Cardiovascular Toxicity in Cancer Survivors: Current Guidelines and Future Directions
Carlyn Tan, MD; Crystal Denlinger, MD
KEYWORDS
Arrhythmias and Clinical EP; Cardio-Oncology; Diabetes and Cardiometabolic Disease; Dyslipidemia; Heart Failure and Cardiomyopathies; Noninvasive Imaging; Prevention; Valvular Heart Disease; Vascular Medicine; Atherosclerotic Disease (CAD/PAD); Implantable Devices; SCD/Ventricular Arrhythmias; Atrial Fibrillation/Supraventricular Arrhythmias; Lipid Metabolism; Novel Agents; Statins; Acute Heart Failure; Heart Failure and Cardiac Biomarkers; Echocardiography/Ultrasound; Magnetic Resonance Imaging; Exercise; Hypertension; Smoking
Conclusions - Management of cancer can no longer be limited solely to the active treatment of malignancy. With increasing numbers of cancer survivors living longer, oncologists and other health care providers are faced with challenges in managing long-term and late toxicities of therapy, recognizing that cardiovascular issues are significant causes of morbidity and mortality in this population. The development of cardiotoxicity-focused guidelines represents early strides in improving overall patient-focused care. However, we must invest in additional research and foster multidisciplinary collaboration to tackle gaps in our knowledge and ultimately improve both cancer- and cardiovascular-related health outcomes in this growing population.
Table 1 Comparison of Guidelines on Cardiac Dysfunction
in Cancer Survivors
Recommendations
SIOG
ESMO
ASE/EACVI
NCCN
ASCO
Identifying risk factors pre-treatment
Yes
Yes
Yes
Yes
Yes
Preventative strategies to minimize risk
during therapy
Yes
Yes
No
No
Yes
Monitor for cardiotoxicity using LVEF
Yes
Yes
Yes
Yes
Yes
Use of cardiac biomarkers (troponin I;
BNP)
No
Yes
Yes (troponin)
No
No
Cardiac imaging of choice for cardiac
monitoring
Echocardiography or MUGA scan
Echocardiography
Echocardiography
Echocardiography
Echocardiography
Timing of cardiac monitoring in
asymptomatic patients
Every 2-3 cycles of anthracycline
exposure
Adjuvant anthracycline and/or trastuzumab:
every 3 months during therapy; then 12 and 18 months after initiation of
therapy
Agents associated with type 1 toxicity:
completion of therapy; then 6 months after for doses <240 mg/m2 or
equivalent.
Consider in high-risk patients within 1
year of the last anthracycline dose
Consider in high-risk patients 6-12
months after completion of therapy
Use of beta-blockers or ACE inhibitors
Yes
Yes
No
No
No
Evaluation and management of
cardiovascular risk factors
Yes
Yes
No
Yes
Yes
Referral to cardiologist or
cardio-oncologist
Yes
Yes
Yes
Yes
Yes
Trastuzumab: every 3 months
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