Cardiotoxicity Monitoring with Echocardiography

Primary Monitoring Parameters

The American Society of Clinical Oncology recommends baseline assessment of systolic and diastolic cardiac function with Doppler echocardiography before starting anthracyclines or monoclonal antibodies, especially in patients aged >60 years or with cardiovascular risk factors 3, 4
Left ventricular ejection fraction (LVEF) is the traditional parameter monitored during treatment, with a reduction of ≥20% from baseline or decline to <50% necessitating reassessment or discontinuation of therapy, as recommended by the European Society of Medical Oncology 4, 5
Tissue Doppler imaging parameters provide quantitative information on myocardial diastolic relaxation and systolic performance before LVEF changes occur, according to the American Heart Association 1, 2

The European Society of Medical Oncology recommends evaluating LVEF after administration of half the planned dose, after cumulative dose of doxorubicin 300 mg/m², epirubicin 450 mg/m², or mitoxantrone 60 mg/m² 3, 4
More frequent monitoring is recommended for patients aged <15 or >60 years after cumulative doses of doxorubicin 240 mg/m² or epirubicin 360 mg/m², as suggested by the American Society of Clinical Oncology 4
Assessment before each anthracycline administration and at 3, 6, and 12 months after completion of therapy is recommended by the European Society of Medical Oncology 3, 4

Troponin I can predict subclinical and clinical cardiac morbidity and mortality after anthracycline therapy, but requires multiple serial measurements, according to the American College of Cardiology 3, 1
B-type natriuretic peptide (BNP) reflects increased LV filling pressure and correlates with LV dysfunction in cancer patients treated with cardiotoxic therapy, as reported by the European Society of Cardiology 1, 2

LVEF reduction of ≥20% from baseline despite normal function or LVEF decline <50% requires reassessment or discontinuation of therapy and frequent echocardiographic checks, as recommended by the American Society of Clinical Oncology 4
Aggressive medical treatment with ACE inhibitors and β-blockers should be initiated within 2 months from the end of anthracycline therapy for patients showing LV dysfunction, even if asymptomatic, according to the European Society of Medical Oncology 4

Two-dimensional echocardiography may only detect LVEF changes of approximately 10%, which may be too late for effective intervention, as reported by the Journal of Clinical Oncology 7
Waiting for symptomatic heart failure before intervention significantly worsens prognosis; early detection and treatment is critical, as emphasized by the American Heart Association 4, 5