CARDIAC PROBLEMS

Consensus- and evidence-based recommendation for surveillance of cardiac problems (including IGHG Cardiomyopathy a) b
This page is part of the PanCare Follow-up recommendations for surveillance of late effects. Click here, for more information on these recommendations.

Who is at risk for cardiac problems?

CAYA cancer survivors treated with

  • radiotherapy to a volume exposing the heart
  • anthracyclines, including doxorubicin, daunorubicin, epirubicin, idarubicin and mitoxantrone (use the table below to calculate the total cumulative anthracycline dose)
Anthracycline and anthraquinone isoequivalency ratios
c
Derivative Multiplier
Doxorubicin (reference) 1.0
Daunorubicin 0.6
Epirubicin 1.0
Idarubicin 5.0
Mitoxantrone 10.5

What cardiac problems might occur?

  • Cardiomyopathy (after radiotherapy ≥ 15 Gy to a volume exposing the heart, c or total cumulative anthracycline dose ≥100 mg/m2 d )

  • Arrhythmia (after radiotherapy ≥ 15 Gy to a volume exposing the heart, c anthracyclines or mitoxantrone)
  • Pericardial disease (after radiotherapy ≥ 15 Gy to a volume exposing the heart c )
  • Valvular heart disease (after radiotherapy ≥ 15 Gy to a volume exposing the heart c )

What surveillance modality should be used and at what frequency should it be performed?

  • Cardiac history at every long-term follow-up visit, at least every 5 years
  • Physical cardiac exam at every long-term follow-up visit, at least every 5 years
  • ECG once at entry into long-term follow-up
  • ECG once after the age of 18 years, if entry into long-term follow-up was at a younger age
  • 2D or 3D echocardiogram with assessment of left ventricular systolic function starting no later than 2 years after cardiotoxic
    therapy:
Radiotherapy to a volume exposing the heart e
Total cumulative
anthracycline dose		 0-14 Gy ≥15 to <30 Gy ≥30 Gy
0-99 mg/m2 – Every 5 years Every 2 years
≥100-249 mg/m2 Every 5 years Every 2 years Every 2 years
≥250 mg/m2 Every 2 years Every 2 years Every 2 years
    • If a female survivor treated with a total cumulative anthracycline dose ≥100 mg/m2 and/or radiotherapy ≥ 15 Gy to a volume exposing the heart e  has a pregnancy wish or is pregnant, b  an additional echocardiogram should be performed at the following time points: prior to pregnancy or in the first trimester and continuing during pregnancy for female survivors who had a history of prior left ventricular systolic dysfunction that has resolved even in the presence of a normal baseline ejection fraction in the first trimester
  • Cardiac magnetic resonance imaging:
    • In survivors at risk for cardiomyopathy for whom echocardiogram is not technically feasible or optimal
  • Echocardiogram with specific attention to the pericardium and valvular structure and function
    • Radiotherapy ≥ 15 Gy to a volume exposing the heart e : at least every 5 years, starting 2 years after cardiotoxic therapy
  • Not recommended: assessment of cardiac blood biomarkers as the only surveillance strategy g 

What other advice should be given?

Survivors treated with anthracyclines and/or radiotherapy exposing the heart:

  • Screening for modifiable cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity, smoking, alcohol intake and low levels of physical activity) so that necessary interventions can be initiated to help avert the risk of symptomatic cardiomyopathy
  • Cardiology consultation for survivors with asymptomatic cardiomyopathy or who are at high risk to define limits and precautions for exercise

What should be done if abnormalities are identified?

  • Refer to or consult a cardiologist if an abnormal ejection fraction or if other abnormalities are identified
  • Treatment with heart failure medications (ACE inhibitors, ARBs, beta-blockers) is recommended in survivors with asymptomatic LV ejection fraction < 40% according to guidelines from the general population
  • No recommendation can be formulated about treatment with heart failure medications in survivors with asymptomatic borderline (LV ejection fraction between 40% and the upper limit of normal) cardiac function

Disclaimer

While PanCare strives to provide accurate and complete information that is up-to-date as of the date of publication, we acknowledge that the sequence of referral and diagnostic tests might vary according to the local and national healthcare system logistics.

It is recognised that survivors and their healthcare professionals have the final responsibility for making decisions concerning their long-term follow-up care. As such, they may choose to either adopt these recommendations or not to do so after individual informed discussion. It is good practice to document this decision.

In addition to regular surveillance, real-time awareness and prompt reporting of new symptoms and signs is essential to the early detection and timely treatment of late effects.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information.

The PanCare materials are free to use for anyone aiming to inform about late effects and long-term survivorship care. However, no financial advantage may be achieved. All communication should reference PanCare and link to the PanCare website.

PanCareFollowUp has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 824982. The material presented and views expressed here are the responsibility of the author(s) only. The EU Commission takes no responsibility for any use made of the information set out.

a The recommendations for cardiomyopathy surveillance reflect the content of the IGHG Cardiomyopathy guideline (Systematic review and updated recommendations for cardiomyopathy surveillance for survivors of childhood, adolescent, and young adult cancer from the International Late Effects of Childhood Cancer Guideline Harmonization Group, Lancet Oncology, 2023; accessible through http://www.ighg.org/guidelines/topics/cardiomyopathy/).

b Further recommendations regarding surveillance in pregnancy specified in the Evidence-based recommendation for obstetric problems.

c The recommendations for the anthracycline and anthraquinone isoequivalency ratios reflect the content of the IGHG Anthracycline cardiac dysfunction equivalence ratios guideline (Recommendations for Anthracycline and Anthraquinone Cardiac Dysfunction Equivalence Ratios After Childhood Cancer: JACC: CardioOncology Expert Panel. JACC: CardioOncology, 2025: accessible through https://www.ighg.org/guidelines/topics/anthracycline-cardiotoxicity-equivalence-ratio/).

d Based on COG guideline because in the IGHG Anthracycline cardiac dysfunction equivalence ratios guideline no recommendation could be made for an idarubicin-to-doxorubicin equivalence ratio with respect to cancer therapy-related cardiac dysfunction risk, as no eligible studies were identified.

e Radiotherapy dose estimations based on the mean dose received to the heart is preferred over the prescribed dose since the latter may not reflect radiation exposure to the heart as accurately.

g Assessment of cardiac blood biomarkers (e.g., natriuretic peptides) in conjunction with imaging studies may be reasonable in instances where symptomatic cardiomyopathy is strongly suspected or in CAYA cancer survivors who have borderline cardiac function during primary surveillance.

References:

EAM Feijen, WM Leisenring, KL Stratton et al. Derivation of anthracycline and anthraquinone equivalence ratios to doxorubicin for late-onset cardiotoxicity. JAMA Oncology. 2019;5(6):864-871. EAM Feijen, A Font-Gonzalez, HJH van der Pal et al. Risk and temporal changes of heart failure among 5-year childhood cancer survivors: a DCOG-LATER study. J Am Heart Assoc. 2019; 8(1):e009122.