Table 3. Current approach for managing and monitoring cardiotoxicity of common classes of chemotherapeutic agents.

Class of chemotherapeutic agent		Cancer Indication	Commonly associated treatment related cardiotoxicity	Current approach	Suggested approach
Anthracycline (doxorubicin/daunorubicin, epirubicin)		Breast cancer, lymphoma, acute leukemia	Heart failure, left ventricular dysfunction	- Baseline LVEF assessment and monitoring during therapy.	Basic: Baseline assessment of LVEF (±NT-proBNP) prior to initiation of chemotherapy. Follow up as required, guided by symptoms.
				- Use of biomarkers such as NT-proBNP/troponin during routine follow up.	Ideal: Risk stratification prior to cancer therapy. Serial follow up to assess LVEF. Early initiation of adjunctive cardioprotective strategies in patients with subclinical cardiotoxicity or at-risk patients.
				- Early initiation of adjunctive cardioprotective strategies such as ACE-inhibitors or betablockers upon detection of subclinical cardiac toxicity.	Optimal: Cancer survivorship program to review patients who may develop late-onset cardiomyopathy
Antimetabolites
	5-Flurouracil	Breast cancer, colorectal cancer, pancreatic cancer, gastric cancer	Vasospasm, myocardial ischemia, arrhythmias, heart failure	- Consider pre-medication with calcium channel blockers. Use of intravenous bolus regimen.	Basic: In patients with pre-existing vascular disease, clinical follow up as needed.
				- ECG monitoring during intravenous infusion.	Ideal: Risk stratification prior to cancer therapy to guide further testing as necessary.
					Optimal: Consider stress test with peripheral vaso-functional study, or even coronary angiogram with full microvascular assessment
	HER-2-targeted therapies (trastuzumab, pertuzumab, trastuzumab ematansine T-DM1)	HER-2+ breast cancer	Heart failure, Left ventricular dysfunction, Hypertension	- Serial monitoring of LVEF	Basic: Basement evaluation of LVEF
		HER-2+ gastric cancer		- Consider suspending therapy and initiation of cardioprotective agents (ACE-inhibitors/β-blockers) when there is a significant drop in LVEF	Ideal: Regular serial monitoring of LVEF during therapy. If significant drop in LVEF to <40%, consider suspending treatment and initiating cardioprotective agents.
					Optimal: Routine monitoring of LVEF. Cancer survivorship surveillance program.
	VEGF inhibitors (sunitinib, sorafenib, vandetanib)	Renal cell carcinoma, Hepatocellular cancer, Medullary thyroid cancer	Hypertension, heart failure, left ventricular dysfunction, arterial thromboembolism, QTc prolongation	- Early recognition and treatment of hypertension. Dose up-titration of antihypertensives for existing patients	Basic: Monitoring of blood pressure, and optimization of anti-hypertensive therapy in patients with pre-existing hypertension.
				- ECG to assess QTc duration	Ideal: Risk stratification prior to starting chemotherapy. Monitoring of blood pressure during follow-up visit.
					Optimal: Echocardiogram after first month of therapy and every 3 monthly
	Androgen deprivation therapies	Prostate cancer	Atherosclerosis, myocardial ischemia and infarction, diabetes mellitus, hypertension	- Baseline assessment of 10-year atherosclerotic CV risk.	Basic: Screening of CV risk factors prior to initiation
	1. GnRH agonists (gosrelin, leuprorelin)			- Control of CV risk factors such as diabetes mellitus, dyslipidemia as per existing guidelines.
	2. GnRH antagonists (degarelix)				Ideal: Baseline assessment of 10-year atherosclerotic CV risk, and optimizing CV risk factors such as diabetes mellitus and dyslipidemia at baseline and follow-up
	3. Antiandrogens (abiraterone)				Optimal: In patients with pre-existing ischemic heart disease, consider stress testing or even coronary angiogram depending on signs and symptoms

ACE = angiotensin-converting-enzyme; CV = cardiovascular; ECG = electrocardiogram; GnRH = gonadotropin-releasing hormone antagonist; LVEF = left ventricular ejection fraction; NT-proBNP = N-terminal prohormone B-type natriuretic peptide.