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Consensus statement outlines imaging strategies for cardiac dysfunction after cancer therapy
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Chemotherapy-related cardiac dysfunction is a common adverse event after cancer treatment, and echocardiography should be used to monitor and diagnose it, according to a new consensus statement.
According to the document, written by a panel of the American Society of Echocardiography and the European Association of Cardiovascular Imaging, chemotherapy-related cardiac dysfunction is defined as a decrease in left ventricular ejection fraction by more than 10 percentage points to less than 53% after chemotherapy.
“This decrease should be confirmed by repeat cardiac imaging,” Juan Carlos Plana, MD, FASE, chair of the panel, and colleagues wrote. “The repeat study should be performed 2 to 3 weeks following the baseline diagnostic study showing the initial decrease in LVEF. [LVEF] decrease may be further categorized as symptomatic or asymptomatic, or with regard to reversibility.”
Echocardiography is best method
Echocardiography is the preferred method for evaluation of cardiac dysfunction in patients with cancer, and 3-D echocardiography should be used if available because, unlike 2-D echocardiography, it is good at detecting small changes in LV contractility, Plana, of Cleveland Clinic, and colleagues wrote.
Other advantages include “better accuracy in detecting LVEF below the lower limit of normal, better reproducibility and lower temporal variability,” they wrote.
An assessment of LV diastolic function should be included, but clinicians should keep in mind that changes in diastolic parameters may be the result of adverse events from chemotherapy as opposed to a real change in LV diastolic performance, the panel wrote.
An assessment of right ventricular chamber and function should also be included, although the prognostic value of right ventricular dysfunction in this population is not known because the right ventricle could be involved in the cardiac dysfunction, according to the panel.
The panel also recommended that patients with baseline or changing valvular findings during chemotherapy have re-evaluation of valve structure and function on serial echocardiograms during and after treatment.
Pericardial disease should be assessed because it may be related to cardiac metastasis, and signs of cardiac tamponade should be investigated, they wrote. Any diagnosis of cardiac tumors should be confirmed with cardiac MRI, according to Plana and colleagues.
Contract agents are not recommended for longitudinal follow-up with 3-D echocardiography, but may be used when two contiguous LV segments are not well visualized on noncontrast images, according to the document.
Stress echocardiography may help with diagnosis in patients who are at risk for CAD and are taking a therapy known to cause ischemia, Plana and colleagues wrote.
The statement contains several recommendations regarding detection of subclinical LV dysfunction. One is that in patients with available baseline strain measurements, “a relative percentage reduction of global longitudinal strain <8% from baseline appear not to be meaningful, and those >15% from baseline are very likely to be abnormal.”
Other modalities
Mutigated blood pool imaging is an alternative diagnostic method that is reproducible, but limitations include radiation exposure and inability to report on pericardial disease, valvular disease and right ventricular dysfunction, according to the panel.
Cardiac MRI is suitable for use when calculation of LVEF is difficult via echocardiographic or equilibrium radionuclide angiography, but availability may be limited and safety standards must be strictly followed, Plana and colleagues wrote.
Disclosure: See the full statement for the panel members’ relevant financial disclosures.
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