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limit in the meta-analysis of GLS to predict future significant LVEF reduction.93 Using the 15% threshold will maximize specificity and minimize overdiagnosis of CTRCD and guide cardioprotective therapy.1,4,93 In patients with poor TTE image quality or when TTE is not diagnostic, CMR should be considered, including fast strain-encoded CMR when available.105,204–206 MUGA can be considered as a thirdline modality. Baseline C4 C5 C6 3 M post tx 12 M post tx C1 C2 C3 Anthracycline chemotherapy surveillance protocol Class 1 Class 1Ia Class 1Ib ECG cTnb / NPb TTEa ECG cTnb / NPb TTEa ECG cTn / NP TTEa High and very high risk Moderate risk Low risk Figure 10 Cardiovascular toxicity monitoring in patients receiving anthracycline chemotherapy. cTn, cardiac troponin; C, chemotherapy cycle; ECG, electrocardiogram; M, months; NP, natriuretic peptides; TTE, transthoracic echocardiography; tx, treatment. Biomarker and TTE assessment should ideally be performed before the corresponding anthracycline cycle (C1–C6). aCardiac magnetic resonance should be considered for the assessment of cardiac function when TTE is unavailable or not diagnostic. In moderate-risk patients, TTE should be considered after a cumulative dose of ≥250 mg/m2 of doxorubicin or equivalent. In low-risk patients, TTE may be considered after a cumulative dose of ≥250 mg/m2 of doxorubicin or equivalent. bMeasurement of NP and/or cTn is recommended in all patients with cancer if these biomarkers are going to be used during treatment monitoring. cTn and NP monitoring every two cycles during anthracycline chemotherapy and within 3 months after therapy completion may be considered in low-risk patients (Class IIb, Level C). cTn and NP monitoring every two cycles during anthracycline chemotherapy and within 3 months after therapy completion should be considered in moderate-risk patients and in low-risk patients receiving a cumulative dose of ≥250 mg/m2 of doxorubicin or equivalent (Class IIa, Level C). Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026