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Team-based approach to manage cancer related myocardial damage

After a very stressful period due to the COVID-19 pandemic, it is time to implement everything we have learned both from the human and the scientific point of view: never let a crisis go to waste – there are several silver linings to the dark COVID-19 cloud!

Cardio-oncology does not escape this reflection and we are obliged to configure cancer patients´ healthcare in future decades around the risk of new pandemic infections. In this new scenario, structured models of teamwork are critical for cardiotoxicity risk stratification and telecare remote patient follow-up.

We wish to draw your attention to two recent cardio-oncology publications that inspire a deep reflection on how to efficiently organise the monitoring of cancer patients.

Cardio-oncology programmes are now recognised as a critical component of high-quality medical care. One of the main challenges we face to integrate them in daily practice is the growing number of cancer patients, not all with the same cardiotoxicity profile or expected risk. If we want to organise robust cardio-oncology structures we need to agree on universal cardiotoxicity definitions and structured baseline risk stratification tools.

The prospective CARDIOTOX registry [1] proposes a new classification of cancer therapy-induced myocardial damage (CTOX) based on the risk of clinical events. As in other heart failure scenarios, grading symptoms, echo and biomarkers changes facilitates clinical decisions making. Results showed that after a median follow-up of 24 months, 37.5% of the patients present objective data of myocardial dysfunction. The CARDIOTOX registry also revealed the number of patients with severe cardiotoxicity is comparatively very low (3.1%) but still strongly related with an all-cause mortality rate (22.9 deaths per 100 patient-years vs. 2.3 deaths per 100 patient-years in the mild and moderate groups). Given that CTOX is a progressive disease, any grade of myocardial damage should be taken into consideration and earlier changes in myocardial health can be detected with sensitive cardiac imaging and biomarkers as exemplified by the previous Royal Brompton Hospital Myocardial Toxicity classification [2]; however, clinical decisions must be tailored to the prognostic implications. This new classification could be useful to define strategies for early identification, prevention and treatment in patients treated with cardiotoxic drugs.

To further improve cardiotoxicity risk stratification, the Cardio-Oncology Study Group of the Heart Failure Association of the European Society of Cardiology, in collaboration with the International Cardio-Oncology Society, has recently published a Position Statement [3] that includes new risk assessment tools. This document includes a series of evidence-based proformas, aim to improve personalised approaches to cardiotoxicity risk stratification before cancer therapy for the main cancer treatments causing cardiovascular toxicity (anthracycline chemotherapy, HER2-targeted therapies, VEGF inhibitors, second and third-generation BCR-ABL inhibitors for chronic myeloid leukaemia, multiple myeloma therapies, combination RAF and MEK inhibitors, and androgen deprivation therapy for prostate cancer). The main goals of these practical and easy-to-use proformas are to minimise cardiovascular events and to optimise medical resources during patients´ follow-up.


We hope you find them useful.

Stay safe!

Dr. Teresa López-Fernández

Dr. Alexander R Lyon

ESC Council of Cardio-Oncology


  1. José López-Sendón, Carlos Alvarez-Ortega, Pilar Zamora Auñon, Antonio Buño Soto, Alexander R. Lyon, Dimitrios Farmakis,Daniela Cardinale, Miguel Canales Albendea, Jaime Feliu Batlle, Isabel Rodríguez Rodríguez, Olaia Rodrríguez Fraga, Ainara Albaladejo, Guiomar Mediavilla, Jose Ramón González-Juanatey, Amparo Martínez Monzonis, Pilar Gómez Prieto, José González-Costello, José María Serrano Antolín, Rosalía Cadenas Chamorro  and Teresa López-Fernández; on behalf of the CARDIOTOX Registry Investigators. European Heart Journal (2020) 41, 1720–1729 doi:10.1093/eurheartj/ehaa006

  2. Nilesh Pareek, Joaquim Cevallos, Pedro Moliner, Mit Shah , Li Ling Tan , Vicki Chambers, A John Baksi , Rajdeep S Khattar , Rakesh Sharma , Stuart D Rosen , Alexander R Lyon. Activity and Outcomes of a Cardio-Oncology Service in the United Kingdom-a Five-Year Experience. Eur J Heart Failure (2018) Dec; 20(12):1721-1731

  3. Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies: a Position Statement and new risk assessment tools from the Cardio-Oncology Study Group of the Heart Failure Association of the European Society of Cardiology in collaboration with the International Cardio-Oncology Society. Eur J Heart Failure (2020) in press. doi: 10.1002/ejhf.1920