Red Flags
- New LVEF drop ≥10% to below 50% during anthracycline or trastuzumab — cancer-therapy-related cardiac dysfunction; pause therapy and refer cardio-oncology[2]
- Acute chest pain during 5-fluorouracil or capecitabine infusion — coronary vasospasm; stop infusion and treat as ACS[2]
- Immune checkpoint inhibitor + new cardiac symptoms (chest pain, dyspnoea, troponin rise, conduction disease) — fulminant myocarditis; emergency steroids and ICU[2]
- QTc prolongation >500 ms or >60 ms increase from baseline on QT-prolonging therapy — pause drug, correct electrolytes[2]
First-line treatment
Interventions
- Multidisciplinary cardio-oncology service[2]Joint cardiology and oncology decision making for risk stratification, monitoring schedule, and management of cardiotoxicity events
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Enalapril or candesartan[2] | ACE inhibitor or ARB (cardioprotective) | Enalapril 5–20 mg PO BD; candesartan 8–32 mg PO daily | — | Initiate when LVEF drops or troponin rises during anthracycline; dual with beta-blocker if symptomatic CTRCD |
| Carvedilol or bisoprolol[2] | Beta-blocker | Carvedilol 3.125–25 mg PO BD; bisoprolol 1.25–10 mg PO daily | — | Add for cancer-therapy-related cardiac dysfunction |
| Methylprednisolone (high-dose IV)[2] | Glucocorticoid | 1 g IV daily for 3–5 days, then taper | — | First-line for immune checkpoint inhibitor myocarditis; permanently discontinue immunotherapy |
| Dexrazoxane[2] | Cardioprotective iron chelator | Per institutional protocol, given before anthracycline | — | Consider in high cumulative anthracycline doses or established LV dysfunction |
Enalapril or candesartan[2]
ACE inhibitor or ARB (cardioprotective)
- Adult
- Enalapril 5–20 mg PO BD; candesartan 8–32 mg PO daily
- Paediatric
- —
Initiate when LVEF drops or troponin rises during anthracycline; dual with beta-blocker if symptomatic CTRCD
Carvedilol or bisoprolol[2]
Beta-blocker
- Adult
- Carvedilol 3.125–25 mg PO BD; bisoprolol 1.25–10 mg PO daily
- Paediatric
- —
Add for cancer-therapy-related cardiac dysfunction
Methylprednisolone (high-dose IV)[2]
Glucocorticoid
- Adult
- 1 g IV daily for 3–5 days, then taper
- Paediatric
- —
First-line for immune checkpoint inhibitor myocarditis; permanently discontinue immunotherapy
Dexrazoxane[2]
Cardioprotective iron chelator
- Adult
- Per institutional protocol, given before anthracycline
- Paediatric
- —
Consider in high cumulative anthracycline doses or established LV dysfunction
Safety-net
- Report new chest pain, breathlessness, palpitations, or leg swelling during cancer therapy promptly — heart effects can be reversible if caught early[2]
- Continue any heart medications started during cancer treatment unless your cardiologist explicitly stops them[2]
- After cancer therapy, attend long-term cardiovascular follow-up — late cardiotoxicity can emerge years later[2]
Referral criteria
- Suspected immune checkpoint inhibitor myocarditisEmergency department + cardio-oncology; high-dose corticosteroids[2]
- Acute chest pain on 5-FU/capecitabine infusionStop infusion; emergency cardiology evaluation as ACS[2]
- LVEF drop ≥10% to <50% during cardiotoxic therapyCardio-oncology to pause therapy and initiate ACE-i + beta-blocker[2]
- Survivor of childhood or anthracycline-exposed cancer with new heart failure symptomsCardiology with cardio-oncology expertise[2]
Clinical summary
Cardiovascular surveillance and management for cancer patients before, during, and after cardiotoxic therapy.