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across the entire continuum of cancer care. In patients who develop CTR-CVT, a MDT discussion is required to balance the risk/benefit of cancer treatment discontinuation. • There is a new international definition of CTR-CVT (Table 3). • CV toxicity risk is a dynamic variable. This guideline is structured to provide a personalized approach to care based upon the baseline CV toxicity risk. A baseline CV risk assessment is recommended for all patients with cancer scheduled to receive a potentially cardiotoxic anticancer therapy. This enables the oncology team to consider CV risk while making cancer treatment choices, educating patients regarding their CV risk, and personalizing CV surveillance and follow-up strategy. • Primary prevention of CV toxicity from cancer therapy aims to avoid or minimize the development of CTR-CVT in patients without CVD. • Secondary prevention refers to interventions in patients with preexisting CVD, including prior or new CTR-CVT. A MDT is recommended when patients with cancer have complex CVD that may impact on their cancer treatment. • Defining and delivering an appropriate prevention and surveillance plan for potential CV complications is recommended. Optimal management of CVRF and pre-existing CVD is mandatory to facilitate cancer therapy and to improve patients’ prognosis. • Detailed monitoring pathways during cancer therapy—including 3D echocardiography, GLS, and cardiac biomarkers—are provided to detect CV toxicity based upon specific cancer therapies and baseline CV toxicity risk. • Treatment recommendations for CTRCD during and after cancer therapy depend upon CTRCD severity and symptoms. New guidance on continuing trastuzumab in BC patients who develop asymptomatic moderate CTRCD (LVEF 40–49%) while starting cardioprotective medication is provided. • Use of a structured algorithm to guide decisions regarding anticoagulation management in patients with cancer presenting with AF or VTE encompassing the TBIP assessment is encouraged. • After cancer treatment is completed, the focus of the cardio-oncology team shifts to coordination of long-term followup. This starts with an ‘end-of-treatment’ assessment in the first year after treatment, reviewing patients with cancer who have received cardiotoxic anticancer therapies to reassess their CV toxicity risk and guide long-term surveillance planning. • A new algorithm (Figure 37) is provided to guide weaning off of CV medication in CS. • Patients with cancer, CS, and the patient’s family/carers should receive guidance to promote healthy lifestyle and recognize and report signs and symptoms of CVD, to receive prompt and effective treatment, without interfering with their cancer treatment. • Patients must receive psychological support when needed and clear and accurate information about their condition to play an active role in managing their treatment and increase adherence to cancer and CV treatments.

13 Future needs

There are a low number of dedicated cardio-oncology services and most patients are reviewed in general cardiology clinics in Europe and worldwide. Strategic investments in cardio-oncology care networks and cardio-oncology services provision are needed to meet the projected increased clinical demand in the near future,834 and to facilitate research, training, and educational activities. A dedicated training core curriculum for a minimum of 1-year medical training is urgently needed. It may include: (1) knowledge of the broad scope of cardiology, oncology, and haematology; (2) CV competencies for CTR-CVT prevention, surveillance, and management of patients with cancer in dedicated outpatients’ cardio-oncology clinics; (3) inpatient consultative services; and (4) dedicated time to achieve competences in CV imaging, HF, and vascular cardiology.

Collaboration between healthcare providers, clinical and basic investigators, healthcare authorities, regulatory bodies, advocacy groups, and patients’ associations is needed to address future needs (see Section 11). As this Guideline was developed, it became clear that there is a significant lack of RCT to guide decision-making, with many recommendations supported by level of evidence C. This is complicated by the fast-moving pace of new oncology treatment developments against a background of dynamic CV toxicity likelihood. Therefore, large numbers of patients and longer follow-up are required to provide sufficient statistical power and definitive answers. In the future, the following strategies and areas of research are priorities:

• New trial designs focusing upon the ‘at-risk’ cancer patient populations. • Validating current HFA-ICOS risk assessment tools and surveillance algorithms. • Assessment of new technologies for the detection of early CTRCD, broadening the biomarker panel and recognizing the specific patterns in early myocardial damage. • Refining CV risk scores (e.g. EuroSCORE II, SCORE2, SCORE2-OP, CHA2DS2-VASc, HAS-BLED, SYNTAX) for application in cancer populations. • Optimal treatment of steroid-resistant ICI CV toxicity and longterm CV effects of ICI therapy. • Selection criteria for modern percutaneous structural (TAVI, Mitraclip, LAA occluder devices) and electrophysiological (ablation) CV therapies in patients with active cancer. • Patient-specific predictive algorithms for QTc prolongation with cancer drugs. • Assessment of genetic profiles in more specific CTRCD risk prediction. • Identification of the cancer patient populations with mild or moderate CTRCD during treatment who can safely wean off long-term CV medication. • Optimal modalities for screening long-term survivor populations for the complications of anthracycline chemotherapy and mediastinal radiation. • Creation of large cardio-oncology registries to collect ‘big data’ on large patient populations. • Application of artificial intelligence and other new data analytics to identify new patients with cancer at risk and new parameters that can predict risk of CTR-CVT, response to specific cardioprotective interventions, and long-term risk and safety to wean off CV therapies initiated during cancer treatment. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026