Addressing cardiotoxicity: insights from a multidisciplinary care pathway for cancer patients

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Abstract Introduction Since 2022, the ESC cardio-oncology guidelines have provided a framework for cardiovascular risk assessment and monitoring in cancer patients undergoing treatment. Based on these guidelines, we implemented a multidisciplinary care pathway in our clinic to identify patients at high risk for cardiotoxicity, ensure early diagnosis, and administer cardioprotective therapies. Methods Targeting patients receiving anthracyclines, our pathway involved collaboration among oncology, hematology, and cardiology departments (Figure 1). Upon cancer diagnosis, oncologists and hematologists referred patients to cardiologists for risk assessment and biomarker evaluations (Troponins, NT-proBNP). Initial visits included ECGs and TTE with advanced strain analysis, alongside education on chemotherapy-related cardiac effects and the importance of physical activity. Patients were categorized as LOW, MEDIUM, or HIGH/VERY HIGH risk using the HFA-ICOS tool. Follow-up visits were scheduled for LOW and MEDIUM risk patients, while those at HIGH/VERY HIGH risk were managed collaboratively. The detection of cardiac damage on echocardiography prompted initiation of cardioprotective medications. Results From March 2023, 213 cancer patients were referred, 118 being new diagnoses. Most of them had breast cancer (178 patients), with 28 having hematologic malignancies and 7 other solid tumors. Of these, 123 patients (59%) were LOW risk, 48 (23%) MEDIUM risk, and 38 (18%) HIGH/VERY HIGH risk. Ten cases were discussed in the multidisciplinary team for optimal management, and cardioprotective medications (mainly ACE inhibitors) were prescribed for those needing cardiotoxic treatment. During follow-up, five HIGH/VERY HIGH risk patients exhibited signs of cardiotoxic damage requiring multidisciplinary approach for optimization of the therapy. Baseline NT-proBNP was elevated in 29 patients; 20 had concurrent troponin elevations. Conclusion and Future Perspectives A multidisciplinary approach is vital for preventing and managing cardiotoxicity in cancer patients. Effective communication and a structured protocol enable close monitoring of HIGH/VERY HIGH risk patients. Incorporating laboratory data into clinical decision-making may enhance patient management and further evidence is needed to justify cardioprotective treatments in asymptomatic patients.

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