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Cardiotoxicity of cancer therapy

Key sources
The following summarized guidelines for the evaluation and management of cardiotoxicity of cancer therapy are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC/ESTRO/EHA/IC-OS 2022), the European Society of Medical Oncology (ESMO 2022; 2020), and the Canadian Cardiovascular Society (CCS 2016).
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Guidelines

1.Classification and risk stratification

Risk assessment: obtain cardiovascular toxicity risk stratification in all patients with cancer before initiating potentially cardiotoxic anticancer therapy.
B
consider using the HFA-ICOS risk assessment tool for risk stratification.
B
communicate the results of the risk assessment to the patient and other appropriate healthcare professionals.
B
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2.Diagnostic investigations

Cardiovascular assessment: as per ESC 2022 guidelines, obtain a specialist cardiovascular assessment for optimal diagnostic workup and management in patients with cancer presenting with new cardiovascular toxicity during and after cancer treatment.
B

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  • ECG

  • Cardiac imaging

  • Cardiac biomarkers

3.Medical management

Management of arterial hypertension: as per ESC 2022 guidelines, initiate effective treatment for cancer therapy-induced arterial hypertension to prevent cancer treatment interruption and cardiovascular complications.
B
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  • Management of QTc prolongation

  • Management of AF

  • Management of acute coronary syndrome

  • Management of HF

  • Management of Takotsubo syndrome

  • Management of late cardiac dysfunction

  • Management of pericarditis

  • Management of VHD

  • Management of carcinoid heart disease

  • Management of cardiac amyloidosis

  • Management of VTE

  • Management of PAD

4.Nonpharmacologic interventions

Lifestyle modifications
Encourage exercising on a regular basis in patients receiving anticancer therapy and long-term cancer survivors.
B
Advise adopting healthy dietary habits (high intake of fresh fruits/vegetables and whole grains as compared with refined grains, processed and red meats, and high-fat foods) and maintaining a normal weight in patients receiving anticancer therapy and long-term cancer survivors.
B

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  • Cardiac rehabilitation

5.Specific circumstances

Pregnant patients: provide pre-pregnancy counseling and management during pregnancy and around delivery in high-risk female cancer survivors by a multidisciplinary pregnancy heart team.
B
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  • Patients receiving anthracyclines (evaluation)

  • Patients receiving anthracyclines (prevention of cardiotoxicity)

  • Patients receiving anthracyclines (management of asymptomatic cardiac dysfunction)

  • Patients receiving anthracyclines (management of symptomatic cardiac dysfunction)

  • Patients receiving anthracyclines (restarting anthracyclines)

  • Patients receiving anti-HER2 therapies (evaluation)

  • Patients receiving anti-HER2 therapies (prevention of cardiotoxicity)

  • Patients receiving anti-HER2 therapies (management of asymptomatic cardiac dysfunction)

  • Patients receiving anti-HER2 therapies (management of symptomatic cardiac dysfunction)

  • Patients receiving anti-HER2 therapies (restarting anti-HER2 therapies)

  • Patients receiving fluoropyrimidines

  • Patients receiving VEGF inhibitors

  • Patients receiving Bcr-Abl TKIs (evaluation)

  • Patients receiving Bcr-Abl TKIs (management of pulmonary hypertension)

  • Patients receiving Bruton's TKIs

  • Patients receiving multiple myeloma therapies (evaluation)

  • Patients receiving multiple myeloma therapies (VTE prophylaxis)

  • Patients receiving RAF/MEK inhibitors

  • Patients receiving immune checkpoint inhibitors (evaluation)

  • Patients receiving immune checkpoint inhibitors (management)

  • Patients receiving CDK4/6 inhibitors

  • Patients receiving ALK/EGFR inhibitors

  • Patients receiving CAR T-cell/TIL therapies

  • Patients receiving endocrine therapy

  • Patients receiving androgen deprivation therapy

  • Patients receiving radiotherapy (minimization of radiation exposure)

  • Patients receiving radiotherapy (evaluation)

  • Patients receiving radiotherapy (considerations for implanted cardiac devices)

  • Patients receiving radiotherapy (management of pericarditis)

  • Patients receiving radiotherapy (management of coronary artery disease)

  • Patients receiving radiotherapy (management of VHD)

  • Patients receiving radiotherapy (surveillance)

  • Patients receiving HSCT

6.Patient education

General counseling
Provide education and support for making appropriate healthy lifestyle choices in patients with cancer.
B
Educate patients with cancer regarding the recognition of early signs and symptoms of CVD.
B

7.Preventative measures

Primary prevention: as per ESC 2022 guidelines, manage cardiovascular risk factors before, during, and after cancer therapy according to current published guidelines on CVD prevention.
B
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  • Thromboprophylaxis

8.Follow-up and surveillance

Indications for referral: as per ESMO 2020 guidelines, ensure close and early collaboration between cardiologists, oncologists, hematologists, and radiation oncologists to ensure lifelong cardiovascular health and to avoid unnecessary discontinuation of cancer therapy.
B
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  • Indications for referral (ECS)

  • Post-cancer therapy assessment

  • Cardiovascular surveillance (asymptomatic childhood/adolescent cancer survivors)

  • Cardiovascular surveillance (asymptomatic adult cancer survivors)