Routine cardiotoxicity echo screening for chemotherapy patients during COVID-19

Very recently, the European Association of Cardiovascular Imaging (EACVI) published recommendations on the COVID-19 pandemic and cardiac imaging¹. This paper states key points on indications for echocardiography and cleaning, disinfection, and protection of equipment, facilities and healthcare personnel.

But at the time of writing (15.04.2020) there are no data from either retrospective or prospective studies addressing the issue of echocardiography for cardiotoxicity screening in cancer patients receiving potentially cardiotoxic cancer therapies (for example anthracycline chemotherapy, trastuzumab, VEGF TKIs)² in the context of the current COVID-19 pandemic.

As a consequence, it is impossible to provide formal guidance or an official statement about this topic.

Below, however, is the consensus opinion of experts from the ESC Council of Cardio-Oncology.

General considerations and principles

• During an epidemic or pandemic of infectious disease, cancer patients should reduce visits to the hospital for investigations, consultations and/or treatments to a minimum, rationalising the risk/benefit of continuing monitoring with blood tests and/or echocardiography. Where possible, phone consultations or teleconsultations can replace selected visits.
• When required, surveillance echocardiography studies should be focused cardiac ultrasound study (FoCUS) answering specific questions¹ and acquired in the shortest possible time to limit contact between patients and healthcare professionals (HCPs).
• Direct cardiotoxicity during cancer treatment may also be evaluated by hs-Tn and BNP if the patient is undergoing blood tests already planned for the oncology pathway.
• Proper precautions and use of personal protective equipment (PPE) for HCPs, and proper disinfection of the environment and of the echocardiography machine and echocardiography probe are required. If possible, examinations should be performed in separate settings for non-COVID patients.

Acute setting

In an acute care situation, echocardiography should be performed as required in any cardiac emergency both in cancer patients and the general population, (e.g. suspected cardiac tamponade, acute coronary syndrome, acute heart failure).

Non-acute setting

In non COVID-19 patients:

• Echocardiography should be performed if there is a high probability of CV complications which justifies the risk to both the patient and HCPs.
• In very high-risk cancer patients hs-Tn and BNP levels should be monitored regularly.
• Very high-risk cancer patients with elevated biomarkers should undergo an echocardiogram to evaluate LV function.
• Patients undergoing cancer treatment who have low to moderate risk of CV toxicity AND who remain asymptomatic should have their echocardiograms postponed. In these patients, consider eventually checking hs-Tn and BNP levels. If biomarkers rise significantly, patients should be re-classified as at very high risk.
• In cancer patients with low absolute CV risk and low short-term likelihood of complications AND who are asymptomatic from a cardiovascular perspective, it is recommended to consider postponing echocardiography.

In COVID-19 patients:

• No routine echocardiography should be performed on a cancer patient with confirmed or suspected COVID-19.
• If a patient is continuing cardiotoxic cancer treatment AND develops new cardiac symptoms or significant increase of biomarkers, then echocardiography may be considered on a case-by-case basis, taking into consideration the risk/benefit to the patient and the risk to the echocardiography team.
• Remember that in COVID-19 infection troponin and/or BNP may rise. In a COVID-19 patient it may therefore be extremely difficult to attribute new cardiac dysfunction to cancer therapy or to the consequences of the viral infection.

In all settings

In all patients undergoing cancer treatment, specific indications where transthoracic echocardiography should be considered include:

• Ongoing cancer treatment with previous cardiac dysfunction
• Development of new symptoms suggestive of cardiotoxicity
• Development of a significant new ECG abnormality e.g. ST elevation, ST depression, new LBBB, new 2:1 or complete heart block
• New significant rise in cardiac troponin (>80ng/L) or natriuretic peptide (BNP >100ng/L, NT-proBNP >400pg/ml)
• Other suspected CV complication (pericarditis, pulmonary thromboembolism, etc.)

Specific studies regarding the role of echocardiography in cancer patients receiving cardiotoxic cancer therapies during a viral pandemic such as COVID-19 are required to guide care pathways in future.

Postponing or neglecting any required appropriate care because of the COVID-19 pandemic may result in increased event rates and must be very carefully considered.

Dr. Riccardo Asteggiano, MD, Chair of the Council

and the Board of the Council of Cardio-Oncology of the ESC