p.81 抽出テキスト
Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e975 CLINICAL STATEMENTS AND GUIDELINES although interventions in nursing facilities can improve care delivery for HF.30,43–45 Lower socioeconomic status is associated with HF incidence and HF mortality.6,46,47 Homelessness,48 substance use, food insecurity, and lack of transportation each represent potential barriers to optimal disease management.49 Case management and social work services are essential to the comprehensive multidisciplinary HF team approach for coordinating complex medical, psychiatric, and social needs across multiple sectors. 2. Health care system factors are a potential source of disparate HF care delivery and outcomes. Women are less likely to receive discharge instructions for HF,50 less likely to be referred to specialty care,21,22 and less likely to receive a heart transplantation,51–54 compared with men. Patients with HF of Black race have been identified as less likely to receive care from a cardiologist during an ICU admission for HF,55 have less access to specialized inpatient HF care,12 and may be vulnerable to clinician biases during evaluation for advanced HF therapies.11,53 Hispanic patients are disproportionately noninsured in the United States,56 may experience language barriers to quality care,7,57 and also have less access to specialized inpatient HF care.12 Native American and Alaskan Native populations experience particular challenges in specialty care access because Indian Health Service facilities are often small and rural.11 Engaging patients in medical care within culturally tailored environments has proven successful.58,59 HF written educational materials for patients and caregivers should be delivered at or below the sixth grade reading level.60 Workplace interventions that improve cultural competency and address implicit biases are increasingly available. Many aspects of GDMT have been inadequately studied by population subgroups, largely as a result of clinical trial underrepresentation.61–65 11.2 Cardio-Oncology Recommendations for Cardio-Oncology Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 B-NR 1. In patients who develop cancer therapy–related cardiomyopathy or HF, a multidisciplinary discussion involving the patient about the riskbenefit ratio of cancer therapy interruption, discontinuation, or continuation is recommended to improve management.1,2 2a B-NR 2. In asymptomatic patients with cancer therapy– related cardiomyopathy (EF <50%), ARB, ACEi, and beta blockers are reasonable to prevent progression to HF and improve cardiac function.2–4 2a B-NR 3. In patients with cardiovascular risk factors or known cardiac disease being considered for potentially cardiotoxic anticancer therapies, pretherapy evaluation of cardiac function is reasonable to establish baseline cardiac function and guide the choice of cancer therapy.2,5–16 2a B-NR 4. In patients with cardiovascular risk factors or known cardiac disease receiving potentially cardiotoxic anticancer therapies, monitoring of cardiac function is reasonable for the early identification of drug-induced cardiomyopathy.2,4,6,8 2b B-R 5. In patients at risk of cancer therapy–related cardiomyopathy, initiation of beta blockers and ACEi/ARB for the primary prevention of drug-induced cardiomyopathy is of uncertain benefit.17–28 2b C-LD 6. In patients being considered for potentially cardiotoxic therapies, serial measurement of cardiac troponin might be reasonable for further risk stratification.29–32 Synopsis Advances in cancer therapy and an aging population have led to a growing number of cancer patients with comorbid CVD receiving treatment for cancer.33,34 Cardiovascular complications of cancer therapy, notably cardiomyopathy and HF, can result in significant morbidity and interruption of treatment, impacting both short- and long-term survival.35,36 Because drug development in cancer therapeutics grows at an exponential pace, establishing a unified framework for the management of cancer therapy–related cardiomyopathy— commonly defined as a decrease in LVEF of at least 10% to <50%—is necessary to mitigate the cardiovascular risks of established novel therapies. Cardiooncology is the practice of precancer therapy cardiovascular risk stratification, prevention, early detection, and treatment of cardiovascular complications.36,37 The evidence from which guideline recommendations in cardio-oncology have emerged has been based on studies of anthracycline and trastuzumab-induced cardiomyopathy. Cancer therapy–related cardiomyopathy is, however, a heterogeneous disease, with a wide range of presentations—from asymptomatic LV dysfunction to cardiogenic shock—and drug-dependent pathophysiologic mechanisms that are often poorly understood. Until sufficient high-quality, drug-specific evidence and cost-effectiveness analyses for screening and monitoring are available, these recommendations are applicable across potentially cardiotoxic therapies (Table 28). Recommendation-Specific Supportive Text 1. HF secondary to cancer therapy–related cardiomyopathy is associated with significantly worse Recommendations for Cardio-Oncology (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026