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cardio.cardio-oncology.surveillance.chronic.v1PRODUCTION
cardio.cardio-oncology.surveillance.chronic.v1

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

cardiologychronicadult
Hard-required inputs
0 / 6
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Identify cardiotoxic agent class + treatment phase (baseline vs on-treatment vs survivorship)

Inputs
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Actions
0
Advance rule
Set
Advance when

agent class + phase framed

Patient inputs (11)

Baseline CV risk; childhood-survivor lifelong surveillance

Anthracycline/HER2/VEGF-TKI/proteasome/BTK/ICI/ADT/RT — class-specific toxicity + pathway

Cardiac biomarkers — early CTRCD + ICI-myocarditis signal

Baseline + serial LVEF/GLS — CTRCD definition + grading

HFA-ICOS baseline CV risk stratification drives surveillance intensity

Cardioprotective/HF drug dosing; contrast

BTK-inhibitor AF; QT-prolonging agents — surveillance

Anthracycline cumulative dose / RT field + dose — risk magnitude

Pregnancy during/after cardiotoxic therapy — drug + surveillance

ICI myocarditis (troponin rise + symptoms/arrhythmia) — emergency route

VEGF-TKI HTN — aggressive control while continuing oncotherapy

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningici_myocarditis_emergency
    Suspected immune-checkpoint-inhibitor myocarditis (troponin rise + symptoms/arrhythmia/conduction) — fulminant, high mortality: HOLD ICI + high-dose corticosteroids — EMERGENCY (route acute) — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverectrcd_grading_branch
    CTRCD detected (GLS relative decline ≥15% / LVEF drop / biomarker rise) — grade (mild/moderate/severe), cardioprotection/GDMT, multidisciplinary continue-vs-interrupt — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanthracycline_dose_branch
    High cumulative anthracycline / high baseline risk — dexrazoxane + intensified GLS surveillance; lifelong survivorship surveillance — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebtk_inhibitor_af_branch
    BTK-inhibitor-associated AF — rate/rhythm + anticoagulation with cancer-bleeding awareness (BTKi increase bleeding; avoid warfarin; DOAC/interaction-aware) — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereradiation_induced_heart_disease_branch
    Prior thoracic radiation — late multi-territory RIHD (CAD, valve, pericardium, conduction, restrictive) — lifelong multi-domain surveillance — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy during/after cardiotoxic therapy — avoid ACEi/ARB/ARNi/SGLT2i in pregnancy (BB ± hydralazine); peripartum CTRCD risk; cardio-obstetric + oncology — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateher2_trastuzumab_branch
    Trastuzumab/HER2 CTRCD — often reversible; hold + GDMT + rechallenge after recovery via MDT (do not permanently abandon if cancer benefit) — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevegf_tki_htn_branch
    VEGF/TKI-induced hypertension — aggressive antihypertensive control to CONTINUE oncotherapy (rarely a reason to stop) — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateadt_hormonal_branch
    Androgen-deprivation / hormonal therapy — accelerated ASCVD + metabolic syndrome — aggressive global CV-risk-factor optimisation — 2022 ESC Cardio-Oncology
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

Cardio-oncology — surveillance + cardioprotection/GDMT + agent-specific + onco-decision (2022 ESC Cardio-Oncology; 2022 AHA/ACC/HFSA HF)
axis: cardio_oncology_surveillance_and_managementstep 1 - Step 1 — Baseline HFA-ICOS risk + surveillance plan (do not delay life-saving oncotherapy)
Selected step "Step 1 — Baseline HFA-ICOS risk + surveillance plan (do not delay life-saving oncotherapy)" — Before / during cardiotoxic therapy
  • HFA-ICOS baseline risk stratification + baseline/serial GLS-echo + troponin/NP surveillance
    first line
    risk_surveillance
    triggers: planned_or_active_cardiotoxic_therapy
    2022 ESC Cardio-Oncology — risk-stratified surveillance intensity; GLS relative decline + biomarkers detect subclinical CTRCD

outpatient playbook — drug actions (3)

  1. 1. cardioprotection (ACEi/ARB + BB) ± dexrazoxane
    lisinopril 2.5–5 mg + carvedilol 3.125→25 mg; dexrazoxane per protocol • PO/IV • daily/BID/cycles
    trigger: High risk / CTRCD (2022 ESC Cardio-Oncology)
    Prevent/treat CTRCD while continuing oncotherapy
  2. 2. full HF GDMT for symptomatic CTRCD
    per HFrEF protocol • PO • per drug
    trigger: Symptomatic moderate-severe CTRCD (2022 ACC/AHA HF)
    Often recovers (esp. trastuzumab)
  3. 3. agent-specific (VEGF-HTN control, BTK-AF AC)
    amlodipine/losartan; AC bleeding-aware • PO • daily
    trigger: VEGF-TKI HTN / BTK AF (2022 ESC Cardio-Oncology)
    Continue oncotherapy with toxicity control

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pre-treatment baseline before anthracycline/HER2/VEGF/ICI/RT; Asymptomatic LVEF / GLS decline during cancer therapy; Rising troponin / natriuretic peptide on cardiotoxic regimen.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardio-oncology cardiotoxicity surveillance & management (chronic, cross-system)** (cardio.cardio-oncology.surveillance.chronic.v1).
Phenotype framing: CTRCD grade (mild/moderate/severe) + agent attribution; RIHD vs CTRCD vs ICI myocarditis vs non-cardiotoxic cause
Scope: Identify cardiotoxic agent class + treatment phase (baseline vs on-treatment vs survivorship)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cardio-oncology — surveillance + cardioprotection/GDMT + agent-specific + onco-decision (2022 ESC Cardio-Oncology; 2022 AHA/ACC/HFSA HF)** — step "Step 1 — Baseline HFA-ICOS risk + surveillance plan (do not delay life-saving oncotherapy)".
1. HFA-ICOS baseline risk stratification + baseline/serial GLS-echo + troponin/NP surveillance (risk_surveillance, first line) — 2022 ESC Cardio-Oncology — risk-stratified surveillance intensity; GLS relative decline + biomarkers detect subclinical CTRCD

