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cardio.cardiac-tamponade.radiation-induced.v1

Cardiac tamponade — radiation-induced pericardial disease

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to radiation-induced pericardial disease across full spectrum: acute pericarditis (weeks post-radiation, less common with modern conformal techniques), subacute pericardial effusion (months to ~1 yr), chronic constrictive pericarditis (years to decades; latency median 7-10 yr per Aleman JCO), and effusive-constrictive pericarditis. Risk thresholds: mediastinal Hodgkin lymphoma (mantle field, >30 Gy), left-sided breast cancer (mean heart dose >5 Gy now significant per Darby NEJM 2013 PMID 23484825), lung + esophageal cancer. Specializes parent for: comprehensive cardiac MRI (LGE pattern + thickening + fibrosis + edema per Lyon EHJ 2022 PMID 35993161); CT for pericardial calcification (highly specific for radiation pericarditis); echo for restrictive vs constrictive physiology + tissue Doppler septal bounce; right heart catheterization for constrictive vs restrictive differentiation; treatment with NSAID + colchicine for acute pericarditis per ESC 2015 / ICAP (PMID 23992557); pericardiocentesis for tamponade physiology; pericardiectomy for refractory constrictive (high-risk surgery in radiation-damaged tissue with operative mortality 10-20% per Bertog EHJ 2004 PMID 15010459); rilonacept for refractory recurrent pericarditis per RHAPSODY (PMID 33999548); palliative if active cancer recurrence + refractory disease + limited prognosis; AVOID corticosteroids early in radiation tissue due to wound healing concern; cancer survivorship long-term cardiology surveillance per Lyon 2022 (annual echo + comprehensive cardiac MRI q3-5 yr in high-risk cohorts: mantle radiation, mean heart dose >15 Gy); multidisciplinary cardiology + oncology + cardiothoracic + palliative care coordination essential; differential between radiation toxicity and cancer recurrence (cytology + tumor markers + PET-CT + MRI pattern) drives management — coexistence common. Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (radiation-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute (Phase E wave 13).

Entry points (5)

  • history
    Cancer survivor (Hodgkin lymphoma, breast, lung, esophageal) with chest radiation history >30 Gy or mean heart dose >5 Gy presenting with dyspnea, edema, fatigue (ESC 2015 §Radiation-Induced; Lyon EHJ 2022 PMID 35993161)
    cancer_survivor_with_chest_radiation_history_dyspnea
  • imaging
    Echo with pericardial thickening or new effusion in radiation survivor (ESC 2015)
    echo_pericardial_thickening_or_effusion_in_radiation_survivor
  • history
    Acute pericarditis within weeks of completing radiation course (less common with modern conformal techniques) (Heidenreich JACC 2010)
    acute_pericarditis_within_weeks_of_radiation
  • history
    Years-decades post-radiation: insidious dyspnea + edema + ascites + JVD with Kussmaul sign → constrictive pericarditis (ESC 2015; Bertog EHJ 2004)
    restrictive_dyspnea_years_post_radiation
  • imaging
    Cardiac MRI showing pericardial late gadolinium enhancement + thickening in radiation survivor (Lyon EHJ 2022)
    cmr_late_gadolinium_pericardial_enhancement

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Cancer survivors often elderly at presentation; latency median 7-10 years (Aleman JCO 2003)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad in tamponade; preserved BP common in chronic constriction (ESC 2015)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade; less prominent in chronic constriction (ESC 2015)
  • jvprequired
    vital • used at INITIAL_WORKUP
    JVD prominent in both tamponade (Beck triad) and constriction (Kussmaul sign — paradoxical inspiratory rise; ESC 2015)
  • echorequired
    imaging • used at INITIAL_WORKUP
    TTE for effusion size + tamponade physiology + restrictive vs constrictive pattern + tissue Doppler for septal bounce (ESC 2015 Class I; Lyon EHJ 2022)
  • cardiac_mri
    imaging • used at INITIAL_WORKUP
    Cardiac MRI for pericardial late gadolinium enhancement + thickening + fibrosis assessment + edema; differentiates inflammatory vs fibrotic component (Lyon EHJ 2022; Heidenreich JACC 2010)
  • chest_ct
    imaging • used at INITIAL_WORKUP
    CT for pericardial calcification (highly specific for radiation pericarditis) + thickening + co-existing lung/mediastinal pathology (Lyon EHJ 2022)
  • radiation_dose_field_timingrequired
    history • used at CONTEXT
    Radiation specifics: dose, field (mantle vs tangential vs IMRT), mean heart dose, timing (latency 7-10 yr median), prior cancer type, current oncologic status (Darby NEJM 2013 PMID 23484825; Lyon EHJ 2022)
  • cancer_status_remission_or_recurrencerequired
    history • used at CONTEXT
    Active malignancy vs remission drives differential (radiation toxicity vs metastatic effusion); current oncologic management may include chemotherapy with cardiotoxic agents (Lyon EHJ 2022)
  • creatininerequired
    lab • used at CONTEXT
    Renal function for diuretic + drug dosing; KDIGO 2021 race-free eGFR (Inker NEJM 2021)

