CV Imaging in Contemporary Cardio-Oncology: Key Points

Addison D, Neilan TG, Barac A, et al., on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention; Cardio-Oncology Committee of the Council on Clinical Cardiology and Council on Genomic and Precision Medicine; and Council on Cardiovascular and Stroke Nursing.
Cardiovascular Imaging in Contemporary Cardio-Oncology: A Scientific Statement From the American Heart Association. Circulation 2023;Sep 21:[Epub ahead of print].

The following are key points to remember from an American Heart Association (AHA) Scientific Statement on cardiovascular (CV) imaging in contemporary cardio-oncology:

  1. This AHA Scientific Statement provides an extensive overview of the use of multimodal CV imaging in the management of patients with cancer, with highly informative tables and figures that are worth maintaining as references.
  2. Echocardiography is the first-line imaging modality for screening and monitoring left ventricular function in patients receiving potentially cardiotoxic cancer therapies. Baseline left ventricular ejection fraction (LVEF) assessment using 3D echocardiography is suggested before anthracycline and human epidermal growth factor receptor 2-positive (HER2)-targeted therapy initiation. Serial echocardiograms during and after treatment should include LVEF and global longitudinal strain.
  3. Cardiac magnetic resonance imaging can provide complementary tissue characterization beyond LVEF to detect inflammation, fibrosis, or perfusion abnormalities. It is most useful when echocardiography is limited by poor acoustic windows or when diagnostic uncertainty exists, such as in suspected myocarditis or heart failure with preserved EF.
  4. Coronary calcium scoring and cardiac computed tomography angiography plays an important role in risk-stratification and evaluating for obstructive coronary artery disease, particularly in high-bleeding-risk cancer patients where invasive angiography poses heightened risk. It can also accurately assess cardiac anatomy, masses, valves, and pericardial disease.
  5. Myocardial perfusion imaging with nuclear techniques (single-photon emission computed tomography/positron emission tomography [SPECT/PET]) is applicable for assessing suspected myocardial ischemia in symptomatic cancer patients during treatment. PET with novel tracers shows promise for detecting immunotherapy-related inflammation if supported by larger trials.
  6. Cardiac PET holds potential for detecting chemotherapy-related inflammation and microvascular dysfunction, though not yet established as routine practice. SPECT aids in noninvasive diagnosis of cardiac amyloidosis using bone-avid tracers.
  7. In clinical practice, cancer patients with cardiac risk factors or receiving high-risk therapies (e.g., anthracyclines, HER2 inhibitors) should be prioritized for serial CV imaging surveillance during treatment to detect subclinical toxicity.
  8. CV imaging guidelines should be integrated into oncology clinical pathways and survivorship care plans to promote appropriate utilization among oncologists responsible for cancer therapy surveillance.
  9. Multidisciplinary cardio-oncology programs are well-suited to provide evidence-based, protocol-driven CV imaging surveillance and optimize coordination of cardiology and oncology care.
  10. Real-world data on imaging practices and outcomes from large databases, registries, and electronic health records are needed to inform evidence-based CV imaging protocols.

Clinical Topics: Cardio-Oncology, Noninvasive Imaging, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Cardio-oncology, Cardiotoxicity, Echocardiography, Magnetic Resonance Imaging, Positron-Emission Tomography

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