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. Author manuscript; available in PMC: 2016 Mar 1.
Published in final edited form as: Lancet Oncol. 2015 Mar;16(3):e123–e136. doi: 10.1016/S1470-2045(14)70409-7

Table 4.

Harmonized recommendations for cardiomyopathy surveillance for childhood cancer survivors.

General recommendation
Survivors treated with anthracyclines and/or chest radiation and their providers should be aware of the risk of cardiomyopathy.
Who needs cardiomyopathy surveillance? Anthracyclines
Cardiomyopathy surveillance is recommended for survivors treated with high dose (≥ 250 mg/m2) anthracyclines.
Cardiomyopathy surveillance is reasonable for survivors treated with moderate dose (≥ 100 to < 250 mg/m2) anthracyclines.
Cardiomyopathy surveillance may be reasonable for survivors treated with low dose (< 100 mg/m2) anthracyclines.
Who needs cardiomyopathy surveillance? Chest radiation
Cardiomyopathy surveillance is recommended for survivors treated with high dose (≥ 35 Gy) chest radiation.
Cardiomyopathy surveillance may be reasonable for survivors treated with moderate dose (≥ 15 to < 35 Gy) chest radiation.
No recommendation can be formulated for cardiomyopathy surveillance for survivors treated with low dose (< 15 Gy) chest radiation with conventional fractionation.
Who needs cardiomyopathy surveillance? Anthracyclines + Chest radiation
Cardiomyopathy surveillance is recommended for survivors treated with moderate-high dose anthracyclines (≥ 100 mg/m2) and moderate-high dose chest radiation (≥ 15 Gy).
What surveillance modality should be used?
Echocardiography is recommended as the primary cardiomyopathy surveillance modality for assessment of left ventricular systolic function in survivors treated with anthracyclines and/or chest radiation.
Radionuclide angiography or cardiac magnetic resonance imaging (CMR) may be reasonable for cardiomyopathy surveillance in at risk survivors for whom echocardiography is not technically feasible/optimal.
Assessment of cardiac blood biomarkers (e.g., natriuretic peptides) in conjunction with imaging studies may be reasonable in instances where symptomatic cardiomyopathy is strongly suspected or in individuals who have borderline cardiac function during primary surveillance.
Assessment of cardiac blood biomarkers is not recommended as the only strategy for cardiomyopathy surveillance in at risk survivors.
Cardiomyopathy surveillance is recommended for High Risk survivors to begin no later than 2 years after completion of cardiotoxic therapy, repeated at 5 years after diagnosis and continued every 5 years thereafter.
More frequent cardiomyopathy surveillance is reasonable for High Risk survivors.
Lifelong cardiomyopathy surveillance may be reasonable for High Risk survivors.
At what frequency should surveillance be performed for Moderate/Low Risk survivors?
Cardiomyopathy surveillance is reasonable for Moderate/Low Risk survivors to begin no later than 2 years after completion of cardiotoxic therapy, repeated at 5 years after diagnosis and continue every 5 years thereafter.
More frequent cardiomyopathy surveillance may be reasonable for Moderate/Low Risk survivors.
Lifelong cardiomyopathy surveillance may be reasonable for Moderate/Low Risk survivors.
At what frequency should surveillance be performed for survivors who are pregnant or planning to become pregnant?
Cardiomyopathy surveillance is reasonable prior to pregnancy or in the first trimester for all female survivors treated with anthracyclines and/or chest radiation
No recommendations can be formulated for the frequency of ongoing surveillance in pregnant survivors who have normal LV systolic function immediately prior to or during the first trimester of pregnancy.
What should be done when abnormalities are identified?
Cardiology consultation is recommended for survivors with asymptomatic cardiomyopathy following treatment with anthracyclines and/or chest radiation.
What advice should be given regarding physical activity and other modifiable cardiovascular risk factors?
Regular exercise, as recommended by the AHA and ESC, offers potential benefits to survivors treated with anthracyclines and/or chest radiation.
Regular exercise is recommended for survivors treated with anthracyclines and/or chest radiation who have normal LV systolic function.
Cardiology consultation is recommended for survivors with asymptomatic cardiomyopathy to define limits and precautions for exercise.
Cardiology consultation may be reasonable for High Risk survivors who plan to participate in high intensity exercise to define limits and precautions for physical activity.
Screening for modifiable cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity) is recommended for all survivors treated with anthracyclines and/or chest radiation so that necessary interventions can be initiated to help avert the risk of symptomatic cardiomyopathy.

Green represents a strong recommendation, with a low degree of uncertainty (high quality evidence). Yellow (moderate quality evidence) and orange (weak quality evidence) represent moderate level recommendations. Red represents a recommendation against a particular intervention, with harms outweighing benefits.