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5.5.16 Radiotherapy

RT increases the risk of developing subsequent CVD and peripheral artery disease (PAD).173,389–394 There is ongoing debate regarding the safest radiation dose, which cardiac substructures are most sensitive to RT-induced injury, and the most appropriate strategies to minimize RT-related CVD.395,396 The heart is considered a radiosensitive ‘organ at risk’ during RT and radiation exposure to the heart should be kept as low as reasonably achievable because there is no ‘safe’ dose (Figure 23).389,390 RT-induced CV toxicity risk categorization based on MHD389,397 is recommended over categorization based on prescribed dose, which may not accurately reflect cardiac radiation exposure (e.g. 35 Gray [Gy] prescribed dose to approximately 70% of the heart is equivalent to approximately 25 Gy MHD, whereas 35 Gy prescribed dose to approximately 40% of the heart is equivalent to approximately 15 Gy MHD). However, MHD is not a perfect metric, and in some patients, a very small portion of the heart might be irradiated to a very high dose, still conveying a substantial risk despite a low MHD.398 Therefore, depending on dose distribution and exposure of specific cardiac substructures and CVRFs, the cancer treatment team may judge the patient to belong to a higher-risk category.397,399–401 Strategies to prevent and attenuate CV complications of RT have focused on reducing radiation exposure of the heart and CV substructures during cancer treatment and include the following. (1) Modification of cancer management to omit RT. This emphasizes

the importance of integrating a personalized cardio-oncology evaluation.402–404 (2) Modification of the dose and volume of RT treatments where possible. RT protocols should target the minimum volume required to the minimum dose needed to obtain the desired clinical benefit. (3) Modification of delivery techniques to reduce cardiac radiation

exposure should lead to a considerable reduction in risk. Modern heart-sparing RT strategies include: the optimal use of modern intensity-modulated photon RT technologies; the use of deep inspiration breath-hold or respiratory-gated techniques in BC,405 lymphoma,406 and lung cancer407; or the use of imageguided RT to ensure accuracy of delivery and proton beam therapy.408

The incidence of cardiac events following RT may vary according to patient risk factors and synergistic effects of radiation with other cardiotoxic cancer treatments.12,173 There are no known RT-specific secondary preventative measures (e.g. drug treatments) to reduce the risk of CV events following RT. However, given the known importance of conventional CVRF on the incidence of RT-related events, optimization of modifiable CVRF is recommended in all patients before and after RT.

5.5.17 Haematopoietic stem cell transplantation

HSCT constitutes a potentially curative therapeutic option for many haematological malignancies. Improvements in HSCT techniques and supportive strategies have markedly decreased treatment-related mortality (Supplementary data, Table S14).409,410 There is a growing recognition of HSCT-related CV toxicities and HSCT survivors constitute a population at high future CV risk. Several factors contribute to define the risk of HSCT-related CV toxicities, including the HSCT

Recommendation Table 20 — Recommendations for baseline risk assessment and monitoring in patients receiving chimeric antigen receptor T cell and tumourinfiltrating lymphocytes therapies

Recommendations Classa Levelb

Baseline ECG, NP, and cTn are recommended in all patients with cancer before starting CAR-T and TIL therapies.388 I C A baseline echocardiography is recommended in patients with pre-existing CVD before starting CAR-T and TIL therapies.388 I C A baseline echocardiography should be considered before starting CAR-T and TIL therapies.388 IIa C Measurement of NP, cTn, and echocardiography are recommended in patients who develop CRS of ASTCT ≥2.c,378,388 I C © ESC 2022

ASTCT, American Society for Transplantation and Cellular Therapy; CAR-T, chimeric antigen receptor T cell; CRS, cytokine release syndrome; cTn, cardiac troponin; CVD, cardiovascular disease; ECG, electrocardiogram; NP, natriuretic peptides; TIL, tumour-infiltrating lymphocytes. aClass of recommendation. bLevel of evidence. cDetermine CRS grade according to ASTCT grading: Grade 1: fever; Grade 2: fever AND hypotension not requiring vasopressors AND/OR hypoxia requiring low-flow nasal oxygen; Grade 3: fever AND hypotension requiring one vasopressor + vasopressin AND/OR hypoxia requiring high-flow nasal cannula or facemask or non-rebreather mask or Venturi mask; Grade 4: fever AND hypotension requiring multiple vasopressors, not including vasopressin AND/OR hypoxia requiring positive airway pressure. Recommendation Table 21 — Recommendations for baseline risk assessment of patients before radiotherapy to a volume including the heart

Recommendations Classa Levelb Baseline CV risk assessmentc and estimation of 10-year fatal and non-fatal CVD risk with SCORE2 or SCORE2-OPd is recommended.19,389 I B Baseline echocardiography should be considered in patients with previous CVD before RT to a volume including the heart. IIa C © ESC 2022

BP, blood pressure; CV, cardiovascular; CVD, cardiovascular disease; ECG, electrocardiogram; HbA1c, glycated haemoglobin; RT, radiotherapy; SCORE2, Systematic Coronary Risk Estimation 2; SCORE2-OP, Systematic Coronary Risk Estimation 2—Older Persons. aClass of recommendation. bLevel of evidence. cBP, lipids, fasting glucose, HbA1c, ECG and patient education on healthy lifestyle and lifestyle risk factor control. dSCORE2 (,70 years) or SCORE2-OP (≥70 years) CV risk stratification: ,50 years: low risk ,2.5%, moderate risk 2.5% to ,7.5%, high risk ≥7.5%; 50–69 years: low risk ,5%; moderate risk 5% to ,10%; high risk ≥10%; ≥70 years: low risk ,7.5%, moderate risk 7.5% to ,15%, high risk ≥15%.19 Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026