Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

TLDR

Cardiotoxicity from cancer therapies, especially VEGF‑targeting agents, poses a risk of hypertension and ischemic events, and the lack of robust clinical data makes monitoring strategies uncertain. This consensus report aims to establish multimodality imaging guidelines for adult patients during and after cancer therapy to improve early detection and management of cardiotoxicity. The authors present a standardized cardio‑oncology echocardiogram protocol, outlining assessment of left ventricular systolic and diastolic function, valve, aortic, and pericardial evaluation, to guide monitoring of cardiotoxicity. Reference II.

Abstract

administration.We recognize that in the setting of a variety of predisposing factors, varying cumulative dosages of recognized cardiotoxic agents, and use of other agents that are known to increase oxidative stress and compromise myocyte stability, the algorithm proposed in this document cannot be based on strong clinical data.Since the approval of trastuzumab, numerous agents have entered the therapeutic armamentarium, including the small-molecule tyrosine kinase inhibitors.It is difficult to make broad generalizations about these agents, because they often have different kinase targets.However, it appears that the most problematic are the agents that target vascular endothelial growth factor (VEGF) and VEGF receptors.These agents typically are associated with severe systemic arterial hypertension and ischaemic events.The development of CTRCD in these patients may be related to transient impairment of the contractile elements within the cell or to the increased afterload on a compromised ventricle.The most concerning of this group are the non-selective agents, including sunitinib and sorafenib, because these drugs can target up to 50 different kinases, in addition to the intended target. 12Because those "off-target" kinases play important roles in the heart and vasculature, the risk of toxicity is increased.As a result of the unspecific nature and predictability of myocardial damage, it is difficult to provide general recommendations regarding how to monitor patients receiving these agents.A number of attempts have been made to unify approaches to manage these patients, all stopping short of proposing guidelines; one attempt focused on arterial hypertension 13 and the other on CTRCD. 14Careful management of comorbidities was urged in these documents.Key points † Highly effective chemotherapeutic agents may cause CTRCD.† CTRCD has been classified as follows:(1) Type I CTRCD is characterized by anthracyclines.It is dosedependent, leads to cell apoptosis, and is therefore irreversible at the cell level.Early detection and prompt treatment may prevent LV remodelling and the progression to the HF syndrome.(2) Type II CTRCD is characterized by trastuzumab.It is not dose dependent, does not lead to apoptosis by itself, and is often reversible. II. Echocardiographical evaluation of cardiac structure and function in cancer patientsEchocardiography is the cornerstone in the cardiac imaging evaluation of patients in preparation for, during, and after cancer therapy, because of its wide availability, easy repeatability, versatility, lack of radiation exposure, and safety in patients with concomitant renal disease.In addition to the evaluation of LV and right ventricular (RV) dimensions, systolic and diastolic function at rest and during stress, echocardiography also allows a comprehensive evaluation of cardiac valves, the aorta, and the pericardium. 15Table 2 summarizes the recommended cardio-oncology-echocardiogram protocol.A. Left ventricular systolic function