Chemotherapy-related cardiotoxicity: Bridging the gap between evidence and practice

Table 1 Suggested stepwise cardiotoxicity surveillance pathway for low- and middle-income countries settings

Phase	Key actions	Recommended tools	Frequency/timing	Intervention triggers
(1) Baseline assessment (pre-chemotherapy)	Assess cardiac history, risk factors. Perform baseline ECG, echocardiography (LVEF ± GLS if available), and troponin	2D echocardiogram (GLS optional); high-sensitivity troponin	Once before treatment	LVEF < 50% or elevated troponin → consider cardiology referral, optimization before therapy
(2) Surveillance during therapy (high-risk regimens)	Repeat troponin testing at mid-cycle and end-of-cycle. Echocardiogram only if troponin rises or symptoms develop	Troponin (hs-TnI or TnT); focused echo if abnormal	Mid-therapy and end-therapy	Troponin rise > 20% from baseline or new symptoms → initiate cardioprotective therapy, repeat echo
(3) End-of-treatment evaluation	Reassess LVEF and troponin. Document change in GLS if available	Echo ± GLS; troponin	Within 2-4 weeks after therapy	GLS decline ≥ 15% or LVEF drop ≥ 10% → start ACEi/BB therapy, closer follow-up
(4) Post-treatment follow-up	Annual troponin or echo for patients with prior abnormalities or cumulative anthracycline > 250 mg/m²	Troponin; limited echo	Every 12 months	Any new troponin elevation or LVEF decline → reinitiate monitoring or therapy

LVEF: Left ventricular ejection fraction; 2D: 2-dimension; GLS: Global longitudinal strain; ACEi: Angiotensin converting enzyme inhibitor; BB: Beta blockers; hs-TnI/TnT: High-sensitivity cardiac troponin I or T.