---
title: Cardiotoxicity of cancer treatment
description: What cardiotoxicity is — weakening of the heart muscle and other heart problems during cancer treatment — which treatments can contribute to it, why the heart is checked before, during and after treatment, which symptoms to report to a doctor straight away and how it is treated.
type: disease
aliases:
  - cardiotoxicity
  - chemotherapy cardiotoxicity
  - cancer therapy-related cardiac dysfunction
  - cancer therapy-related cardiomyopathy
  - cardio-oncology
  - CTRCD
sources:
  - tier: guideline
    org: esc
    title: 2022 ESC Guidelines on cardio-oncology
    year: 2022
    doi: 10.1093/eurheartj/ehac244
    url: https://doi.org/10.1093/eurheartj/ehac244
  - tier: guideline
    org: minzdrav-rf
    title: Дилатационная кардиомиопатия
    year: 2025
    doi: 10.15829/1560-4071-2026-6672
    url: https://cr.minzdrav.gov.ru/view-cr/1008_1
  - tier: guideline
    org: minzdrav-rf
    title: Хроническая сердечная недостаточность
    year: 2024
    doi: 10.15829/1560-4071-2024-6162
    url: https://cr.minzdrav.gov.ru/view-cr/156_2
  - tier: reference
    org: statpearls
    title: Anthracycline Toxicity
    year: 2024
    url: https://pubmed.ncbi.nlm.nih.gov/38261713/
  - tier: reference
    org: statpearls
    title: Radiation-Induced Cardiac Toxicity
    year: 2023
    url: https://pubmed.ncbi.nlm.nih.gov/32119340/
sources_checked: 2026-10-14
review: null
---

Some cancer treatments can increase the risk of heart and blood vessel problems; these complications are called cardiotoxicity, or cardiovascular toxicity.<Cite n={1} /> One of them is weakening of the heart muscle, which can develop into [heart failure](../heart-failure/), when the heart does not pump blood properly.<Cite n={1} /> The European Society of Cardiology (ESC) calls it cancer therapy-related cardiac dysfunction, and the Russian Ministry of Health describes cardiomyopathy related to anticancer therapy in its guideline on [dilated cardiomyopathy](../dilated-cardiomyopathy/).<Cite n={[1, 2]} />

Cardiotoxicity does not happen to everyone: most people go through cancer treatment without heart or blood vessel complications.<Cite n={1} /> Fear of such complications should not stop anyone from getting the best treatment for their cancer.<Cite n={1} />

<Diagram name="cancer-therapy-related-cardiac-dysfunction">
  <p slot="normal">
    The diagram shows the <Structure id="left-ventricle">left ventricle</Structure> in a
    lengthwise section: the solid outline is before contraction, the dashed one after contraction
    before treatment starts. If cancer treatment may harm the heart, baseline tests may be done
    before it starts, for example a heart ultrasound (echocardiography): it shows how well the
    heart is working, and results during treatment are later compared with it.<Cite n={1} />
  </p>
  <p slot="disease">
    With cardiotoxicity the heart muscle weakens: the same ventricle contracts more weakly and
    pumps blood less well.<Cite n={1} /> The dashed outline shows how it contracted before
    treatment: if baseline tests were done, cardiologists compare new results with them and look
    for any changes.<Cite n={1} />
  </p>
</Diagram>

## Why it happens

<Patient>

Weakening of the heart muscle is most often linked to anthracyclines, one group of chemotherapy drugs, and to drugs against the HER2 protein (anti-HER2 therapy); less often to other groups of anticancer drugs.<Cite n={2} /> According to the Russian Ministry of Health guideline, damage after anthracyclines is irreversible, while heart weakening with anti-HER2 therapy is potentially reversible: these drugs do not kill heart muscle cells.<Cite n={2} />

Radiotherapy to the chest can also harm the heart, for example in Hodgkin lymphoma, lung cancer and breast cancer.<Cite n={5} /> Its late effects — [coronary heart disease](../coronary-heart-disease/), valve disease and heart failure — can appear months to years later, sometimes 20 years or more.<Cite n={5} />

