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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.
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.
Why: Knowing the risk lets people report symptoms early and take part in decisions about monitoring.
“It is important for health care providers to initiate the discussion regarding the potential for cardiac dysfunction in individuals in whom the risk is sufficiently high before beginning therapy.”
Why: A structured score finds the people who need a cardiologist before treatment and closer monitoring during it.
“Applying these risk stratification proformas will allow clinicians to stratify cancer patients into low, medium, high and very high risk of cardiovascular complications prior to starting treatment, with the aim of improving personalised approaches to minimise the risk of cardiovascular toxicity from cancer therapies.”
HFA of the ESC and IC-OS, European Journal of Heart Failure 2020
Why: For most people the cancer is the greater threat; only those at highest heart risk need a cardiology decision first.
“Baseline CV risk stratification should be completed promptly and should not delay starting cancer treatment (unless high or very high risk or pre-existing CVD is present).”
HFA of the ESC and IC-OS, European Journal of Heart Failure 2020
Why: Stopping a treatment that controls the cancer has its own cost, and the balance needs both specialists.
“Decisions to withhold effective but potentially cardiotoxic cancer treatments in cancer patients at high or very high risk of CVD should only be made after multidisciplinary team discussion between the treating oncologist/haematologist and cardiologist”
HFA of the ESC and IC-OS, European Journal of Heart Failure 2020
Why: Heart inflammation from these treatments is rare but serious, and a baseline makes a later change easy to see.
“we recommend all patients scheduled to receive ICI or CAR-T therapy have a baseline echocardiogram, electrocardiogram (ECG) and measurement of cardiac troponin and a natriuretic peptide, which serve as a baseline reference if new cardiac complications develop.”
HFA of the ESC and IC-OS, European Journal of Heart Failure 2020
Why: Later scans are compared with this one, so it must measure the same things the same way.
“All patients should undergo a comprehensive baseline echocardiogram to include the BSE minimum transthoracic dataset ( 3 ) with additional cardio-oncology measurements ( Table 1 ).”
Why: Guidelines differ on how often, and no schedule has been shown to improve outcomes, so higher-risk people are scanned more often.
“Furthermore, there is no strong evidence to support a specific schedule of screening or any evidence that it improves outcomes for screened patients ( 22 ).”
Why: A shared definition lets oncology and cardiology act on the same finding.
“We define CTRCD as a decrease in LVEF by > 10% (10 absolute percentage points) to a value < 50%.”
Why: Severity guides whether treatment can continue with heart medicines or needs to pause.
“A reduction in LVEF to <40% indicates severe asymptomatic CTRCD, with recent data suggesting an association with poor prognosis in multiple cancers and treatment regimens.”
Why: Growing evidence shows many people in this range can finish their cancer treatment safely with heart medicines and closer monitoring.
“However, there are increasing data to suggest that patients with asymptomatic reductions in LVEF to 40 to 49%, with guidance from a cardio-oncology team and personalized monitoring and treatment, can safely complete their cancer treatment without a significant increase in cardiac events ( 24 , 25 ).”
Why: Heart damage can appear years later, and treating it early can stop or reverse it.
“Clinical suspicion for cardiac disease should be high and threshold for cardiac evaluation should be low in any survivor who has received potentially cardiotoxic therapy.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The 2022 ESC cardio-oncology guideline, developed with EHA, ESTRO and IC-OS, is the current comprehensive guideline, and it could not be read here. The sources read agree on the shape of care: structured baseline risk assessment (HFA-ICOS 2020), a comprehensive baseline echocardiogram with LVEF and GLS (BSE/BCOS 2021), a shared definition of cardiac dysfunction (IC-OS 2022 grades it mild, moderate or severe; BSE/BCOS use an LVEF fall of more than 10 points to below 50 per cent), and a low threshold for evaluating survivors (ASCO 2017). They disagree on how often to scan during treatment: from every 3 months on trastuzumab (FDA, ESMO 2020) to risk-based schedules (HFA-EACVI 2020) to a frequency left to the clinician (ASCO 2017), with no strong evidence for any schedule.
HFA of the ESC and IC-OS, European Journal of Heart Failure 2020 · IC-OS, European Heart Journal 2022 · BSE and BCOS, Echo Research and Practice 2021 · ASCO, Journal of Clinical Oncology 2017 · ESC, European Heart Journal 2022
Where it differs: For anthracyclines, scans after a cumulative 240 mg/m² of doxorubicin or equivalent at low risk, at half of planned treatment as well at medium risk, and every two cycles at high risk; for adjuvant HER2 therapy, every four cycles (12 weeks) at low risk, every three cycles at medium risk and every two cycles at high risk, reducing if stable at 4 months.
Evidence: Expert consensus; BSE/BCOS note wide variation between guidelines and no strong evidence for any schedule. The HFA-EACVI paper itself was not read.
Where it differs: A fixed 3-monthly echocardiogram throughout HER2-targeted therapy, regardless of baseline risk; ESMO 2020 scans after 250 mg/m² of doxorubicin or equivalent and then after each further 100 mg/m².
Evidence: BSE/BCOS call the 3-monthly frequency controversial with limited compliance. The ESMO paper was not read.
Where it differs: Leaves the frequency of surveillance to the treating team, with routine imaging offered to those at increased risk.
Evidence: ASCO survivors guideline; read as an abstract and as tabulated by BSE/BCOS.
ASCO, Journal of Clinical Oncology 2017 · BSE and BCOS, Echo Research and Practice 2021
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Moderate asymptomatic CTRCD “Moderate asymptomatic CTRCD requires (i) a fall in LVEF into a clearly abnormal range (40–49%) with a change in LVEF beyond the described variability of the most commonly used Echo-based 2D LVEF measurements (i.e. by >10 percentage points), or (ii) a smaller change in LVEF but with a concomitant significant fall in GLS and/or new rise in cardiac biomarkers.” | IC-OS consensus definition | IC-OS, European Heart Journal 2022 |
| Mild asymptomatic CTRCD “Mild asymptomatic CTRCD is defined as preserved LVEF (i.e. LVEF ≥ 50%) with >15% reduction in GLS relative to baseline and/or new rise in troponin or NPs.” | IC-OS consensus definition | IC-OS, European Heart Journal 2022 |
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares Trastuzumab cardiotoxicity, Strain echocardiography (global longitudinal strain), Epirubicin, Cardio-oncology and the tag survivorship.
Shares Trastuzumab cardiotoxicity, Epirubicin, Cardio-oncology, Trastuzumab and the tag survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares 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), American Society of Clinical Oncology (ASCO) and the tags protocol, cardio-oncology.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.