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................................................... of NPs or troponin at baseline are additional criteria of medium risk for most of the cancer treatments.846

During cancer treatment with potential cardiotoxic therapies, LV systolic function can be monitored through echocardiography. Chemotherapy should be reconsidered and treatment with an ACE-I and a beta-blocker (preferably carvedilol) should be started in patients who develop LV systolic dysfunction, defined as 10% or more absolute reduction in LVEF to a value below 50%.844,861864 Global longitudinal strain can detect cardiac dysfunction at an earlier stage.865,866 A >_12% relative reduction in global longitudinal strain was compared with an LVEF decline in a prospective randomized trial in high-risk patients undergoing potentially cardiotoxic chemotherapy. Compared to treatment based on LVEF, treatment based on changes in global longitudinal strain led to the same decrease in LVEF (primary endpoint) but with fewer patients who developed cardiac dysfunction at the end of the study, thus suggesting usefulness of global longitudinal strain for the early detection of cardiotoxicity.867 Promising results for the early detection of cardiac dysfunction have also been obtained through monitoring of biomarkers, such as NPs and troponin.868,869 Patients on immunotherapy with immune checkpoint inhibitors are at increased risk of myocarditis and should be monitored for related symptoms and signs and by weekly assessment of cardiac troponin during at least the first 6 weeks of therapy and managed accordingly.870

Timing of the imaging procedures and biomarkers assessment depend on the anticancer treatment and patient’s risk profile (Figure 18).865 In general, all patients scheduled for potential cardiotoxic therapies must undergo a baseline evaluation that would define the level of risk for cardiotoxicity (low, medium, or high) and the intensity of monitoring and follow-up during and after cancer treatment.865 Cancer survivors exposed to potentially cardiotoxic therapies should be periodically monitored in the long term as HF may develop several years after cancer therapy.865,871

Table 23 Cancer drugs causing heart failure

Cancer therapy Indication Anthracycline chemotherapy (doxorubicin, epirubicin, daunorubicin, idarubicin) Breast cancer, lymphoma, acute leukaemia, sarcoma HER2-targeted therapies (trastuzumab, pertuzumab, trastuzumab emtansine T-DM1, lapatinib, neratinib, tucatinib) HER2þ breast cancer

HER2þ gastric cancer

VEGF inhibitors TKIs (sunitinib, pazopanib, sorafenib, axitinib, tivozanib, cabozantinib, regorafenib, lenvatinib, vandetinib) and antibodies (bevacizumab, ramucirumab) VEGF TKIs: renal cancer, hepatocellular cancer, thyroid cancer, colon cancer, sarcoma, GIST

Antibodies: breast cancer, ovarian cancer, gastric cancer, gastro-oesophageal cancer, colon cancer

Multi-targeted kinase inhibitors: second and third generation BCR-ABL TKIs (ponatinib, nilotinib, dasatinib, bosutinib) Chronic myeloid leukaemia Proteasome inhibitors (carfilzomib, bortezomib, ixazomib) Immunomodulatory drugs (lenalidomide, pomalidomide) Multiple myeloma Combination RAF and MEK inhibitors (dabrafenibþtrametinib, vemurafenibþcobimetinib, encorafenibþ binimetinib) RAF mutant melanoma Androgen deprivation therapies GnRH agonists (goserelin, leuprorelin) Antiandrogrens (abiraterone) Prostate cancer, breast cancer Immune checkpoint inhibitors: anti-programmed cell death 1 inhibitors (nivolumab, pembrolizumab) anti-cytotoxic T-lymphocyte-associated protein 4 inhibitor (ipilimumab) anti-programmed death-ligand 1 inhibitors (avelumab, atezolizumab, durvalumab) Melanoma (metastatic and adjuvant) Metastatic renal cancer, non-small cell lung cancer, small cell lung cancer,

refractory Hodgkin’s lymphoma, metastatic triple negative breast cancer, metastatic urothelial cancer, liver cancer, MMR-deficient cancer

GIST = gastrointestinal stromal tumour; GnRH = gonadotropin-releasing hormone; HER2 = human epidermal growth factor receptor 2; MEK = mitogen-activated protein kinase; MMR = mismatch repair; TKI = tyrosine kinase inhibitor; VEGF = vascular endothelial growth factor. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026