| Characteristic | Cancer therapy-related cardiomyopathy | ||
|---|---|---|---|
| Type I | Type II | Type III | |
| Definition | Direct impairing effect on the myocardium | Indirect impairing effect on the myocardium | Impairing effect owing to myocarditis |
| Risk with cancer therapy | |||
| Doxorubicin | Yes | Yes | Yes (toxic or reactive) |
| Cyclophosphamide | Yes | Yes | Yes (toxic or reactive) |
| 5-Fluorouracil | Yes | Yes | NR |
| HER2 (ERBB2) inhibitors | Yes | Unclear | NR |
| VEGF inhibitors | Yes (TKIs) | Yes | Unclear |
| ICIs | Possible | Possible | Yes (immunomediated) |
| Radiation therapy | Yes (at high dose) | Yes | Yes (toxic or reactive) |
| Diagnosis | |||
| Imaging | Echocardiography, cardiac MRI, MUGA scan | (Stress) echocardiography, (stress) cardiac MRI, nuclear stress test, CT coronary angiography, vasoreactivity studies | Cardiac MRI, PET, echocardiography |
| Biomarkers | Cardiac troponins, natriuretic peptides (especially long term) | Thyroid function studies, cytokines, catecholamines ECG abnormalities (e.g. ST-segment shifts, T-wave inversions) | Cardiac troponins, natriuretic peptides, ECG abnormalities (e.g. heart block, ectopy) |
| Management | |||
| Treatment | Stop cancer therapy, β-blocker(carvedilol), ACE inhibitor, ARB, spironolactone | Stop cancer therapy, therapy directed at the underlying cause (e.g. correction of myocardial ischaemia or valve disease) | Stop cancer therapy; for ICI therapy, anti-inflammatory and immunosuppressive therapy, supportive care as needed (e.g. ECMO) |
| Prevention | Screening for and optimal treatment of comorbidities, exercise; for anthracyclines, cardiovascular medications (carvedilol or nebivolol, ACE inhibitor, ARB or spironolactone, statins, dexrazoxane) | Screening for and optimal treatment of predisposing conditions, dose and type of administration; for radiation therapy, dose reduction (e.g. shielding, positioning or proton beam) | Screening for and optimal treatment of comorbidities (efficacy not proven), early detection with biomarkers |
ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; ECG, electrocardiogram; ECMO, extracorporeal membrane oxygenation; ICI, immune checkpoint inhibitor; MUGA, multigated acquisition; NR, not reported; PET, positron emission tomography; TKI, tyrosine kinase inhibitor; VEGF, vascular endothelial growth factor.