Echocardiography in Cardio-Oncology


  • Echocardiography plays a central role in the field of cardio-oncology
  • Many of the trials use LVEF in the definition for cardio-toxicity
  • Ongoing area of research to determine how early and how best to predict cardiac complications of cancer therapy

Cardiac Complications of Chemotherapy and Radiation

  • Cardiomyopathies
    • LV dysfunction (HFpEF or HFrEF)
    • Myocarditis
    • Takotsubo
    • Thrombus
    • Infiltration
  • Vascular Disease
    • Arterial stiffness
    • Accelerated athersclerosis
  • Pericardial Disease
    • Tamponade
    • Constriction
  • Pulmonary Hypertension
    • RV Dysfunction
  • Valvular Disease
    • Regurgitation
    • Stenosis
    • Endocarditis
  • Arrhythmias
    • QTC prolongation
Circ Res 2016: An overview of the cardiovascular side effects of chemotherapy and radiation
ESC 2020: Assessment of Cardiotoxicity Risk

Frequency of Monitoring

  • Surveillance is initially stratified by baseline risk (low, medium, high) and then frequency is determined by chemotherapy cycles while on treatment and monthly after treatment
  • Recommendations vary greatly between guidelines
  • CCS does not have any recommendation for anthracyclines and recommends q3months for Anti-HER2
  • Example surveillance protocols below from ESC
Example Anthracycline Surveillance Protocol from ESC
ESC 2020: Echocardiographic surveillance during and after anthracycline chemotherapy
ESC 2020: Echocardiographic surveillance during and after HER2-targeted therapies
BSE 2021: Frequency of Echo Monitoring During Anthracycline or Anti-HER2

Echo Assessment

Definition of Cancer Treatment Related Cardiac Dysfunction (CRTCD)

  • EF drop of >10% from baseline and <50% (or 50%)
  • Relative reduction in GLS > 15% from baseline
ESC 2020: The difference in published defnitions of cardiotoxicity

Echo Protocol

ESC 2020: Parameters relevant for cardio-oncology surveillance: echocardiography protocol

LV Systolic Function


  • Acquisition
    • Images should be acquired at end-respiration
    • Simpsons method preferred
    • In atrial fibrillation use beats with similar R-R interval


  • Acquisition:
    • High-quality ECG with clear R-wave (used for software to trigger full volume)
    • Recommend breath hold with shallow breathing, preferably end-expiration (if deep inspiration needed, recommended to document and recreate at next exam)
    • Review images before patient patient leaves to look for stitch artifact and ensure if contouring possible
    • Some variations between software thus should use same machine and analysis software for serial echo
    • Sensitive to image quality thus 2D and 3D images should be taken
  • Benefits:
    • No assumptions made about LV geometry (ie. short axis view of ventricle is circular)
    • Ability to discriminate smaller % changes (5-8%)
    • Semi-automated and thus better intra- and interobserver variability


  • Poor endocardial definition can occur in patients post mastectomy, chest radiation or breast reconstruction surgery)
  • Contrast should be used when 2 contiguous LV segments from any apical view are no adequately visualized

LV Diastolic Function

  • Diastolic dysfunction may appear earlier than systolic dysfunction so important to acquire on each exam

Global Longitudinal Strain

  • Acquisition:
  • Interpretation
    • ASE 2015: “peak GLS in the range of -20% can be expected in a healthy person, and the lower the absolute value of strain is below this value, the more likely it is to be abnormal”
    • Cardiotoxicity defined as relative reduction in GLS > 15% from baseline
    • Currently being studied how well GLS can predict cardiotoxicity (SUCCOUR study + commentary)
Beginner’s Guide to Strain - Bonita Anderson
JACC 2015: Steps for Myocardial Strain Measurement
ASE 2015:Normal LV strain values from meta-analysis and individual recent publications using specific vendors’

Right Heart

  • Not officially included in the definition of cancer treatment related cardiac dysfunction
  • Recommended parameters as expected: RV dimenions, RV S’, TAPSE, TR Velocity, FAC
  • Certain cancer treatments can cause PH (dasatinib) and/or RV dysfunction (anthracycline, anti-HER2, cyclophosphamide, dasatinib)

Radiation Related Cardiac Dysfunction

  • Pericardial disease is the most frequent radiation related complication
    • Can occur months to years later 
    • Should assess for constriction and pericardial effusion
  • Valvular disease can occur with radiation
    • Fibrotic process which can cause leaflet thickening, shortening and calcifications that may result in stenosis or regurgitation
    • More often left-sided valves
    • Recommended to image 5 years after RT in high risk patients and 10 years in non high risk followed by q5years

Multimodal Imaging

  • CT
    • Useful in non-invasive evaluation of coronary disease, pericardial disease, and cardiac tumours
  • MRI
    • Useful in patients with poor echocardiographic windows
    • Great inter- intrareader variability and thus sensitive in detecting small changes in EF


Phillips EPIQ Strain Tutorial

Phillips Dynamic Heart Model (Single-Beat) Tutorial


The case of a 66‐year‐old female with invasive breast ductal carcinoma (ER+ HER2+) treated by the combination of doxorubicin, cyclophosphamide, paclitaxel, radiotherapy (35 Gy + 10) and trastuzumab. (A) Baseline apical two‐dimensional (2D) echocardiographic four‐, two‐ and three‐chamber views, showing normal left ventricular ejection fraction (LVEF), with speckle tracking‐derived bull's eye and normal global longitudinal strain (GLS). (B) Baseline three‐dimensional (3D) volumetric analysis of the left ventricle and left atrium; measurements are normal. (C) At 3‐month follow‐up, 2D LVEF remains normal, while 3D LVEF drops by 10% and GLS by 19%. This entailed the initiation of anti‐remodelling treatment with no interruption of oncologic drugs. (D) At 6‐month follow‐up, while continuing cancer and cardiac medications, the 3D LVEF reversed by 5%, and GLS recovered by 10%.

Further Reading

  • 2020 HFA/EACVI/ESC: Role of cardiovascular imaging in cancer patients receiving cardiotoxic therapies (html) (pdf)
  • 2021 BSE/BCOS: Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab (html) (pdf)
  • 2015 ASE/EACVI: Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults (html) (pdf)
  • 2015 JACC: Practical Guidance in Echocardiographic Assessment of Global Longitudinal Strain (html) (pdf)


  • Author: Atul Jaidka (MD, FRCPC, Cardiology Fellow)
  • Last Updated: March 24, 2021
  • Comments or questions please email