Clinical Commander

All dossiers
cardio.cardio-oncology.surveillance.chronic.v1

Cardio-oncology cardiotoxicity surveillance & management (chronic, cross-system)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Cardio-oncology surveillance chronic — HFA-ICOS risk + GLS/biomarker surveillance; cardioprotection (ACEi/ARB/BB ± dexrazoxane) + HF GDMT; agent-specific (VEGF-HTN/BTK-AF/QT/ADT/RIHD); multidisciplinary interrupt/rechallenge (do NOT reflexively stop oncotherapy); ICI myocarditis = emergency (route acute). Manifest points at existing sibling cardio.acute-hf.core.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (surveillance + cardioprotection/GDMT + agent-specific axis + workups + calculators + panels), test_files, 5-PMID evidence object, chronic phases all present. Drug RxCUIs RxNav-validated 2026-05-16 (carvedilol 20352, lisinopril 18867, sacubitril/valsartan 1656340, dexrazoxane 1294534, dapagliflozin 1488564, amlodipine 17767, losartan 52175, metoprolol succinate 866427, spironolactone 9997); surveillance/MDT/ICI-emergency non_pharm; SNOMED deferred. 9 trigger/special-pop branches: ICI-myocarditis (not-to-miss), CTRCD-grading, anthracycline-dose, HER2/trastuzumab, VEGF-TKI-HTN, BTK-AF, radiation-induced heart disease, ADT/hormonal, pregnancy.

Entry points (5)

  • history
    Pre-treatment baseline before anthracycline/HER2/VEGF/ICI/RT
    pre_cardiotoxic_therapy_baseline
  • imaging
    Asymptomatic LVEF / GLS decline during cancer therapy
    lvef_gls_decline_on_therapy
  • lab_abnormality
    Rising troponin / natriuretic peptide on cardiotoxic regimen
    rising_troponin_np
  • symptom
    New HF symptoms during/after cancer therapy
    hf_symptoms_on_oncotherapy
  • history
    Cancer-survivor late cardiotoxicity surveillance
    cancer_survivor_surveillance

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Baseline CV risk; childhood-survivor lifelong surveillance
  • cardiotoxic_agent_classrequired
    history • used at FRAME
    Anthracycline/HER2/VEGF-TKI/proteasome/BTK/ICI/ADT/RT — class-specific toxicity + pathway
  • cumulative_dose_rt_field
    history • used at CONTEXT
    Anthracycline cumulative dose / RT field + dose — risk magnitude
  • lvef_glsrequired
    imaging • used at RISK_STRATIFICATION
    Baseline + serial LVEF/GLS — CTRCD definition + grading
  • troponin_nprequired
    lab • used at INITIAL_WORKUP
    Cardiac biomarkers — early CTRCD + ICI-myocarditis signal
  • baseline_cv_riskrequired
    history • used at RISK_STRATIFICATION
    HFA-ICOS baseline CV risk stratification drives surveillance intensity
  • blood_pressure
    vital • used at TREATMENT
    VEGF-TKI HTN — aggressive control while continuing oncotherapy
  • arrhythmia_or_qt
    history • used at BRANCHING_WORKUP
    BTK-inhibitor AF; QT-prolonging agents — surveillance
  • myocarditis_features
    symptom • used at RED_FLAGS
    ICI myocarditis (troponin rise + symptoms/arrhythmia) — emergency route
  • creatininerequired
    lab • used at TREATMENT
    Cardioprotective/HF drug dosing; contrast
  • pregnancy_status
    demographic • used at CONTEXT
    Pregnancy during/after cardiotoxic therapy — drug + surveillance

12-phase flow (12)

  1. 1FRAME
    Identify cardiotoxic agent class + treatment phase (baseline vs on-treatment vs survivorship)
    inputs: cardiotoxic_agent_class
    advance: agent class + phase framed
  2. 2ENTRY
    Baseline, surveillance, asymptomatic LVEF/GLS/biomarker change, symptoms, survivor
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Regimen, cumulative anthracycline dose, RT field/dose, CV risk factors, pregnancy
    inputs: cumulative_dose_rt_field, pregnancy_status
    advance: oncologic + CV context complete
  4. 4RED_FLAGS
    ICI myocarditis (fulminant — high mortality), decompensated CTRCD, malignant arrhythmia
    inputs: myocarditis_features, troponin_np
    actions: cardiogenic_shock
    advance: no red flags or routed to acute ICI-myocarditis pathway
  5. 5INITIAL_WORKUP
    Echo + GLS, troponin/NP, ECG (QT, conduction)
    inputs: lvef_gls, troponin_np
    actions: panel.cardiac
    advance: cardiac function + biomarkers documented
  6. 6BRANCHING_WORKUP
    CMR (myocarditis/RIHD), repeat biomarkers, HFA-ICOS risk, arrhythmia/QT assessment
    inputs: baseline_cv_risk, arrhythmia_or_qt
    actions: preop_cardiac
    advance: CTRCD grade + agent attribution resolved
  7. 7DIFFERENTIAL
    CTRCD grade (mild/moderate/severe) + agent attribution; RIHD vs CTRCD vs ICI myocarditis vs non-cardiotoxic cause
    inputs: lvef_gls, cardiotoxic_agent_class
    advance: cardiotoxicity type + grade assigned
  8. 8RISK_STRATIFICATION
    HFA-ICOS baseline risk + on-treatment CTRCD grading drive surveillance + therapy + onco-decision
    inputs: baseline_cv_risk, lvef_gls
    advance: risk + CTRCD grade + decision context assigned
  9. 9TREATMENT
    Cardioprotection (ACEi/ARB + BB ± dexrazoxane) + HF GDMT for CTRCD + agent-specific (VEGF-HTN, BTK-AF, QT, ADT-ASCVD, RIHD) + multidisciplinary interrupt/rechallenge; ICI myocarditis → emergency route
    inputs: lvef_gls, blood_pressure, creatinine
    advance: cardioprotection/GDMT + agent-specific + onco-decision documented
  10. 10DISPOSITION
    Cardio-oncology multidisciplinary clinic; oncology co-decision
    inputs: baseline_cv_risk
    actions: preop_cardiac
    advance: cardio-oncology co-management plan set
  11. 11MONITORING
    Regimen-specific surveillance cadence (GLS/biomarkers); on-treatment + post-treatment
    inputs: lvef_gls, troponin_np
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Survivorship lifelong surveillance (anthracycline/RT/childhood-cancer); re-phenotype if HF persists
    inputs: cardiotoxic_agent_class
    advance: survivorship plan documented