The risk depends on three main things: how healthy the heart is before treatment, how risky the treatment itself is for the heart, and how the heart changes during treatment.<Cite n={1} /> It is raised by age, previous cancer treatment, heart risk factors such as high blood pressure, and lifestyle.<Cite n={1} /> People who already have heart disease are at higher risk, but this usually does not stop them from getting the best cancer treatment.<Cite n={1} />

</Patient>

<Student>

According to the Russian Ministry of Health guideline, the key mechanism of anthracycline cardiotoxicity is inhibition of topoisomerase 2β, which leads to double-strand DNA breaks and cardiomyocyte death.<Cite n={2} /> StatPearls calls this type 1 cardiotoxicity — dose-dependent and irreversible cardiomyocyte death leading to dilated cardiomyopathy and heart failure.<Cite n={4} /> According to the Russian Ministry of Health guideline, anti-HER2 therapy has no cytotoxic effect and does not cause cardiomyocyte death, so the dysfunction it causes is potentially reversible.<Cite n={2} /> After anthracyclines, cardiomyopathy and heart failure can develop several months or years after the end of therapy.<Cite n={2} />

The Russian Ministry of Health guideline lists as risk factors female sex, genetic factors, age over 65 or under 18 years, smoking, renal failure, combining anthracyclines with alkylating agents or radiotherapy, raised cardiac biomarkers at baseline, reduced left ventricular ejection fraction (LVEF) at baseline and electrolyte disturbances.<Cite n={2} /> For radiation cardiotoxicity, StatPearls names higher radiation doses, combination with cardiotoxic chemotherapy, irradiation of the left side of the chest and pre-existing cardiovascular disease.<Cite n={5} />

</Student>

## Symptoms

<Patient>

Heart weakening may cause no symptoms, and it is important to find signs of cardiotoxicity early, before they turn into a serious complication.<Cite n={[1, 2]} /> During and after cancer treatment, tell your doctor straight away if you get chest pain, shortness of breath, swelling of one or both legs, feeling faint or dizzy, unusual tiredness or a fast heartbeat.<Cite n={1} /> If chest pain is severe or does not go away, breathlessness is severe or you have fainted, do not wait for an appointment: call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK). Not every heart problem during cancer treatment is caused by the treatment itself: doctors may look for other causes.<Cite n={1} />

Cancer treatment can also cause other heart and blood vessel complications: high blood pressure, [myocarditis](../myocarditis/), arrhythmias, [deep vein thrombosis](../deep-vein-thrombosis/) and [pulmonary embolism](../pulmonary-embolism/).<Cite n={1} />

</Patient>

<Student>

The 2022 ESC guidelines give a new international definition of cancer therapy-related cardiovascular toxicity.<Cite n={1} /> The ESC divides cardiac dysfunction into symptomatic — heart failure from mild to very severe, the most severe requiring inotropic or mechanical circulatory support or consideration of transplantation — and asymptomatic: mild, moderate and severe, by a fall in LVEF, a fall in global longitudinal strain (GLS) from baseline and a rise in cardiac biomarkers.<Cite n={1} /> The Russian Ministry of Health guideline gives an ESC definition based only on a fall in LVEF on echocardiography.<Cite n={2} />

</Student>

## How it is diagnosed

<Patient>

Before treatment that may harm the heart, the risk of heart and blood vessel complications is assessed, and doctors discuss the result with the patient.<Cite n={1} /> If the treatment carries little or no risk to the heart, no separate heart tests are needed.<Cite n={1} /> If the risk is low, cancer treatment starts without delay; if it is high, the person is referred to a cardiologist before treatment starts.<Cite n={1} />

Tests may include an [ECG](../../diagnostic/ecg/), blood tests for troponin and [natriuretic peptides](../../diagnostic/natriuretic-peptides/) (BNP, NT-proBNP), and a [heart ultrasound (echocardiography)](../../diagnostic/echocardiography/), cardiac MRI or CT.<Cite n={1} /> These substances are released into the blood when the heart is damaged or under strain.<Cite n={1} /> The main method for assessing how the heart works is echocardiography.<Cite n={[1, 2]} /> Which tests are needed and when is decided by the treating doctor.

