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type (higher risk after allogeneic HSCT), multiple uncontrolled CVRF, pre-existing CV conditions (AF or atrial flutter, sick sinus syndrome, ventricular arrhythmias, CAD, MI, moderate-to-severe VHD, and HF or LVEF ,50%),411 direct cardiotoxic effects of anticancer therapies received prior to and during HSCT (anthracyclinecombined induction regimen, mediastinal RT, total body irradiation, or cyclophosphamide-based conditioning regimen) (Supplementary data, Table S14) and the development of graft vs. host disease (GVHD), thrombotic microangiopathy, or sepsis.410,412 In the early phase following HSCT (,100 days), the most frequent CV event is AF, although some patients may experience HF, hypertension, hypotension, pericardial effusion, or VTE.413,414 Late toxicities include DM, dyslipidaemia, metabolic syndrome, hypertension, HF, CAD, conductions disorders, and pericardial effusion.410 Acute >25 Gy MHDb >15 Gy MHDb + cumulative doxorubicinc ≥100 mg/m2 Very high risk >15 to 25 Gy MHDb 5 to 15 Gy MHDd+ cumulative doxorubicinc ≥100 mg/m2 5 to 15 Gy MHDd <5 Gy MHDe + cumulative doxorubicinc ≥100 mg/m2 <5 Gy MHDe High risk Moderate risk Low risk RT doses CVa toxicity risk Low risk Figure 23 Radiotherapy mean heart dose and associated cardiovascular toxicity risk. CV, cardiovascular; Gy, Gray; MHD, mean heart dose; RT, radiotherapy. aRT risk categorization based on MHD is recommended over categorization based on prescribed dose, which may not accurately reflect cardiac radiation exposure. Depending on dose distribution and exposure of specific cardiac substructures (as well as clinical risk factors) the treatment team may judge the patient to belong to a higher risk category. In addition, a patient may be judged to belong to a lower risk category if only a small part of the heart was exposed to a relatively low prescribed dose.397,399–401 bOr prescribed RT ≥35 Gy to a volume exposing the heart if MHD is not available. Note that in this case, the limited information about cardiac exposure does not allow one to distinguish between high- and very high-risk categories. cOr equivalent. dOr prescribed RT 15–34 Gy to a volume exposing the heart if MHD is not available. eOr prescribed RT , 15 Gy to a volume exposing the heart if MHD is not available. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026