your provider

Contact your care team if any of the following happen:

Worsening heart pumping strength (LVEF) despite the four foundational heart-failure medications → advanced HF evaluation
Recurrent reaction at any future infusion → emergent allergy/immunology + cardio-oncology
Cancer progression requiring restart of cardiotoxic agent → joint cardio + onc shared decision with intensive premedication and pre-emptive tocilizumab if CAR-T
ICD therapy delivered → urgent EP

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

CAR-T patient with CRS grade 3-4 (high-grade fever + hypotension requiring vasopressor + hypoxia requiring O2 ≥40%) + new cardiac decompensation (troponin elevation, heart pumping strength (LVEF) drop, takotsubo pattern) — STAT tocilizumab + steroid + ICU + advanced HF consult(life-threatening)
Patient within 6h of blood transfusion with hypoxemic respiratory failure + bilateral infiltrates + no JVD/HTN (TRALI pattern) + PaO2/FiO2 <200 — intubation + lung-protective vent + AABB notification(life-threatening)
Anaphylaxis with cardiac arrest OR refractory hypotension despite IM epinephrine × 3 + crystalloid bolus 1-2 L — IV epinephrine infusion + ICU + ECMO consideration(life-threatening)
Patient with recurrent reactions at re-infusion despite full premedication protocol (acetaminophen + diphenhydramine + corticosteroid 30-60 min prior) — alternative agent + slow infusion rate + pre-emptive tocilizumab if CRS pattern

5. Follow-up

Cardio-oncology / cardiology follow-up at 2 wks + 6 wks + 3 mo with echo (heart pumping strength (LVEF) reversibility for CRS-CMP); allergy/immunology consult for premedication protocol + future infusion guidance + alternative agent recommendation; for transfusion reactions: blood-bank donor exclusion + future transfusion strategy (washed RBC, male-only plasma); for repeat CAR-T → CRS prophylaxis with pre-emptive tocilizumab in high-risk; iron-deficiency anemia switch to slow IV iron formulations (ferric carboxymaltose / ferric derisomaltose); patient + family education on early reaction recognition

6. Sources

Guideline: ASH 2024 transfusion reactions + Lee CRS PMID 24876563 + ASCO/SITC CRS guidelines + WAO 2020 anaphylaxis + AHA cardio-oncology 2022 + ESC cardio-oncology 2022