Table 3.

Proposal for a risk-based approach to planned cardiac monitoring during anthracycline and trastuzumab treatment in the vaccination era.

Treatment	Recommendations before pandemic	Recommendation during pandemic	Recommendation during vaccination
Anthracyclines: basal evaluation	• Cardiological visit only in intermediate and high-risk patients* • Echocardiography to all patients	• Cardiological visit only in high-risk patients* • Echocardiography only in high-risk patients*	• Cardiological visit only in high-risk patients* • Echocardiography only in high-risk patients*
Anthracyclines: on treatment	• Echocardiography at mid-cycle if high CV risk • Echocardiography at the end of treatment to all patients	• No screening in asymptomatic patients • Echocardiography if high-dose RT, high cumulative anthracycline dose (>400 mg/m2) or with doses of 250 mg/m2 in presence of CV risk factors or cardiopathy	• Echocardiography at the end of treatment to all patients (OOH) • Early assessment if high-dose RT, high cumulative anthracycline dose (>400 mg/m2) or with doses of 250 mg/m2 in presence of CV risk factors or cardiopathy
Anthracyclines: follow-up	• If no cardiotoxicity echocardiography at 6– 12 months and after 2–3–5 years • If cardiotoxicity echocardiography at 3–6–12 months and each year until 5 years	• In asymptomatic patients defer the echo-imaging	• If no cardiotoxicity echocardiography at 12 months and after 2–5 years in intermediate and high-risk patients* • If no cardiotoxicity echocardiography at 12 months in low-risk patients** (OOH) • If cardiotoxicity echocardiography at 3–6–12 months and each year until 5 years
Trastuzumab: basal evaluation	• Echocardiography to all patients	• Echocardiography only in high-risk patients	• Echocardiography only in intermediate and high-risk patients
Trastuzumab: during treatment	• If LVEF is normal, echocardiography every 3 months. • If LVEF 40–49%, optimize HF therapy. Continue treatment if LVEF stable after 4 weeks and repeat echocardiography after 4 weeks. • If LVEF <40% stop treatment, optimize HF therapy and evaluate after 4 weeks	• In low-risk** patients with no previous anthracyclines, echocardiography at 6–12 months; if metastatic disease echocardiography every 6 months • In high-risk patients* echocardiography every 3 months • If LV dysfunction or signs and symptoms of HF follow pre-pandemic recommendations	• In low-risk** patients with no previous anthracyclines, echocardiography every 6 months (OOH) • In high-risk patients* echocardiography every 3 months • If LV dysfunction during treatment or signs and symptoms of HF follow pre-pandemic recommendations
Trastuzumab: follow-up	• The same as anthracyclines	• If asymptomatic defer the echo imaging	• If no cardiotoxicity echocardiography at 12 months and after 2 years in intermediate and high-risk patients* • If no cardiotoxicity echocardiography at 12 months in low-risk patients** (OOH) • If cardiotoxicity echocardiography at 3–6–12 months and each year until 5 years

Adapted from Calvillo-Arguelle et al. (86) and Bisceglia et al. (13, 14) for before pandemic and during pandemic sections. CV, cardiovascular; RT, radiotherapy; OOH, out-of-hospital; LVEF, left ventricular ejection fraction.

^*Two or more of the following risk factors: age ≥60 years, cardiopathy, high-dose radiotherapy, ≥2 cardiovascular risk factors, high-dose anthracyclines.

^**No risk factors.