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 epirubicin ≥600 mg/m2)

Cumulative dose doxorubicin <250 mg/m2 or epirubicin <600 mg/m2)

Cardio-oncological evaluation*

before each cycle

AND

Troponin** after each cycle (end of infusion)

Presence of any of the following factors:
age ≥ 60, mediastinal radiotherapy, 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

Cardio-oncological evaluation*

at the end of cancer treatment and at 6 months, 1 year, 2 years, and periodically 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

***Cardiological evaluation should be performed before each cycle if the cumulative dose:

-Doxorubicn > 250 mg/m2

-Epirubicin > 600 mg/m2

-Idarubicin > 48 mg/m2

-Daunorubicin > 288 mg/m2

-Mitoxantrone > 60 mg/m2

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