Systemic Melanoma Therapy in Patients with Pre-Existing Heart Failure: An HF-Centered Decision Framework and Critical Narrative Review

Figures

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  Figure 1. HF-centered decision framework for systemic melanoma therapy. Four interacting domains determine treatment readiness and the intensity of monitoring: (1) HF phenotype and current stability; (2) oncological urgency and alternatives; (3) treatment-specific cardiovascular toxicity phenotype; and (4) detectability, reversibility, frailty, support, and patient priorities. The framework is an author-generated clinical synthesis intended to operationalize existing guidance for patients with pre-existing HF; it is not a validated prediction score. Figure 1 defines the conceptual structure only. It deliberately contains no thresholds, no surveillance intervals and no management steps: the operational sequence from assessment to a documented output is shown in Figure 2, and the therapy-specific management algorithm, including the separate BRAF/MEK inhibitor and checkpoint inhibitor pathways, is shown in Figure 3. The three figures are intended to be read in that order and not to duplicate one another.

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  Figure 2. Operational pathway from four-domain assessment to a documented decision output. Blue rectangles denote assessment steps, tan diamonds denote decision nodes, green rounded boxes denote management outputs/actions, and the yellow box summarizes the composite precedence rules. Colors are used to distinguish functional components of the pathway and do not represent the green/amber/red domain grading described in Table 2. Rectangles with a solid outline denote assessment steps, diamonds denote decision nodes, and rounded boxes denote the five possible outputs: proceed; optimize then treat; modify the regimen or sequence; initiate under enhanced monitoring; and restructure care rather than withhold it. The dashed arrow from “Restructure care” to “Proceed” indicates that, once monitoring and care delivery have been made feasible, treatment may proceed rather than being withheld solely because of a Domain 4 deliverability limitation. The composite rule box specifies how simultaneously abnormal domains are resolved, and the dashed box specifies the events that mandate re-grading. The pathway is an author-generated consensus construct that operationalizes existing guidance for patients…

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  Figure 3. Proposed therapy-specific cardio-oncology pathway for melanoma patients with pre-existing heart failure. Read from top to bottom: the left column follows BRAF/MEK inhibitor management and the right column follows immune checkpoint inhibitor management. Figure 1 provides the conceptual four-domain framework and Figure 2 provides the decision logic; Figure 3 begins only after that assessment is complete. Steps are labeled [G] when directly guideline-supported and [AP] when author-proposed. CMR, cardiac magnetic resonance; CTRCD, cancer therapy-related cardiac dysfunction; EMB, endomyocardial biopsy; GDMT, guideline-directed medical therapy; IVIG, intravenous immunoglobulin; MDT, multidisciplinary team; TTE, transthoracic echocardiography.