12-phase flow (9)

  1. 1FRAME
    Radiation-induced pericardial disease — spectrum from acute pericarditis (weeks) to chronic constriction (years-decades); cardiac MRI + CT essential for differentiating inflammatory vs fibrotic phenotype (ESC 2015 §Radiation-Induced; Lyon EHJ 2022 PMID 35993161)
    inputs: radiation_dose_field_timing
    advance: radiation context confirmed
  2. 2ENTRY
    Recognize patient with prior chest radiation presenting with dyspnea, edema, fatigue, or chest pain; latency from months to >30 years; surveillance in cancer survivors with mean heart dose >5 Gy or mantle radiation (Lyon EHJ 2022)
    inputs: age
    advance: radiation survivor with cardiac symptoms identified
  3. 3CONTEXT
    Document radiation specifics (dose, field, mean heart dose, timing), cancer status (remission vs active vs recurrent), concurrent cardiotoxic chemo (anthracyclines, trastuzumab), comorbidities (CAD risk also elevated post-radiation per Hancock JAMA 1993; PMID 8455714 if available)
    inputs: radiation_dose_field_timing, cancer_status_remission_or_recurrence, creatinine
    advance: radiation + cancer context fully captured
  4. 4RED_FLAGS
    Tamponade physiology in radiation survivor — emergent drainage; concurrent malignancy can cause hemorrhagic effusion (need to differentiate radiation toxicity vs metastatic vs combined); large rapidly accumulating effusion (Roy JAMA 2007)
    inputs: sbp, hr, jvp
    advance: tamponade physiology recognized → drainage prepared
  5. 5INITIAL_WORKUP
    TTE (effusion + tamponade physiology + restrictive vs constrictive pattern), cardiac MRI (LGE + thickening + fibrosis + edema), CT (calcification + co-existing pathology), pericardial fluid analysis if drained (cytology + cell count + chemistry to rule out malignancy), CBC + BMP + LDH + tumor markers, ECG; right heart catheterization with simultaneous LV/RV pressures for constrictive vs restrictive (Lyon EHJ 2022; Heidenreich JACC 2010)
    inputs: echo, cardiac_mri, chest_ct
    actions: panel.cardiac, panel.cbc
    advance: imaging + fluid analysis define inflammatory vs fibrotic vs malignant pattern
  6. 6DIFFERENTIAL
    Differentiate: pure radiation toxicity (LGE pattern + thickening + calcification + remission) vs metastatic recurrence (mass + cytology + tumor markers; route to cardio.cardiac-tamponade.malignant.v1) vs effusive-constrictive pericarditis vs concurrent cardiotoxic chemo (anthracycline cardiomyopathy with secondary effusion); cancer survivorship requires comprehensive workup (Lyon EHJ 2022)
    advance: mechanism identified
  7. 7TREATMENT
    Step 1 NSAID + colchicine for acute pericarditis (per ESC 2015 / ICAP PMID 23992557); Step 2 pericardiocentesis if tamponade physiology (ESC 2015 Class I); Step 3 pericardiectomy for refractory constrictive (high-risk surgery in radiation-damaged tissue; operative mortality 10-20% per Bertog EHJ 2004); Step 4 palliative if active cancer recurrence + refractory disease + limited prognosis (Lyon EHJ 2022); avoid corticosteroids early as they may impair healing in radiation tissue
    advance: treatment plan tailored to acute vs chronic + active vs remission cancer
  8. 8DISPOSITION
    CCU/ICU for tamponade with drainage; cardiothoracic surgery referral for pericardiectomy decision in constriction; oncology + palliative care + cardiology multidisciplinary management for cancer survivors (Lyon EHJ 2022)
    advance: multidisciplinary disposition confirmed
  9. 9MONITORING
    Re-accumulation surveillance (echo q12-24h initial then per clinical course); long-term cancer-survivorship surveillance per Lyon 2022 (annual echo + symptom assessment + comprehensive cardiac MRI q3-5 yr for high-risk cohorts: mantle radiation, mean heart dose >15 Gy)
    actions: panel.pleural
    advance: stable + surveillance plan established