Cardiology · ESC

Cardio-oncology

ESC

Source:2022 ESC Guidelines on cardio-oncology developed in collaboration with EHA, ESTRO and IC-OS

Verified Apr 2026

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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.

References

1.2022 ESC Guidelines on cardio-oncology developed in collaboration with EHA, ESTRO and IC-OS (2022)
2.2022 ESC Guidelines on cardio-oncology developed in collaboration with EHA, ESTRO and IC-OS. European Heart Journal (2022)

Drug

Class

Adult

Paediatric

Notes