wileyonlinelibrary.com/journal/echo Echocardiography. 2018;35:860–868.
© 2018 Wiley Periodicals, Inc.
It is estimated that roughly 1.7 million new cancer cases will be diag-
nosed and approximately 609 640 are expected to die of cancer in
2017 in the USA alone.
This represents 1 in 4 deaths due to cancer,
only surpassed by heart disease. We have made tremendous strides
in combating cancer; however, we are faced with a new foe which in-
volves premature cardiac disease in the patients with cancer, largely
due to the chemotherapeutics and/or radiation treatment. Thus, a
new discipline has been created, onco- cardiology/cardio- oncology,
which specializes in caring for the patients suffering from cancer
therapeutic- related cardiac dysfunction (CTRCD).
Historically, several definitions of cardiotoxicity have been pro-
In 1982, the National Cancer Institute (NCI) implemented
the Common Terminology Criteria (CTC) to better define and cat-
egorize adverse events including cardiotoxicity. Over the years,
these criteria have changed attempting to become more inclusive
while maintaining the specificity. Now, the CTC have evolved under
the NCI’s Cancer Therapy Evaluation Program (CTEP) to become
Common Terminology Criteria for Adverse Events (CTCAE) and are
currently on its fifth version. However, the most specific description
of cardiomyopathy was formulated by the cardiac review and eval-
uation committee supervising trastuzumab clinical trials, which de-
fined drug- associated cardiotoxicity as one or more of the following:
(1) cardiomyopathy characterized by a decrease in left ventricular
ejection fraction (LVEF) globally or due to regional changes in inter-
ventricular septum contraction; (2) symptoms associated with heart
failure (HF); (3) signs associated with HF, such as S3 gallop, tachy-
cardia, or both; and (4) decline in initial LVEF of at least 5% to <55%
with signs and symptoms of heart failure or asymptomatic decrease
in LVEF of at least 10% to <55%.
This description has a limited scope
as it does not encompasses all the cardiotoxic effects secondary to
chemotherapy (which was the original intention), albeit it does serve
well as a definition for cardiomyopathy.
Evolution of echocardiography in subclinical detection of
cancer therapy– related cardiac dysfunction
Department of Cardiology, MD Anderson
Cancer Center, The University of Texas,
Houston, TX, USA
Rohit Moudgil, Department of Cardiology,
MD Anderson Cancer Center, Houston, TX,
Cancer therapies have resulted in increased survivorship in oncological patients.
However, the benefits have been marred by the development of premature cardio-
vascular disease. The current definition outlines measurement of ejection fraction as
a mean to diagnose cancer therapeutic– related cardiac dysfunction (CTRCD); how-
ever, up to 58% of the patients do not regain their cardiac function after the CTRCD
diagnosis, despite therapeutic interventions. Therefore, there has been a growing
interest in the markers for early myocardial changes (ie, changes with normal left
ventricular ejection fraction [LVEF]) that may predict the development of subsequent
left ventricular ejection fraction reduction or progression to heart failure. This review
will highlight the use of diastolic parameters, tissue Doppler imaging (TDI), and
speckle tracking echocardiogram (STE) as emerging technologies which can poten-
tially detect cardiac dysfunction thereby stratifying patients for cardioprotective
therapies. The goal of this manuscript was to highlight the concepts and discuss the
current controversies surrounding these echocardiographic imaging modalities.
cancer therapy–related cardiac dysfunction, global longitudinal strain, speckle tracking
echocardiogram, strain imaging, tissue Doppler