ESC risk categories for asymptomatic adult cancer survivors
| Risk category* | Patient characteristics |
| Very high risk | Very high baseline cardiovascular toxicity risk pretreatment |
| Doxorubicin† ≥400 mg/m2 | |
| RT >25 Gy MHD‡ | |
| RT >15–25 Gy MHD‡+doxorubicin† ≥100 mg/m2 | |
| Early high risk (<5 years after therapy) | High baseline cardiovascular toxicity risk |
| Symptomatic or asymptomatic moderate-to-severe CTRCD during treatment | |
| Doxorubicin† 250–399 mg/m2 | |
| High-risk HSCT§ | |
| Late high risk | RT >15–25 Gy MHD‡ |
| RT 5–15 Gy MHD¶+doxorubicin† ≥100 mg/m2 | |
| Poorly controlled cardiovascular risk factors | |
| Moderate risk | Moderate baseline cardiovascular toxicity risk |
| Doxorubicin† 100–249 mg/m2 | |
| RT 5–15 Gy MHD¶ | |
| RT <5 Gy MHD**+doxorubicin† ≥100 mg/ m2 | |
| Low risk | Low baseline cardiovascular toxicity risk and normal end-of-therapy cardiac assessment |
| Mild CTRCD during therapy but recovered by the end of cancer | |
| RT <5 Gy MHD** | |
| Doxorubicin†, 100 mg/m2 |
*RT risk categorisation based on MHD is recommended over categorisation based on prescribed dose, which may not accurately reflect cardiac radiation exposure. Depending on dose distribution and exposure of specific cardiac substructures (as well as clinical risk factors), the treatment team may judge the patient to belong to a higher risk category. In addition, a patient may be judged to belong to a lower risk category in case only a small part of the heart is exposed to a relatively high prescribed dose.
†Or equivalent.
‡Or prescribed RT ≥35 Gy to a volume exposing the heart if MHD is not available. Note that in this case, the limited information about cardiac exposure does not allow one to distinguish between high-risk and very high-risk categories.
§High-risk HSCT patients: allogenic HSCT; pre-existing CVD or multiple uncontrolled cardiovascular risk factors; cancer treatment history (mediastinal or mantle field radiation, alkylating agents, >250 mg/m2 doxorubicin or equivalent); conditioning schemes (total body irradiation, alkylating agents); development of GVHD.
¶Or prescribed RT 15–34 Gy to a volume exposing the heart if MHD is not available.
**Or prescribed RT, 15 Gy to a volume exposing the heart if MHD is not available.
CTRCD, cancer therapy-related cardiac dysfunction; CVD, cardiovascular disease; ESC, European Society of Cardiology; GVHD, graft-versus-host disease; Gy, Gray; HSCT, haematopoietic stem cell transplant; MHD, mean heart dose; RT, radiotherapy.