This state-of-the-art review by the American College of Cardiology (ACC) Cardio-Oncology and Imaging Councils presents updated and practical approaches for the use of multimodality cardiovascular imaging in the patients with cancer and comorbid cardiovascular disease, including testing recommendations to diagnose various cardiotoxicities including cardiomyopathy, atherosclerosis, vascular toxicity, myocarditis, and valvular heart disease. The following are 10 key points to remember:

1. Baseline assessment of left ventricular (LV) function should be performed within 3 months of planned cardiotoxic therapies. Long-term surveillance is reasonable in patients who have received cardiotoxic therapies, with yearly or bi-yearly imaging.
2. Patients with pre-existing cardiomyopathy should be monitored closely when receiving cardiotoxic therapies; for example, echocardiography should be performed prior to every anthracycline infusion.
3. Global longitudinal strain (GLS) is a more sensitive and reproducible measure of LV systolic function compared to ejection fraction (EF) and may detect subclinical cardiac dysfunction that precedes a decline in LVEF. The absolute GLS and the relative change compared to prior measurements should be reported.
4. Cardiac magnetic resonance imaging (CMR) is the gold standard for LVEF assessment, and can characterize myocardial tissue; differentiating ischemic from toxic, inflammatory, infiltrative, restrictive, or constrictive causes. Alternatives such as multigated acquisition (MUGA) can be used in patients with suboptimal echocardiographic windows and CMR incompatible implanted devices, or when CMR is not available. CMR can be useful in the diagnosis of immune checkpoint inhibitor myocarditis, using the Lake Louise criteria.
5. Echocardiography, CMR, and nuclear imaging are used in the diagnosis of cardiac amyloidosis. Imaging with 99mTc-pyrophosphate (PYP) is specifically useful for identifying ATTR amyloidosis, with 98% sensitivity and 96% specificity.
6. Standard serial computed tomography (CT) imaging performed for the diagnosis and staging of malignancy represents an opportunity for the early recognition and surveillance of atherosclerotic disease.
7. Coronary CT angiography is a useful noninvasive method to assess for obstructive coronary artery disease in states such as 5-fluorouracil vasospasm, immune checkpoint myocarditis, and takotsubo cardiomyopathy.
8. Pregnancy in cancer survivors with a history of cardiotoxicity is associated with a 47x increase in the risk of pregnancy-related LV dysfunction or heart failure, and thus should be monitored closely with a prepregnancy and serial echocardiography.
9. Cancer childhood survivors should undergo surveillance with echocardiography every 5 years or more frequently based on their risk of cardiotoxicity.
10. The choice and use of imaging modalities for the monitoring of cardiotoxicity should incorporate value-based care and resource availability.

Clinical Topics: Cardio-Oncology, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Amyloidosis, Anthracyclines, Atherosclerosis, Cancer Survivors, Cardiomyopathies, Cardiotoxicity, Computed Tomography Angiography, Coronary Artery Disease, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Immune Checkpoint Inhibitors, Magnetic Resonance Imaging, Myocarditis, Neoplasms, Pregnancy, Stroke Volume, Takotsubo Cardiomyopathy, Technetium Tc 99m Pyrophosphate, Tomography, X-Ray Computed, Vascular Diseases, Ventricular Function, Left

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