Reduced left ventricular ejection fraction (LVEF <50% by echocardiogram or MUGA). Anthrac...

Deterministic view of the source YAML entity. Clinical authority remains with the cited source IDs and reviewer sign-off state.

ID	`RF-ORGAN-CARDIAC-LVEF-LOW`
Type	Red flag
Status	reviewed 2026-04-27 \| pending_clinical_signoff
Diseases	None declared
Sources	`SRC-ESMO-DLBCL-2024` `SRC-NCCN-BCELL-2025`

Red Flag Origin

Definition	Reduced left ventricular ejection fraction (LVEF <50% by echocardiogram or MUGA). Anthracyclines (doxorubicin, daunorubicin, epirubicin, idarubicin) and HER2-targeted antibodies (trastuzumab, pertuzumab, T-DM1, T-DXd) are relatively/absolutely contraindicated. Triggers substitution with non-anthracycline regimens (R-CEOP, R-GCVP, liposomal doxorubicin) and cardiology co-management.
Clinical direction	de-escalate
Category	organ-dysfunction

Trigger Logic

{
  "any_of": [
    {
      "comparator": "<",
      "finding": "lvef_percent",
      "threshold": 50
    }
  ],
  "type": "lab_value"
}

Notes

LVEF threshold 50% per most cooperative-group protocols; some centers use 55% with comorbidity. R-CEOP (etoposide for doxorubicin) shows comparable PFS in elderly with cardiac dysfunction (Moccia 2009). R-GCVP (gemcitabine + cyclophosphamide + vincristine + prednisolone) for severe LV impairment (LVEF <40% or class III/IV CHF). Liposomal doxorubicin (R-COMP) reduces but does not eliminate cardiotoxicity — acceptable at LVEF 40-50% with cardiology agreement. HER2 agents: hold trastuzumab if LVEF drops ≥10% from baseline AND below LLN per AHA cardio-oncology guidance. Cumulative anthracycline dose tracking is separate (see RF-OBLIGATE-CARDIO-TOXIC-NAIVE).

Used By

Algorithms

ALGO-HGBL-DH-2L - ALGO-HGBL-DH-2L
ALGO-PMBCL-2L - ALGO-PMBCL-2L

Red flag

RF-OBLIGATE-CARDIO-TOXIC-NAIVE - Patient has never received cumulative cardio-toxic therapy (anthracycline, mitoxantrone,...