# Heart function after anthracyclines, trastuzumab and chest radiotherapy

Source: https://onco.cc/technologies/cardiotoxicity-surveillance-recovery/  
OnCo record `cardiotoxicity-surveillance-recovery` (Technology). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Most heart damage from anthracycline chemotherapy appears within the first year after it finishes, and most of it improves at least partly when it is caught and treated. Heart muscle weakened by trastuzumab usually recovers when the drug is stopped. Radiotherapy to the chest raises the risk of coronary disease years later, in proportion to the dose the heart received.

## Summary

The best single description of anthracycline cardiotoxicity comes from a cohort of 2,625 patients whose ejection fraction was measured before treatment, every three months during it and for a year afterwards, then twice yearly. Cardiotoxicity, defined as a fall in ejection fraction of more than ten absolute points to below 50 per cent, occurred in 9 per cent. The median time from the end of chemotherapy was 3.5 months, and 98 per cent of cases appeared within the first year. Everyone affected was started on heart failure treatment: 11 per cent recovered fully to their baseline ejection fraction and most of the rest recovered partly. That reframes the old idea of late-onset damage appearing out of nowhere decades later: the first year is when to look.

Trastuzumab is a different and gentler picture. In the HERA trial, one year of trastuzumab after anthracycline chemotherapy caused severe heart failure in 0.8 per cent against none in the observation arm, and a confirmed significant fall in ejection fraction in 3.6 per cent against 0.6 per cent. Of the 73 patients in the trastuzumab arm who reached a cardiac endpoint, 59 reached acute recovery.

Radiotherapy is slower. In a case-control study of 2,168 women treated in Sweden and Denmark between 1958 and 2001, the rate of major coronary events rose by 7.4 per cent for every gray of mean heart dose, with no apparent threshold, starting within five years and continuing into the third decade. Those women were treated with older techniques and received an average mean heart dose of 4.9 gray; breath-hold, prone positioning and modern planning have cut cardiac doses substantially since, so the risk per patient today is lower while the dose-response relationship still holds.

Who is watched, and how. ASCO's 2017 guideline says the threshold for cardiac evaluation should be low in anyone who received potentially cardiotoxic therapy, that higher-risk survivors may benefit from prevention and screening during treatment, and that routine imaging surveillance after treatment may be warranted for higher-risk survivors so that progression can be halted or reversed. The 2022 European Society of Cardiology guideline, the first devoted to cardio-oncology, is the reference for baseline risk stratification and the surveillance schedule. Echocardiography with global longitudinal strain detects dysfunction earlier than ejection fraction, and troponin rises before either.

What comes back, and when: usually partial, sometimes complete, and the timing favours the watchful. For anthracyclines, 11 per cent of those affected returned fully to baseline and most of the rest improved, with treatment started promptly. For trastuzumab, recovery after stopping is the usual outcome. For radiation coronary disease, nothing reverses, which is why the lever is the dose at planning rather than anything done afterwards.

## Fields

- Kind: Technology
- Status: standard-of-care
- Last checked: 2026-10-02
- Tags: rejuvenation; survivorship; evidence:strong
- Principle: Anthracyclines damage cardiomyocytes through topoisomerase-2-beta-mediated DNA damage and oxidative stress, causing cell loss that is largely irreversible once established but partly compensated if heart failure treatment starts early. Trastuzumab blocks HER2 signalling that cardiomyocytes use for repair, which is why its effect is usually reversible on withdrawal. Radiation injures the coronary microvasculature and endothelium, producing accelerated atherosclerosis years later.
- Strengths: The window to find anthracycline damage is defined: the first year after treatment; Trastuzumab-related dysfunction usually recovers when the drug stops; Strain imaging and troponin detect injury before the ejection fraction falls
- Limitations: Surveillance is patchy outside large centres, and survivorship plans rarely name who does it; Radiation coronary disease does not reverse; The dose-response figure comes from cohorts treated with older, higher-dose techniques

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Cardio-oncology
- Early detection of anthracycline cardiotoxicity and improvement with heart failure therapy (Circulation 2015): https://doi.org/10.1161/CIRCULATIONAHA.114.013777
- Longer-term assessment of trastuzumab-related cardiac adverse events in the HERA trial (JCO 2010): https://doi.org/10.1200/JCO.2009.26.0463
- Risk of ischemic heart disease in women after radiotherapy for breast cancer (NEJM 2013): https://doi.org/10.1056/NEJMoa1209825
- Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: ASCO guideline (JCO 2017): https://doi.org/10.1200/JCO.2016.70.5400
- 2022 ESC Guidelines on cardio-oncology (Eur Heart J 2022): https://doi.org/10.1093/eurheartj/ehac244

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- ideas: [Biomarker-guided cardioprotection for everyone on cardiotoxic cancer therapy](https://onco.cc/ideas/idea-moon-cardioprotection-by-default/)
- cancers: [Diffuse large B-cell lymphoma](https://onco.cc/cancers/dlbcl/), [HER2-positive breast cancer](https://onco.cc/cancers/breast-her2-positive/), [Hodgkin lymphoma](https://onco.cc/cancers/hodgkin-lymphoma/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Sarcomas (soft tissue, bone, GIST)](https://onco.cc/cancers/sarcoma/)
- fronts: [Chemotherapy](https://onco.cc/fronts/chemotherapy/), [Recovery & Rejuvenation](https://onco.cc/fronts/rejuvenation/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Cardio-oncology](https://onco.cc/technologies/cardio-oncology/), [Hormones, metabolism and the heart after transplant](https://onco.cc/technologies/rejuv-tx-endocrine-and-cardiometabolic/), [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Protecting the heart during anthracycline treatment: dexrazoxane, beta blockers and ACE inhibitors](https://onco.cc/technologies/anthracycline-cardioprotection/), [Strain echocardiography (global longitudinal strain)](https://onco.cc/technologies/strain-echocardiography-gls/), [Survivorship care and late-effects surveillance](https://onco.cc/technologies/survivorship-care-plan/), [The heart after anthracyclines and chest radiotherapy in childhood](https://onco.cc/technologies/rejuv-paed-heart/), [Troponin and natriuretic peptide monitoring during cancer treatment](https://onco.cc/technologies/cardiac-biomarker-monitoring/)
- drugs: [Doxorubicin](https://onco.cc/drugs/doxorubicin/), [Epirubicin](https://onco.cc/drugs/epirubicin/), [Trastuzumab](https://onco.cc/drugs/trastuzumab/)
- terms: [Late effects and survivorship toxicity](https://onco.cc/terms/late-effects/), [Trastuzumab cardiotoxicity](https://onco.cc/terms/trastuzumab-cardiotoxicity/)
- bottlenecks: [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)

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