Setting playbook (outpatient) — Risk-stratify + surveil, cardioprotect/GDMT for CTRCD, manage agent-specific toxicity, enable continued oncotherapy via multidisciplinary decision (2022 ESC Cardio-Oncology)
2. cardioprotection (ACEi/ARB + BB) ± dexrazoxane lisinopril 2.5–5 mg + carvedilol 3.125→25 mg; dexrazoxane per protocol PO/IV daily/BID/cycles — High risk / CTRCD (2022 ESC Cardio-Oncology) (Prevent/treat CTRCD while continuing oncotherapy)
3. full HF GDMT for symptomatic CTRCD per HFrEF protocol PO per drug — Symptomatic moderate-severe CTRCD (2022 ACC/AHA HF) (Often recovers (esp. trastuzumab))
4. agent-specific (VEGF-HTN control, BTK-AF AC) amlodipine/losartan; AC bleeding-aware PO daily — VEGF-TKI HTN / BTK AF (2022 ESC Cardio-Oncology) (Continue oncotherapy with toxicity control)

Non-pharmacologic actions:
- Cardio-oncology multidisciplinary clinic + oncology co-decision — 2022 ESC Cardio-Oncology
- ICI myocarditis → emergency hold + acute pathway — 2022 ESC Cardio-Oncology
- Survivorship lifelong surveillance (anthracycline/RT/childhood-cancer) — 2022 ESC Cardio-Oncology

AVOID / contraindication checks:
- Do not reflexively stop life saving oncotherapy multidisciplinary decision — 2022 ESC Cardio Oncology
- ICI myocarditis is an emergency hold ICI high dose steroids route acute — 2022 ESC Cardio Oncology
- Control VEGF TKI HTN aggressively rather than stop oncotherapy — 2022 ESC Cardio Oncology
- Dexrazoxane for high cumulative anthracycline high risk — 2022 ESC Cardio Oncology
- Lifelong survivorship surveillance anthracycline RT childhood cancer — 2022 ESC Cardio Oncology

Monitoring

Regimen monitoring:
- baseline then regimen specific GLS echo and troponin NP — 2022 ESC Cardio-Oncology
- on treatment surveillance cadence by HFA ICOS risk — 2022 ESC Cardio-Oncology
- post treatment and survivorship surveillance — 2022 ESC Cardio-Oncology
- BP for VEGF TKI and QT for QT prolonging agents — 2022 ESC Cardio-Oncology
- BMP during GDMT titration — 2022 ACC/AHA HF

Setting (outpatient) monitoring:
- Regimen-specific GLS/biomarker surveillance; survivorship — 2022 ESC Cardio-Oncology

Follow-up plan: Survivorship lifelong surveillance (anthracycline/RT/childhood-cancer); re-phenotype if HF persists
- Close-out criterion: survivorship plan documented

Monitoring phase: Regimen-specific surveillance cadence (GLS/biomarkers); on-treatment + post-treatment

Disposition

Current setting: outpatient — Risk-stratify + surveil, cardioprotect/GDMT for CTRCD, manage agent-specific toxicity, enable continued oncotherapy via multidisciplinary decision (2022 ESC Cardio-Oncology)

Disposition criteria:
- Stable on surveillance ± cardioprotection → continue oncotherapy + cardio-oncology follow-up
- CTRCD → GDMT + multidisciplinary decision
- ICI myocarditis → acute pathway

Escalation triggers (move to higher acuity):
- Suspected ICI myocarditis → ED + acute ICI-myocarditis pathway — 2022 ESC Cardio-Oncology
- Severe CTRCD → multidisciplinary interrupt decision + GDMT — 2022 ESC Cardio-Oncology
- Uncontrolled VEGF-TKI HTN → intensify (avoid stopping oncotherapy if possible) — 2022 ESC Cardio-Oncology

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Suspected immune-checkpoint-inhibitor myocarditis (troponin rise + symptoms/arrhythmia/conduction) — fulminant, high mortality: HOLD ICI + high-dose corticosteroids — EMERGENCY (route acute) — 2022 ESC Cardio-Oncology
- [SEVERE] CTRCD detected (GLS relative decline ≥15% / LVEF drop / biomarker rise) — grade (mild/moderate/severe), cardioprotection/GDMT, multidisciplinary continue-vs-interrupt — 2022 ESC Cardio-Oncology
- [SEVERE] High cumulative anthracycline / high baseline risk — dexrazoxane + intensified GLS surveillance; lifelong survivorship surveillance — 2022 ESC Cardio-Oncology

Citations

- 2022 ESC Cardio-Oncology Guideline (Lyon) + 2022 AHA/ACC/HFSA HF Guideline [PMID:36017575](https://pubmed.ncbi.nlm.nih.gov/36017575/)
- Cited evidence (PMID 35379504) [PMID:35379504](https://pubmed.ncbi.nlm.nih.gov/35379504/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)
- Cited evidence (PMID 31535829) [PMID:31535829](https://pubmed.ncbi.nlm.nih.gov/31535829/)
- Cited evidence (PMID 25176015) [PMID:25176015](https://pubmed.ncbi.nlm.nih.gov/25176015/)

Last reconciled with current guidelines: 2026-05-16.
References