</Patient>

<Student>

The ESC recommends cardiovascular toxicity risk stratification for all patients with cancer before potentially cardiotoxic therapy, and an ECG for all as part of the baseline assessment.<Cite n={1} /> Baseline echocardiography is recommended for all patients before anthracyclines and before anti-HER2 therapy; the Russian Ministry of Health heart failure guideline also recommends echocardiography when planning and giving treatment with potential cardiotoxic effects.<Cite n={[1, 3]} /> Echocardiography is the first-line method; GLS is recommended to detect early, asymptomatic LV dysfunction, and cardiac MRI if echocardiography is non-diagnostic.<Cite n={[1, 2]} />

</Student>

## How it is treated

<Patient>

Care is shared by a cardiologist, an oncologist or haematologist, and a radiation oncologist.<Cite n={2} /> If a heart problem appears during cancer treatment, doctors decide whether to continue the treatment, pause it or switch to another one; the decision is made together with the patient.<Cite n={1} /> If heart failure develops, it is treated according to the usual principles, described in [its article](../heart-failure/).<Cite n={[1, 2]} /> The outlook largely depends on how early the heart damage is found and treatment started.<Cite n={2} />

Risk factors — blood pressure, cholesterol, diabetes — are managed before, during and after cancer treatment.<Cite n={1} /> For people at high risk, doctors may prescribe medicines that protect the heart.<Cite n={1} /> Stopping smoking, drinking less alcohol, staying as active as you can and eating healthily help.<Cite n={1} /> Do not stop blood pressure or heart medicines on your own without talking to your doctor.<Cite n={1} /> If you have a pacemaker or a defibrillator, tell your medical team before radiotherapy.<Cite n={1} />

After potentially cardiotoxic treatment, the ESC recommends regular heart check-ups.<Cite n={1} /> The risk of long-term effects is higher after anthracyclines, chest radiation and long-term hormonal treatment, for example for prostate cancer.<Cite n={1} /> Heart disease can also appear years after treatment for childhood cancer, so these people need regular follow-up with their doctors.<Cite n={1} /> For women who received anthracyclines or chest radiation as a child, adolescent or young adult, the ESC advises a cardiology assessment before or early in pregnancy.<Cite n={1} /> Doctors decide which treatment and follow-up are needed.

</Patient>

<Student>

The approach depends on the severity of the dysfunction and on symptoms.<Cite n={1} /> For symptomatic dysfunction during anthracycline treatment, heart failure therapy is recommended; for severe symptomatic dysfunction, stopping anthracyclines; for moderate, a temporary interruption and a multidisciplinary team decision on restarting.<Cite n={1} /> For mild asymptomatic dysfunction during anti-HER2 therapy, continuing treatment with more frequent cardiac monitoring is recommended.<Cite n={1} /> The Russian Ministry of Health guideline recommends discussing continuation of cardiotoxic therapy in a multidisciplinary team and with the patient.<Cite n={2} />

For primary prevention in high-risk patients, the ESC (in those receiving anthracyclines and/or anti-HER2 therapy) and the Russian Ministry of Health guideline allow ACE inhibitors or angiotensin receptor blockers and beta-blockers; this is a class IIa recommendation, and the decision rests with the doctor.<Cite n={[1, 2]} /> If severe dysfunction develops during cancer treatment, long-term continuation of cardiac medication is recommended.<Cite n={1} />

</Student>

## When to call an ambulance

Report any new heart symptoms during and after cancer treatment to your treating doctor straight away.<Cite n={1} /> The signs that need an ambulance straight away are described in the articles on acute [heart failure](../heart-failure/), [myocardial infarction](../myocardial-infarction/) and [pulmonary embolism](../pulmonary-embolism/). As with any heart or blood vessel condition, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) for fainting, chest pain or severe breathlessness: this is the site's general safety rule, repeated at the bottom of every page.

<Quiz />