Chemotherapy-derived cardiotoxicity: a mini-review of the guidelines

Introduction: The spectrum of cancer therapy-related cardiovascular toxicity (CTR-CVT) is one of the major complications of cancer therapies and causes increased morbidity and mortality in oncologic patients. Anthracyclines, Anti-HER2 drugs, fluoropyrimidines, VEGF and TK1 inhibitors, and immune-checkpoint inhibitors are known to increase the risk of premature onset of cardiac diseases. Therefore, these patients have to be strictly monitored regarding their heart functionality, also after the therapies ending since the toxic effect of these agents can also occur after years. Aim of this study was to review the guidelines written so far for the management of CTR-CVT. Evidence acquisition: The literature research was performed by using the PRISMA Statement. It was conducted on August 30th, 2022 on the PubMed library, using the following “Cardiotoxicity guidelines” and “Cardiooncology guidelines.” Other guidelines known by the authors and judged relevant to the aim of this study were also considered. Evidence synthesis: The selection process of the studies is schematically showed by the PRISMA flow-chart. A total of 603 articles (601 from PubMed and two from other sources) were identified. After the removal of 77 duplicates, 526 studies were retrieved. Five hundred and thirteen articles were excluded since they did not match the inclusion criteria. Therefore, 13 studies were included. Conclusions: Currently, guidelines recommended a careful monitoring for patients receiving potentially cardiotoxic treatment and they are fairly uniform about the approaches. Before the onset of the anticancer therapy, the oncologic patients should be stratified for the risk to develop cardiovascular complications. Risk assessment should include measurement of cardiac function. Strategies for screening and detection of cardiotoxicity include cardiac imaging (echocardiography, nuclear imaging, cardiac magnetic resonance) and cardiac biomarkers (troponin, natriuretic peptides). Although echocardiography is the method of choice, other imaging methods are recommended to improve reproducibility. Cardiac biomarkers, albeit not common used in clinical practice, are a reliable diagnostic tool for the early identification and monitoring of cardiotoxicity. A combined approach based on cardiac imaging and biomarkers looks promising. Identifying early cancer therapy-related cardiac dysfunction before a significant decline in LVEF may allow clinicians to promptly start cardioprotective treatments. Therefore, in patients with asymptomatic CTR-CVT (LVEF ≥50% with a significant new global longitudinal strain (GLS) reduction and/or cardiac biomarker increase), a cardioprotective therapy with (ACE-I/ARB and/or beta-blockers) should be considered. Currently, there are no evidence-based guidelines on how often or how long cardiac function should be monitored during and after cancer treatment. The timing of surveillance depends greatly on the cardiovascular risk of cancer patients and treatment protocol so that further research needs to establish the optimal protocol.