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Recommendation
Cardiac risk assessment
A baseline cardiac risk assessment, including an echocardiogram, should be undertaken for patients whose treatment will include chemotherapy (especially anthracyclines) or HER2 therapy (especially trastuzumab) or left-sided radiation therapy.
Clinicians should perform a comprehensive assessment in patients with cancer that includes a history and physical examination, screening for cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity, smoking) and an echocardiogram before initiation of potentially cardiotoxic therapies. (Evidence and consensus based – benefits outweigh harms; Evidence quality – high)
Moderate
Cardiac dysfunction is an increasingly rare complication but can still occur in some patients undergoing adjuvant treatment (e.g., anthracycline-based chemotherapy or trastuzumab or left-sided breast/chest wall adjuvant radiation therapy)
For patients with a cancer diagnosis that requires treatment with a potentially cardiotoxic treatment, a baseline ECG, including measurement of heart rate QTc, is recommended (Level of evidence – I)
There is high confidence that the recommendation reflects best practice. This is based on (1) strong evidence for a true net effect (eg. benefits exceed harms); (2) consistent results, with no or minor exceptions; (3) minor or no concerns about study quality; and/or (4) the extent of panellists’ agreement. Other compelling considerations (discussed in the guideline’s literature review and analyses) may also warrant a strong recommendation
Strong evidence for efficacy with a substantial clinical benefit, strongly recommended
How this guidance was developed
This recommendation was adapted from two source recommendations: one from the ASCO (2017) guideline on prevention and monitoring of cardiac dysfunction (US) based on a systematic review of the evidence conducted in February 2016 and graded ‘strong’ (using ASCO methods) by the source guideline authors; and one from the AHS (2015) guideline (Canada) which was based on a systematic review of the evidence to April 2013 and was not graded. It is also supported by the recent ESMO (2020) consensus recommendations on cardiac disease management in cancer patients, based on a systematic evidence review to June 2018 with the relevant recommendation graded ‘A’ using the Infectious Diseases Society of America-United States Public Health Service Grading System.
Further specific recommendations for baseline cardiovascular assessment are included on the ESMO (2020) guidelines and include: the potential for making baseline measurement of cardiac biomarkers for high risk patients (with pre-existing significant cardiovascular disease) and those receiving high doses of cardiotoxic chemotherapy such as anthracycline; and, in patients scheduled to undergo anticancer therapy associated with HF or LVD, baseline evaluation of LVEF and diastolic functioning according to comprehensive imaging practice is recommended.
Related guidance by topic
Cardiac risk assessment
Recommendation
A baseline cardiac risk assessment, including an echocardiogram, should be undertaken for patients whose treatment will include chemotherapy (especially anthracyclines) or HER2 therapy (especially trastuzumab) or left-sided radiation therapy.
Principles in action
Patient-centred care
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Safe and quality care
This recommendation was adapted from two source recommendations: one from the ASCO (2017) guideline on prevention and monitoring of cardiac dysfunction (US) based on a systematic review of the evidence conducted in February 2016 and graded ‘strong’ (using ASCO methods) by the source guideline authors; and one from the AHS (2015) guideline (Canada) which was based on a systematic review of the evidence to April 2013 and was not graded. It is also supported by the recent ESMO (2020) consensus recommendations on cardiac disease management in cancer patients, based on a systematic evidence review to June 2018 with the relevant recommendation graded ‘A’ using the Infectious Diseases Society of America-United States Public Health Service Grading System.
Further specific recommendations for baseline cardiovascular assessment are included on the ESMO (2020) guidelines and include: the potential for making baseline measurement of cardiac biomarkers for high risk patients (with pre-existing significant cardiovascular disease) and those receiving high doses of cardiotoxic chemotherapy such as anthracycline; and, in patients scheduled to undergo anticancer therapy associated with HF or LVD, baseline evaluation of LVEF and diastolic functioning according to comprehensive imaging practice is recommended.
Related guidance by topic
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Wellbeing & psychosocial care
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