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anthracycline chemotherapy, the total planned cumulative anthracycline dose is also relevant, and ≥250 mg/m2 of doxorubicin or equivalent should be considered higher risk (Table 5).32 CV risk stratification results should be discussed with the patient and documented in clinical notes. This process will also enable future validation of these tools. Cardiology referral (cardio-oncology programme or cardiologist with expertise in managing CVD in patients with cancer) is recommended for patients identified to be at high or very high risk for CTR-CVT at baseline (Table 4) to institute strategies to mitigate risk.33 Patients at moderate risk can benefit from closer cardiac monitoring, strict management of traditional CVRF, and selected moderate-risk patients may also benefit from a cardio-oncology referral (Figure 6). Low-risk patients can be followed within the oncology programme with appropriate referral to cardio-oncology if a CTR-CVT emerges or new or uncontrolled CVRF appear.

AND AND

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CV risk stratification be f o

f f r e anticancer ther a p y

p

p

(Class I)

Com m unicate the CV t o xicity risk assessment r esults (Class I) Educate patients r ega r ding risks and p r otecti v e healt h y li f estyle (Class I)

f f

Management of CVRF and CVD acco r ding to ESC Guidelines (Class I)

H F A-ICOS baseline risk assessment

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(Class IIa)

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Routine oncolo g y f oll

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Ca r diolo g y a r e f e

f f r ral if

CV t o xicity d e v elops

(Class I) Closer oncolo g y f oll

f f o w-up

Ca r diolo g y a r e f e

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CV t o xicity d e v elops

(Class I)

Ca r diolo g y r e f e

f f r ral a (Class IIb) Ca r diolo g y a r e f e

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Ca r diop r otecti v e strategies

(Class IIa)

Discussion of the risk/benefit

balance of ca r diot o xic anticancer t r eatment

(Class I)

H F A-ICOS

F F r esults

High/ v e r y high risk

Patient with cancer

Figure 6 General cardio-oncology approach after Heart Failure Association–International Cardio-Oncology Society cardiovascular toxicity risk assessment. CV, cardiovascular; CVD, CV disease; CVRF, CV risk factors; ESC, European Society of Cardiology; HFA, Heart Failure Association; ICOS, International Cardio-Oncology Society. aCardio-oncology referral is recommended when available; alternatively, patients should be referred to a specialized cardiologist with expertise in managing CVD in patients with cancer. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026