ABC | Volume 112, Nº3, March 2019

Review Article Jorge et al Imaging for chemotherapy-related ventricular dysfunction Arq Bras Cardiol. 2019; 112(3):309-316 Figure 1 – Proposal for cardiovascular monitoring of patients undergoing chemotherapy based on information in the literature and authors’ expertise. ECG: electrocardiogram; CT: chemotherapy; RT: radiation therapy; 2D-ECHO: two-dimensional echocardiography; RNV: radionuclide ventriculography; CMRI: cardiac magnetic resonance imaging; ECHO: echocardiography. • Few risk factors or diseases • Normal clinical exam • Normal ECG • CT with low cardiotoxic potential • Absence of prior CT or RT • Presence of risk factors or diseases • Abnormal clinical exam • Abnormal ECG • CT with considerable cardiotoxic potential • Prior CT or RT In the event of doubts or poor image quality: RNV or CMRI CLINICAL EVALUATION (anamnesis + physical exam + ECG) Symptoms? Risk factors? Prior disease? Cardiotoxic potential of previous or proposed treatment? LOW RISK Normal ECHO and normal strain Normal ECHO and ↓ strain Altered ECHO Normal ECHO and normal strain Normal ECHO and ↓ strain Altered exam image Clinical follow-up Clinical follow-up and 2D-ECHO at the end of treatment Individualized follow-up and evaluation Clinical follow-up and 2D-ECHO at the end of treatment Clinical follow-up and 2D-ECHO in the middle and at the end of treatment Individualized follow-up and evaluation INTERMEDIATE or HIGH RISK Pre-CT 2D ECHO with with strain Myocardial tissue characterization by CMRI may detect early myocardial injury during CT and identify subclinical myocardial alterations in cancer survivors; however, prospective studies are needed to confirm this hypothesis. The cost-effectiveness of using CMRI in comparison with other sequential follow-up techniques for patients undergoing CT still needs to be quantified. Cardiac computed tomography (coronary angiotomography) Coronary angiotomography is a method with growing clinical applicability that uses low doses of radiation (1–2 mSv) and iodinated contrast (50 mL). 57 In addition to its classical indications, it is possible to quantify the volumes and ejection fractions of both ventricles. 58 After the study by Nacif et al., 59 the use of angiotomography for the quantification of myocardial interstitial fibrosis via the quantification of VEC may be of great clinical utility. VEC values greater than 35% are associated with interstitial fibrosis. Rational approach strategy for early detection of CTX In Figure 1, we propose a flowchart showing the rational approach for patients undergoing CT. This algorithm is based on a review of the literature and the authors’ expertise. It thus lacks validation in randomized controlled clinical trials. This approach should be adapted to the reality of each service’s supply and demand conditions. 8 Faced with a cancer patient, the following steps are recommended: (a) integrated actions, shared by cardiologists and oncologists, within a multidisciplinary team; (b) clinical evaluation of estimated global cardiovascular risk, previous diseases, previous chemo- or radiotherapy and, when indicated, specific intervention prior to CT; (c) within the institution’s limitations, consider two-dimensional echocardiography with measurements of strain. (d) In the event that baseline cardiac evaluation is not available for all patients, prioritize those with high risks of CTX, such as those with CVD or cardiovascular risk factors; LV systolic dysfunction; over 65 years of age; a regimen with doses of ANT (DOX) greater than 350 mg/m²; or combination CT (Figure 1). If one the following is detected in a patient being monitored: LVEF < 53%, LVGLS below the lower limit of normality, or elevated troponins, in the absence of symptoms, the cardiologist should be consulted and the risk-benefit ratio related of CT discussed with the oncologist. Whether to continue or not is, however, the oncologist’s decision. The healthcare flowcharts depend on the cardiotoxic potential of the CT regimen. In accordance with documents by the American and European societies of echocardiography, patients with cumulative doses below 240 mg/m² of DOX should repeat the cardiac evaluation at the conclusion of the CT regimen and 6 months later. 8 In patients with doses above 240 mg/m² there should be a new evaluation before each additional 50 mg/m² cycle. In patients receiving TZU, there should, ideally, be an echocardiogram every 3 months. 8 Owing to the unavailability of data, in patients undergoing therapy with vascular endothelial growth factor inhibitors, evaluation with echocardiography 1 month after the initial dose and, subsequently, every 3 months, is recommended. 8 313