Cardio-oncology
Baseline and serial LVEF and GLS by the same method, CTRCD grading, and the other toxicities echo must find.
Numbers to remember
- Severe CTRCD: new LVEF <40% [15]
- Moderate: new LVEF fall ≥10 points to 40–49%, or <10 points to 40–49% with a relative GLS fall >15% or rising biomarkers [15]
- Mild: LVEF ≥50% with a relative GLS fall >15% and/or rising biomarkers [15]
- A relative GLS change <8% is unlikely to be real; >15% is likely abnormal [29]
Questions echo must answer
Cancer therapy-related cardiac dysfunction (CTRCD) is defined by the 2022 ESC cardio-oncology guideline using LVEF, GLS and biomarkers [15]. Echo, ideally 3D LVEF plus GLS, is the first-line imaging test at baseline and during follow-up [15,29]. The main errors are measurement variability and changing vendors. A 5-point EF change is within the noise of 2D biplane measurement.
- BaselineLVEF (3D preferred), GLS, diastolic function, valves, pericardium, RV and PASP before cardiotoxic therapy [15].
- SerialSame machine or vendor, same sonographer where possible, and the same views [29,90].
- GradeCTRCD severity from LVEF, relative GLS change and biomarkers [15].
- Other toxicitiesMyocarditis from immune checkpoint inhibitors, pericardial disease, radiation valve and pericardial disease, PH with dasatinib, vasospasm with fluoropyrimidines [15].
Acquisition protocol
- Apical3D LVEF if available, otherwise biplane. Use contrast if the endocardium is poorly seen [1,15].
- StrainGLS from A4C, A2C and A3C with a good frame rate. Record the vendor and software version [16,90].
- DiastolicE/e′, LAVI, TR velocity [2].
- RVTAPSE, S′ and PASP (RV dysfunction or PH with some agents) [3].
- ValvesAfter mediastinal radiotherapy: aortic and mitral thickening and calcification, including the aorto-mitral curtain.
- PericardiumEffusion and constriction [31].
- ComparisonSide-by-side with the baseline study, noting the relative change in GLS (%) and the absolute change in LVEF (points).
- LVEF (3D or biplane) and method
- GLS, vendor and software
- Relative GLS change from baseline
- Diastolic indices
- RV, PASP
- Valves and pericardium
- CTRCD grade (with biomarkers)
Diagnosis & severity
Asymptomatic CTRCD — ESC 2022 [15]
| Grade | Definition |
|---|---|
| Severe | New LVEF reduction to <40% |
| Moderate | New LVEF reduction ≥10 points to 40–49%, or <10 points to 40–49% plus a new relative GLS decline >15% or a new rise in cardiac biomarkers |
| Mild | LVEF ≥50% with a new relative GLS decline >15% and/or a new rise in cardiac biomarkers |
Symptomatic CTRCD is heart failure graded from mild to very severe [15].
Key pointGLS is compared as a relative change against the patient's own baseline on the same vendor. A relative fall of >15% is likely meaningful and <8% is unlikely to be [15,29].
Thresholds that change management
- Mild asymptomatic CTRCD → continue cancer therapy; consider ACE inhibitor or ARB and/or beta-blocker; monitor more often [15].
- Moderate → continue cancer therapy with cardioprotection after multidisciplinary discussion; in some regimens (HER2-targeted) pause temporarily [15].
- Severe → interrupt the cardiotoxic therapy; start HF therapy; discuss in a multidisciplinary team [15].
- Strain-guided cardioprotection (SUCCOUR): starting cardioprotection when GLS fell >12% relative did not change the primary LVEF endpoint overall, but fewer patients met the definition of CTRCD at 1 year [74].
- Survivors: echo 12 months after completing high-risk therapy and then long-term surveillance according to risk [15].
Pitfalls & mimics
PitfallA different vendor or software version can change GLS by 1–3 points, more than half of a "15% relative" change. Never compare across vendors without re-establishing the baseline [90].
- Loading conditions: dehydration, anaemia, fever and tachycardia during chemotherapy change LVEF and GLS. Note heart rate and blood pressure.
- 2D biplane LVEF variability is about ±10 points between observers. Prefer 3D or contrast in the same laboratory [1,15].
- Immune checkpoint myocarditis may have a normal LVEF. A fall in GLS, troponin, ECG changes and CMR are the clues [15].
- Radiation heart disease appears years later: aortic stenosis with a calcified aorto-mitral curtain, constriction and coronary disease.