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ESC and updated. The Task Force received its entire financial support from the ESC without any involvement from the healthcare industry. The ESC CPG supervises and coordinates the preparation of new guidelines. The Committee is also responsible for the approval process of these guidelines. The ESC Guidelines undergo extensive review by the CPG and external experts, including a mix of members from across the whole of the ESC region and from relevant ESC Subspecialty Communities and National Cardiac Societies. After appropriate revisions, the guidelines are signed off by all the experts involved in the Task Force. The finalized document is signed off by the CPG for publication in the European Heart Journal. The guidelines were developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of their writing. The task of developing ESC Guidelines also includes the creation of educational tools and implementation programmes for the recommendations, including condensed pocket guideline versions, summary slides, summary cards for non-specialists and an electronic version for digital applications (smartphones, etc.). These versions are abridged and thus, for more detailed information, the user should always access the fulltext version of the guidelines, which is freely available via the ESC website and the European Heart Journal. The National Cardiac Societies of the ESC are encouraged to endorse, adopt, translate and implement all ESC Guidelines. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgement, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, the ESC Guidelines do not override in any way whatsoever the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient or the patient’s caregiver where appropriate and/or necessary. It is also the health professional’s responsibility to verify the rules and regulations applicable in each country to drugs and devices at the time of prescription and to respect the ethical rules of their profession. Off-label use of medication may be presented in this guideline if sufficient level of evidence shows that it can be considered medically appropriate to a given condition and if patients could benefit from the recommended therapy. However, the final decisions concerning an individual patient must be made by the responsible health professional giving special consideration to: (1) the specific situation of the patient. In this respect, it is specified that, unless otherwise provided for by national regulations, offlabel use of medication should be limited to situations where it is in the patient’s interest to do so, with regard to the quality, safety and efficacy of care, and only after the patient has been informed and has provided consent; (2) country-specific health regulations, indications by governmental

drug regulatory agencies and the ethical rules to which health professionals are subject, where applicable.

2 Introduction

This is the first European Society of Cardiology (ESC) guideline on cardio-oncology. The aim of this guideline is to help all the healthcare professionals providing care to oncology patients before, during, and after their cancer treatments with respect to their cardiovascular (CV) health and wellness. This guideline provides guidance on the definitions, diagnosis, treatment, and prevention of cancer therapy-related CV toxicity (CTR-CVT), and the management of CV disease (CVD) caused directly or indirectly by cancer. This area of medicine has limited trials and evidence on which to base decision-making and, where evidence is limited, this guideline provides the consensus of expert opinion to guide healthcare professionals.

This guideline includes the definitions of CTR-CVT (Section 3),1 and provides a personalized approach to care based upon the baseline CV toxicity risk assessment (Section 4) and new protocols for CV surveillance during cancer treatment (Section 5). The management of acute CTR-CVT is addressed in Section 6, where patients with activecancer are those receiving anticancer treatment. Throughout these sections, decision-making depends upon the risk/benefit balance of oncology treatment efficacy and the severity and impact of CTR-CVT. Guidance is provided for the first 12 months after completion of cardiotoxic treatments (Section 7), when subacute CVD can emerge, and when patients who developed CTR-CVT during cancer treatment are reviewed. Diagnosis and management of the long-term CV complications of previous oncology treatments, beyond 12 months after completing the cardiotoxic treatments, and integration into the overall survivorship strategy for cancer survivors (CS) is presented in Section 8 with new long-term surveillance recommendations for high-risk patients. In Section 9, we address special populations where CVDs are directly caused by the cancer, or where special considerations are required. Section 10 provides information for patients’ involvement in their own care. The final section highlights the role of the ESC and the ESC Council of Cardio-Oncology (ESC-CCO). CTR-CVT risk is a dynamic variable, and the risk changes throughout the pathway of care (Figure 1, Video 1). Absolute risk of CTR-CVT is important to understand and balance against the absolute benefit of the cancer treatment before and during treatment. However, CTR-CVT risk can be influenced by several variables, including implementation of primary prevention treatments, optimization of pre-existing CVD, dose, frequency, and duration of oncology treatment, emergence of CV complications during treatment and their severity, and in CS, the overall cumulative treatment received, the time since treatment, and the interaction with other CVDs.

2.1 Cancer and cardiovascular needs of

patients with cancer Since the 1990s, there has been a steady decline in cancer-related mortality mirrored by a steady increase in CS.2,3 In this context, treatment-related side effects have gained more significance. Management of CTR-CVT has a tremendous impact on the type of anticancer therapies that patients can receive as well as the long-term morbidity and mortality outcomes of patients with cancer. Effective management of patients with both cancer and CVD requires the unique interest and expertise of healthcare providers, which has led to the formation of a new discipline: cardio-oncology.4,5 A recently published ESC-CCO document describes appropriate criteria for the organization and implementation of cardio-oncology services.5

2.2 Role of cardio-oncology services

The overarching goal of the cardio-oncology discipline is to allow patients with cancer to receive the best possible cancer treatments safely, Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026