# Heart risk assessment and monitoring before, during and after heart-toxic cancer treatment

Source: https://onco.cc/protocols/cardio-oncology-risk-assessment-and-cardiac-surveillance/  
OnCo record `cardio-oncology-risk-assessment-and-cardiac-surveillance` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Some cancer treatments, such as anthracyclines (doxorubicin, epirubicin) and trastuzumab, can weaken the heart. Before they start, your team should check your heart risk, usually with blood pressure, blood tests, an ECG and a heart scan, repeated during treatment; a fall in heart function does not always mean stopping. Afterwards, tell any doctor about new breathlessness, swelling or chest pain.

## Summary

Before treatment with anthracyclines, HER2-targeted therapy, VEGF inhibitors, some kinase inhibitors for CML, proteasome inhibitors and immunomodulatory drugs, RAF and MEK inhibitors or androgen deprivation therapy, the HFA-ICOS proformas (2020) stratify cardiovascular risk as low, medium, high or very high from history, blood pressure, glycated haemoglobin, kidney function, ECG, cardiac biomarkers (troponin and natriuretic peptides, where available) and echocardiography. Risk stratification should be prompt and should not delay treatment unless risk is high or very high or there is pre-existing cardiovascular disease; withholding effective treatment in those groups is a multidisciplinary decision with a cardiologist. HFA-ICOS also recommend a baseline echocardiogram, ECG, troponin and natriuretic peptide for everyone starting immune checkpoint inhibitors or CAR-T therapy.

BSE and BCOS (2021) set a comprehensive baseline echocardiogram including LVEF, global longitudinal strain (GLS) and right ventricular function, and define cancer therapy-related cardiac dysfunction (CTRCD) as an LVEF fall of more than 10 percentage points to below 50 per cent; IC-OS (2022) grades asymptomatic CTRCD as mild (LVEF 50 per cent or more with a new relative GLS fall over 15 per cent and/or a rise in biomarkers), moderate or severe (LVEF below 40 per cent). How often to repeat the echocardiogram differs widely between guidelines (from every 3 months on trastuzumab to undefined), with no strong evidence that any schedule improves outcomes; risk-based schedules such as those of HFA-EACVI (2020) repeat it more often at higher risk. Asymptomatic falls to 40 to 49 per cent may allow HER2 therapy to continue with cardio-oncology support. In survivors, ASCO (2017) asks for a low threshold for cardiac evaluation after any potentially cardiotoxic therapy, and imaging surveillance for certain higher-risk survivors.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: cardio-oncology baseline assessment; echocardiogram during trastuzumab; anthracycline cardiotoxicity monitoring; HFA-ICOS risk score; cancer therapy-related cardiac dysfunction; cardiac monitoring in cancer survivors
- Tags: protocol; cardio-oncology; survivorship

## Connected records

- key papers: [2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS)](https://onco.cc/key-papers/paper-lyon-eur-heart-j/)
- ideas: [A risk-stratified cardio-oncology pathway for everyone receiving heart-toxic cancer therapy](https://onco.cc/ideas/idea-acc-risk-stratified-cardio-oncology-pathway/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Cardio-oncology](https://onco.cc/technologies/cardio-oncology/), [Strain echocardiography (global longitudinal strain)](https://onco.cc/technologies/strain-echocardiography-gls/)
- drugs: [Doxorubicin](https://onco.cc/drugs/doxorubicin/), [Epirubicin](https://onco.cc/drugs/epirubicin/), [Pertuzumab](https://onco.cc/drugs/pertuzumab/), [Trastuzumab](https://onco.cc/drugs/trastuzumab/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/)
- terms: [Anthracyclines (doxorubicin, epirubicin)](https://onco.cc/terms/anthracycline/), [Cardiotoxicity (LVEF decline, cardiomyopathy)](https://onco.cc/terms/cardiotoxicity/), [Trastuzumab cardiotoxicity](https://onco.cc/terms/trastuzumab-cardiotoxicity/)

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