Cardiotoxicity (LVEF decline, cardiomyopathy)

Anthracycline cardiomyopathy risk rises steeply above 400-450 mg/m² doxorubicin and with radiotherapy or age; trastuzumab causes asymptomatic LVEF declines in 5-10% and heart failure in 1-4%, more after anthracyclines, monitored every 3 months and usually reversible on stopping. VEGF inhibitors cause hypertension and rarely heart failure; ibrutinib causes atrial fibrillation; immune checkpoint inhibitors cause rare fulminant myocarditis; androgen deprivation and aromatase inhibitors raise cardiovascular risk over years. Cardio-oncology clinics manage risk with ACE inhibitors, beta-blockers, statins and dexrazoxane; anthracycline-free regimens and non-anthracycline ADC payloads reduce exposure. Childhood cancer survivors carry lifelong cardiac risk.