Table 2:

Suggested echocardiographic and CMR surveillance protocols of cardiotoxicity for patients undergoing targeted therapy, immunotherapy, or radiation therapy.

Suggested Clinical Imaging Surveillance Protocols for CTRCT in Various Cancer Therapies
Class	Echocardiography	Cardiac MRI
All Classes	Consider baseline for all intermediate and high risk patients prior to initiation of therapy Any time there are signs or symptoms concerning for possible CTRCT	Consider with abnormal echo or poor visualization Consider if clinical suspicion for CTRCT persists despite normal/equivocal echo Unexplained CVD
Proteasome inhibitors	Periodically if history of other cardiotoxic cancer therapy, personal CVD or risk factors, or specifically taking carfilzomib	Consider with abnormal echo or poor windows/visualization Unexplained CVD
VEGF-I and TKI (including BRAF, MEK, and VEGF inhibitors with TKI mechanism)	High risk patients on TKI: Consider screening echo every 1–3 months during therapy Intermediate risk patients on TKI: consider every 6–12 months during therapy Intermediate or greater risk of CAD prior to initiation of TKI: consider stress All patients on VEGFI, high risk in particular: consider echo every 3–6 months during therapy High risk patients on combination BRAF/MEK therapy: consider echo every 1–3 months during therapy Low or Intermediate risk patients on BRAF or BRAF/MEK therapy: consider echo at 6 months, then every 6–12 months while on therapy.	Consider in those with potential unexplained cardiomyopathy. Consider in evaluation of ischemic disease Unexplained CVD
Immunotherapies (ex. ICIs, CAR-T cell therapies, allogeneic stem transplantation)	High risk or taking other cardiotoxic therapy (including 2nd ICI): serial echo reasonable In high risk patients, first echo should be obtained within 1–2 months after initiation of therapy If LV function abnormal prior to initiation of ICI, every 3–6 months for duration of therapy Consider anytime screening ECG or serum biomarkers are abnormal	Low threshold to move to CMR after echo With any cardiac symptoms, suspicious elevation in troponin, or ECG change Consider if concern for ischemic cardiotoxicity Unexplained CVD
Radiotherapy	High risk patients: 1–2 years after completion of therapy and every 5–10 years following Intermediate risk or lower: every 5–10 years after therapy completion	If concern for radiation-induced myocardial or pericardial disease despite normal or equivocal echo Unexplained CVD

Abbreviations: BRAF, B-Raf proto-oncogene; CAD, coronary artery disease; CAR-T, chimeric antigen T-cell therapy; CTRCT, cancer therapy-related cardiotoxicity; CMR, cardiovascular magnetic resonance imaging; CVD, cardiovascular disease; ECG, electrocardiogram; Echo, echocardiography; ICI, immune checkpoint inhibitor; LV, left ventricular; MEK, mitogenactivated protein kinase kinase; RV, right ventricular; TKI, tyrosine kinase inhibitor; VEGF-I, vascular endothelial growth factor inhibitor.