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constriction, or tamponade.709 Percutaneous balloon pericardiotomy or pericardial window creation should be used in selected cases for large or growing chronic effusions if haemodynamic compromise develops. Management of these conditions should follow general guideline recommendations.14,444

8.7 Arrhythmias and autonomic disease

Arrhythmias, conduction disease, and autonomic disease are common complications in CS. Conduction disease after thoracic RT is typically associated with other CTR-CVT.710 It may include AV block, bundle branch block, and sick sinus syndrome that should be monitored and treated according to the 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy.443 Patients who require valve replacement after thoracic RT have a high risk of post-operative AV block requiring permanent pacemaker therapy.711 Supraventricular and ventricular arrhythmias are more common in patients after thoracic RT,712 possibly due to RT-induced myocardial fibrosis. A common long-term complication after HSCT is supraventricular arrhythmia including AF and atrial flutter,457 particularly in CS treated with anthracyclines or with new CVRF or CV toxicity. Autonomic dysfunction is an emerging but poorly understood complication observed in CS, and is most frequently observed as a late complication after thoracic RT. Orthostatic hypotension, postural orthostatic tachycardia syndrome, inappropriate sinus tachycardia, and loss of circadian heart rate variability can occur.713,714 Physicians caring for these patients should consider referral for autonomic evaluation. In addition, the perception of angina pain may be impaired,714 making the diagnosis of post-radiation CAD challenging. Evidence-based pharmacological treatment strategies are based on studies of patients with other autonomic dysfunction aetiologies (e.g. DM or infiltrative diseases) and the reported effectiveness is generally poor.714

8.8 Metabolic syndrome, lipid

abnormalities, diabetes mellitus, and hypertension There is a growing understanding about shared CVRF that may be responsible for cancer development or progression and premature CV morbi-mortality.34 Modifiable CVRF continue to be underdiagnosed and undertreated in CS, especially hypertension,715 obesity, DM, metabolic syndrome,716 and dyslipidaemia. Early diagnosis via standardized risk-based screening and management of these conditions according to general ESC Guidelines is recommended19 to improve long-term outcomes in CS.672

Increasing numbers of patients with cancer are already overweight or obese at cancer diagnosis,717 and additional weight gain is a frequent complication of anticancer treatments.718 Obesity is associated with metabolic syndrome, worsening CVRF, and cancer. Increasing evidence indicates that being overweight increases the risk of cancer recurrence and reduces the likelihood of disease-free survival and overall survival among those diagnosed with cancer.719– 724 There is also growing evidence to support intentional weight loss post-treatment in CS, which may result in improved prognosis and survival.719 Dietary patterns characterized by a high intake of vegetables/fruits and whole grains has been shown to be associated with reduced mortality and cancer recurrence when compared with a high intake of refined grains, processed and red meats, and high-fat dairy products.725–727 The identification and treatment of hyperlipidaemia in CS is associated with a profound impact on outcomes.182,183 There is a benefit for CS from an all-cause mortality perspective as well as for decreasing cancer recurrence.728–730 Several studies have demonstrated the therapeutic benefits of exercise during primary anticancer treatment,731,732 and exercise is recommended during and after anticancer treatment.11,733 For CS,734 aerobic exercise results in improved survival.735 Based on current guidelines, patients undergoing anticancer therapy and long-term CS should be encouraged to exercise for at least 150 min per week.736

8.9 Pregnancy in cancer survivors

Improvements in the treatment of cancer have led to an increasing number of female paediatric and adolescent CS who experience pregnancy many years after their oncological treatments. Approximately 60% of them will have been previously exposed to anthracycline chemotherapy or chest RT and they have a 15-fold increase in their lifetime risk of developing HF.737 As young CS enter their reproductive years and contemplate pregnancy, it is important to understand the impact of cancer and its treatment on fertility, pregnancy outcomes, and CV health. There are limited data available regarding CV risk in pregnancy following cancer treatments. The overall incidence of LVD or HF associated with pregnancy in female adult CS varies according to the studied population. In a single institution report including 337 female CS treated with cardiotoxic therapies, 58 (17%) had a subsequent pregnancy.738 Cardiac events, defined as LVEF , 50% on two TTE or new CAD, were identified in 17 patients.738 Patients with cardiac events were likely to be younger at cancer diagnosis, received a higher cumulative dose of anthracycline, and had a longer delay (in years) from cancer treatment to first pregnancy compared with pregnant women with no cardiac event.738 In a recent meta-analysis of six studies, the weighted risk of pregnancy-associated LVD or HF in CS treated with anthracyclines was 1.7% with no reported maternal cardiac deaths.739 Major risk factors for CV events during pregnancy in CS include CTRCD (incidence 28%; 47.4-fold higher odds),739 younger age at cancer diagnosis,738,740 longer time from cancer treatment to first pregnancy, and cumulative anthracycline dose.738

Recommendation Table 45 — Recommendation for adult cancer survivors with pericardial complications

Recommendation Classa Levelb

Patients with acute pericarditis during RT to a volume including the heart are at higher risk of developing chronic constrictive pericarditis, hence echocardiography surveillance every 5 years may be considered. IIb C © ESC 2022

RT, radiotherapy. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026