Before initiating this treatment, risk stratification must be performed with evaluation of :

• Cardiovascular risk factors.
• History: cardiac and oncological.
• ECG: arrhythmia? - QTc interval?
• Clinical examination, blood pressure, heart rate.

• In case of pre-existing cardiac disease or increased risk hereof :
  • Blood sample for biomarkers: troponin, NT-proBNP.
  • Transthoracic echocardiography: LVEF, global longitudinal strain (GLS).
• Optimal treatment of cardiovascular risk factors (arterial hypertension, etc.) and underlying heart disease.
• If there is an increased cardiovascular risk, it is best to consider initiating an ACE-inhibitor (or ARB) and/or a beta-blocker to prevent deterioration of LV function when oncological therapy is initiated that can cause progressive LV dysfunction and heart failure.

In general, the following factors increase the risk of cardiotoxicity:

• Known heart failure.
• Underlying structural heart disease (known cardiomyopathy, LV dilation, LVEF < 55%, etc.).
• History of coronary artery disease, PCI or CABG.
• Increased troponin.
• Age > 65 years.
• Arterial hypertension, diabetes mellitus, obesity, smoking.
• Chronic renal insufficiency.
• Previous chemotherapy (anthracyclines, anti-HER2 therapy, other chemotherapy, etc.) or radiotherapy where the heart is in the radiation field.

How?

• Clinical.
• ECG.
• Biochemical:
  • Troponin: to be determined serially during each day admission.
  • Possibly NT-proBNP.
• Imaging: transthoracic echocardiography (TTE) - if in doubt, MRI of the heart.

Scheme?

The proposed scheme differs in the guidelines according to :

• Specific oncological therapy. For example:
  • During anthracyclines: TTE at start and then every 2 cycles (if moderate and especially if high risk).
  • During anti-HER2 treatments: TTE at start and every 3 months thereafter.
• The underlying cardiovascular risk profile or cardiac abnormalities.

New cardiac symptoms always require cardiological reevaluation.

Follow-up is also necessary after the end of potentially cardiotoxic oncological therapy, as heart failure can also develop later on.

• Troponin and echocardiography monitoring is suggested 12 months after the end of oncological therapy. Depending on which treatment the patient received, the recommended follow-up schedule may be different.
• For example: after therapy with anthracyclines and after anti-HER2 treatments, a follow-up transthoracic echocardiography is recommended after 12 months. If there is a high risk of cardiotoxicity, this is also recommended after 3 months.
• In asymptomatic patients at increased risk, further follow-up with echocardiography every 2 to 5 years is suggested.