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New and first ESC cardio-oncology guideline

Presented by
Dr Teresa López-Fernández, La Paz University Hospital, Spain & Dr Alexander Lyon, Royal Brompton Hospital, London, UK
ESC 2022
The first ever ESC Guideline on cardio-oncology has been developed by a multidisciplinary team of specialists and medical societies, in order to provide guidance to healthcare professionals for achieving the most favourable cardiovascular (CV) conditions for cancer patients before, during, and after cancer therapy.

“The aim of cardio-oncology is to minimise the risk of unnecessary cancer treatment interruptions and to optimise cardiovascular disease (CVD) at baseline. We need to consider cardioprotective treatment in high-risk patients, organise cancer treatment surveillance, and also, at the end of the treatment, reassess the CV toxicity risk in order to identify cancer survivors who require long-term follow-up,” said guideline co-chairperson Dr Teresa López-Fernández (La Paz University Hospital, Spain) [1]. CV toxicity is regarded as a dynamic variable and the 272 guideline recommendations allow for personalised assessment, surveillance, and management of cancer patients, thus enabling the most effective cancer treatment acceptable for each patient in each phase of cancer therapy [1–3].

  • Throughout the course of treatment, management of CV risk factors and CVD according to ESC guidelines is a class I recommendation, together with informing, advising, and supporting patients to promote a healthy lifestyle (class I)

The recent definition of cancer therapy-related cardiac dysfunction was included to cover the extensive spectrum of possible heart disease in cancer patients. It distinguishes and defines symptomatic cancer therapy-related cardiac dysfunction of (very) severe, moderate, and mild degree and asymptomatic cancer therapy-related cardiac dysfunction of severe, moderate, and mild degree [3].

For the baseline CV toxicity risk assessment, the use of the HFA-ICOS tools is endorsed. “We built a score to analyse the risk of future CV toxicity according to the type of treatment the patient receives,” Dr López-Fernández explained. This includes a wide range from age and sex, overt prior CVD, medical and lifestyle risk factors, and the results of complimentary diagnostic assessment from the medical team.

  • In all cancer patients scheduled for cardiotoxic therapies, baseline clinical CV assessment, physical exam, and ECG are recommended (class I)
  • Referral to a cardiologist in case of abnormal ECG findings (class I)
  • Baseline measurement of natriuretic peptides and/or cardiac troponin is recommended in all patients with cancer at risk of cancer therapy-related cardiac dysfunction if these biomarkers are going to be measured during treatment to detect cancer therapy-related cardiac dysfunction (class I)
  • For imaging echocardiography, first-line 3D echocardiography is preferred for LVEF measuring and echocardiography with global longitudinal strain is recommended if available (class I)

“After this baseline CV toxicity risk stratification, every patient fits in one of these 3 categories: low risk, moderate risk, high or very high risk, and this enables the oncology team to make appropriate treatment choices, to educate patients on their own CV risk, and also to organise a preventive and surveillant personalised plan during treatment,” Dr López-Fernández stated.
Prevention of cancer therapy-related CV toxicity

Besides the above-mentioned guideline conform management of CVD and CV risk factors that is recommend for primary and secondary prevention, primary prevention includes:

  • Minimising the use of cardiotoxic drugs (class I)
  • ACE inhibitors, ARB, and beta-blockers in (very) high risk of CV toxicity in anthracycline, anti-HER2 drugs and targeted therapy with HF risk (class IIa)
  • Dexrazoxane/liposomal anthracyclines in (very) high risk patients considered for anthracyclines (class IIa)
  • Statins in patients with (very) high CV toxicity risk

Also, specific surveillance protocols and monitoring pathways are available for nearly all cancer drugs, as well as radiotherapy that may also induce CV toxicity.
Management of CVD and cancer therapy-related CV toxicity

At the start, the algorithms for management of cancer therapy-related cardiac dysfunction under the different drugs, distinguish between symptomatic and asymptomatic cancer therapy-related cardiac dysfunction in their different grades or severity. A suitable oncologic strategy is adjudicated that may range from uninterrupted treatment with monitoring to discontinuation of therapy and also includes multidisciplinary team discussions. The algorithm is of course also complemented with a suitable CV strategy for the treatment of cancer therapy-related cardiac dysfunction according to patient’s features.

“In patients with asymptomatic moderate cancer therapy-related cardiac dysfunction, where the LVEF has fallen to 40-49%, a new recommendation is that anti-HER2 targeted therapy can continue, but with close CV monitoring and that is a class IIa indication,” guideline co-chairperson Dr Alexander Lyon (Royal Brompton Hospital, London, UK) described management recommendations in an example of trastuzumab for breast cancer. “Patients with moderate or severe cancer therapy-related cardiac dysfunction due to HER2-targeted therapy should be treated with HF therapy as a class I indication and if mild asymptomatic cancer therapy-related cardiac dysfunction is detected due to a decrease in their global longitudinal strain or a rise in cardiac biomarkers, then ACE inhibitors and/or beta-blockers should be considered,” he continued.

A common problem in cancer patients is QT prolongation that can be induced by many cancer drugs. Baseline assessment is important together with the determination of a threshold for levels acceptable of commencing treatment that is provided in an algorithm together with advice on when to stop/ resume treatment or multi-disciplinarily discuss alternative cancer regimens.

“Guidance is provided for example for arterial hypertension with new cut-offs for treatment decisions depending on the nature of the cancer, and we provide guidance for anticoagulation decisions in patients with either AF and cancer or VTE and cancer and who might be eligible for vitamin K antagonists, for direct oral anticoagulation, and low molecular weight heparin,” Dr Lyon highlighted.

After cancer treatment has ended, the cardiovascular risk has to be reassessed and among the class I recommendations are:

  • Cardiology referral in patients with cancer with new cardiac symptoms or new asymptomatic abnormalities in echocardiography and/or cardiac serum biomarkers at the end of therapy assessment
  • Echocardiography and cardiac serum biomarkers at 3 and 12 months after completion of cancer therapy in asymptomatic high-risk patients
  • Long-term continuation of cardiac medication in patients who develop severe cancer therapy-related cardiac dysfunction during cancer therapy
  • CV follow-up and treatment optimisation in patients who developed tyrosine kinase inhibitor (TKI)-mediated hypertension or vascular toxicities during cancer therapy

The next step is the planning of the adequate long-term CV surveillance that depends on the individual risk of the cancer survivor. There are tailored recommendations depending on, whether e.g. the patient has survived cancer as a child, adolescent, or adult, and on whether the survivor is asymptomatic or suffers from long-term complications of the treatment.

There is also a special section on radiotherapy in the presence of cardiac implantable electronic devices with different management algorithms depending on whether the radiation field includes the site of the device or not. “Finally, in the clinical section, we focus on some special populations,” Dr Lyon mentioned referring to conditions like cardiac tumours, carcinoid heart disease, amyloid light-chain cardiac amyloidosis or pregnant women requiring cancer treatment.

  1. Presentations in Session: “2022 ESC Guidelines Overview, ESC Congress 2022, Barcelona, Spain, 26–29 August.
  2. Presentations in Session:” 2022 ESC Guidelines on cardio-oncology”, ESC Congress 2022, Barcelona, Spain, 26–29 August.
  3. Lyon AR, et al. Eur Heart J. 2022 Aug 26;ehac244. doi: 10.1093/eurheartj/ehac244. Online ahead of print.


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