Recommendations for cardiotoxicity risk identification and management of patients with hematological malignancies
| . | Recommendation . |
|---|---|
| Definition of at risk or high risk (risk increases with number of risk factors present) | Planned, ongoing, or completed cancer therapy • High dose anthracycline therapy (≥250 mg/m2 doxorubicin equivalent) • Chest radiation therapy (treatment doses ≥30 Gy) • Combination of anthracycline and chest radiation therapy Cardiovascular risk factors, especially • Age ≥65 • Hypertension • Diabetes • Smoking Cardiovascular diseases, especially • Reduced or borderline cardiac function (ejection fraction ≤55%) • Heart failure • Coronary artery disease • Prior cardiovascular events such as myocardial infarction and stroke |
| Prevention | • Healthy lifestyle, including physical exercise, optimized weight, blood pressure, lipid, and glucose control • Control of cardiovascular risk factors (preferred use of beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers for management of hypertension, statins for hyperlipidemia) • Optimal management of cardiovascular diseases (preferred use of beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, statins as indicated for cardiomyopathy, heart failure, and coronary artery disease) • Consider non-anthracycline-based regimens, use of dexrazoxane, or liposomal doxorubicin if doxorubicin lifetime dose >300 mg/m2 or underlying cardiomyopathy/ heart failure (history) |
| Surveillance | • Baseline assessment of cardiac function (preferred echocardiogram with strain imaging), ECG, and cardiac biomarkers (cardiac troponin [cTn] and natriuretic peptides [NPs]), especially in high-risk patients, ideally in all undergoing potentially cardiotoxic therapy (as a reference) • cTn and/or NPs every 3-6 wk or before each cycle depending on therapy and risk scenario • Reassessment of cardiac function (ideally echocardiogram with strain) after a cumulative dose of 250 mg/m2 doxorubicin equivalent and every 100 mg/m2 thereafter and end of therapy • Echocardiogram and cardiac biomarkers at 6-12 mo, 2 y and possibly periodically thereafter following completion of anthracycline therapy |
| Treatment | New abnormal cardiac biomarkers or significant change from baseline (significant delta for cTn, 100% increase for NPs): • Cardiology (preferably cardio-oncology) consultation • Consider echocardiogram (with strain), other tests as needed • Consider beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, if not already prescribed • Anticancer therapy may be continued, if only mild elevation and without significant change in cardiac function or other acute cardiac pathology, recognizing that a decline in cardiac function may not become evident until after cancer therapy New abnormal global longitudinal strain or significant change from baseline (12% to 15% relative change or 3% to 5% absolute change): • Cardiology, preferably cardio-oncology consultation • Consider beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, if not already prescribed • Anticancer therapy may be continued if no significant change in cardiac function or other acute cardiac pathology, recognizing that a decline in cardiac function may not become evident until after cancer therapy Asymptomatic decrease in LVEF by >10% to 40% to 49%: • Cardiology, preferably cardio-oncology consultation • Initiation of beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, if not already prescribed • Intensification of cardiac surveillance with echocardiogram before each or every other cycle, cTn and NPs after each anthracycline dose, recognizing that a decline in cardiac function may not become evident until after cancer therapy • If further anthracycline-based therapy is planned, risk-benefit discussion and consideration for non-anthracycline-based regimens, use of dexrazoxane, or liposomal doxorubicin Symptomatic heart failure or LVEF <40%: • Cardiology, preferably cardio-oncology consultation • Cardiac function re-assessment and other tests as needed • Initiation and optimization of guideline-directed therapy • Withdrawal of therapy only after a period of stabilization and no active risk factors, and no further anticancer therapy • Hold anti-cancer therapy until careful risk-benefit discussion, seek alternatives to cardiotoxic medications, close surveillance (every cycle) if proceeding, recognizing that a decline in cardiac function may not become evident until after cancer therapy • At least annual review indefinitely Chest radiation therapy exposure: • Evaluation for heart failure, coronary artery, valvular heart, and chronic pericardial disease, starting at 5 y post-treatment and then at least every 3-5 y thereafter |
| . | Recommendation . |
