Anthracyclines
(e.g., doxorubicin, epirubicin, idarubicin, daunorubicin, mitoxantrone)

Cardio-oncological evaluation*, BNP or NT-proBNP and Troponin**

before cancer treatment begins

  • In patients with LVEF <40%, anthracyclines are not recommended unless there are no effective alternative cancer treatment options.

  • In patients with LVEF <50% but ≥40%, ACEi (or ARB) and/or BB are recommended before treatment.

  • In patients exposed to multiple cardiotoxic agents with a normal LVEF and cardiovascular risk factors, ACEi (or ARB)

  • and/or BB may be considered.

  • In patients with advanced or metastatic breast cancer who have received a cumulative dose of >300 mg/m2 doxorubicin or >540 mg/m2 epirubicin and would benefit from continued anthracycline-based therapy, dexrazoxane can be considered.

Cumulative dose doxorubicin ≥250 mg/m2 or equivalent***

Cumulative dose doxorubicin <250 mg/m2 or equivalent***

Cardio-oncological evaluation*

before each cycle

AND

Troponin** after each cycle (end of infusion)

Presence of any of the following risk factors:
age ≥ 65, mediastinal radiotherapy, previous cardiotoxic drugs, previous heart disease, ≥two risk factors (including smoking, hypertension, diabetes, dyslipidemia, chronic renal insufficiency, and obesity), baseline elevation of cardiac biomarkers

yes

Troponin**

after each cycle (end of infusion)

no

CV symptoms/signs OR Troponin +

yes

Cardio-oncological evaluation*

before the next cycle and tailored monitoring on case-by-case basis

no

Annual cardiovascular risk assessment
and
Cardio-oncological evaluation*

at the end of cancer treatment and at 6 months, 1 year, 3 years, 5 years and every 5 thereafter

* A cardio-oncological evaluation will systematically include at least one visit with blood pressure, blood glucose, lipid profile, GFR calculation, ECG and trans-thoracic echocardiography (TTE). Measurements of global longitudinal strain and 3D LVEF (if feasible) are recommended with the same machine.

**Assays should be carried out by the same laboratory (same type of troponin, same method of measurement).

Troponin + if >99e percentile of the URL

***To obtain the doxorubicin equivalent dose, multiply the dose of the anthracylcine of interest by the following number:

1 for Doxorubicin

0.8 for Epirubicin

0.6 for Daunorubicin

10.5 for Mitoxantrone

5 for Idarubicin

ACE=angiotensin converting-enzyme inhibitor; ARB=angiotensin receptor blocker; BB=beta-blocker; LVEF=left ventricular ejection fraction