|---|---|
| Definition of at risk or high risk (risk increases with number of risk factors present) | Planned, ongoing, or completed cancer therapy • High dose anthracycline therapy (≥250 mg/m2 doxorubicin equivalent) • Chest radiation therapy (treatment doses ≥30 Gy) • Combination of anthracycline and chest radiation therapy Cardiovascular risk factors, especially • Age ≥65 • Hypertension • Diabetes • Smoking Cardiovascular diseases, especially • Reduced or borderline cardiac function (ejection fraction ≤55%) • Heart failure • Coronary artery disease • Prior cardiovascular events such as myocardial infarction and stroke |
| Prevention | • Healthy lifestyle, including physical exercise, optimized weight, blood pressure, lipid, and glucose control • Control of cardiovascular risk factors (preferred use of beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers for management of hypertension, statins for hyperlipidemia) • Optimal management of cardiovascular diseases (preferred use of beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, statins as indicated for cardiomyopathy, heart failure, and coronary artery disease) • Consider non-anthracycline-based regimens, use of dexrazoxane, or liposomal doxorubicin if doxorubicin lifetime dose >300 mg/m2 or underlying cardiomyopathy/ heart failure (history) |
| Surveillance | • Baseline assessment of cardiac function (preferred echocardiogram with strain imaging), ECG, and cardiac biomarkers (cardiac troponin [cTn] and natriuretic peptides [NPs]), especially in high-risk patients, ideally in all undergoing potentially cardiotoxic therapy (as a reference) • cTn and/or NPs every 3-6 wk or before each cycle depending on therapy and risk scenario • Reassessment of cardiac function (ideally echocardiogram with strain) after a cumulative dose of 250 mg/m2 doxorubicin equivalent and every 100 mg/m2 thereafter and end of therapy • Echocardiogram and cardiac biomarkers at 6-12 mo, 2 y and possibly periodically thereafter following completion of anthracycline therapy |
| Treatment | New abnormal cardiac biomarkers or significant change from baseline (significant delta for cTn, 100% increase for NPs): • Cardiology (preferably cardio-oncology) consultation • Consider echocardiogram (with strain), other tests as needed • Consider beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, if not already prescribed • Anticancer therapy may be continued, if only mild elevation and without significant change in cardiac function or other acute cardiac pathology, recognizing that a decline in cardiac function may not become evident until after cancer therapy New abnormal global longitudinal strain or significant change from baseline (12% to 15% relative change or 3% to 5% absolute change): • Cardiology, preferably cardio-oncology consultation • Consider beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, if not already prescribed • Anticancer therapy may be continued if no significant change in cardiac function or other acute cardiac pathology, recognizing that a decline in cardiac function may not become evident until after cancer therapy Asymptomatic decrease in LVEF by >10% to 40% to 49%: • Cardiology, preferably cardio-oncology consultation • Initiation of beta-blockers such as carvedilol and nebivolol, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, if not already prescribed • Intensification of cardiac surveillance with echocardiogram before each or every other cycle, cTn and NPs after each anthracycline dose, recognizing that a decline in cardiac function may not become evident until after cancer therapy • If further anthracycline-based therapy is planned, risk-benefit discussion and consideration for non-anthracycline-based regimens, use of dexrazoxane, or liposomal doxorubicin Symptomatic heart failure or LVEF <40%: • Cardiology, preferably cardio-oncology consultation • Cardiac function re-assessment and other tests as needed • Initiation and optimization of guideline-directed therapy • Withdrawal of therapy only after a period of stabilization and no active risk factors, and no further anticancer therapy • Hold anti-cancer therapy until careful risk-benefit discussion, seek alternatives to cardiotoxic medications, close surveillance (every cycle) if proceeding, recognizing that a decline in cardiac function may not become evident until after cancer therapy • At least annual review indefinitely Chest radiation therapy exposure: • Evaluation for heart failure, coronary artery, valvular heart, and chronic pericardial disease, starting at 5 y post-treatment and then at least every 3-5 y thereafter |
Integrative approach based on recommendations by American and European cancer societies (see supplemental Table 1).