Rationale, design and baseline characteristics of the cardio-oncology registry (CARE) study: a prospective, observational study of cardiotoxic effects during breast cancer therapy

Incorporating poor oral health into pre-chemotherapy heart failure association/international cardio-oncology society (HFA-ICOS) baseline cardiovascular risk stratification

Pre-chemotherapy risk assessment using the Heart Failure Association – International Cardio-Oncology Society (HFA-ICOS) score helps identify patients at risk for cancer therapy–related cardiac dysfunction (CTRCD). [1] Oral health is a potentially modifiable factor that may contribute to cardiovascular vulnerability. [2] In the ROOT-CTRCD study, poor oral health was significantly associated with increased risk and delayed recovery of CTRCD in patients receiving HER2-targeted therapy. [3] Poor oral health was also evaluated as an additional point in the HFA-ICOS risk score to assess potential reclassification of risk (Fig. 1). This post-hoc analysis was conducted using data from the ROOT-CTRCD study. Among 604 patients treated with trastuzumab, 307 completed all planned cycles and had at least one year of follow-up. Patients with prior chemotherapy, major cardiovascular comorbidities, smoking, chronic kidney disease, ischemic heart disease, heart failure, dyslipidaemia, or established risk factors for periodontitis were excluded. The final analysis included 62 patients who developedCTRCDand 65 matched controls. Baseline oral health was assessed using the DMFT index and periodontal staging/grading.Patients were categorized into poor or good oral health groups.Logistic regression and receiver operating characteristic (ROC) analyses were performed, and positive and negative predictive values were calculated to evaluate the predictive value of oral health for CTRCD (Fig. 2).Results: Poor oral health was more frequent in the CTRCD group (40/62) than in controls (21/65), corresponding to an odds ratio of 3.8 (p < 0.001). ROC analysis of oral health alone yielded an AUC of 0.66, with a positive predictive value of 65.6% and negative predictive value of 66.7%. Incorporation of poor oral health as 1 additional point in the HFA-ICOS risk score would reclassify all previously low-risk patients as intermediate risk, potentially improving sensitivity for identifying patients at risk for CTRCD. Adding poor oral health to the pre-chemotherapy HFA-ICOS risk score may enhance early identification of patients at increased risk of CTRCD. These results support considering oral health as a modifiable risk factor in baseline cardiovascular risk assessment, and prospective studies are warranted to validate this approach.Figure 1  Figure 2

Baseline cardiovascular and cardiotoxicity risk in newly diagnosed breast cancer: insights from a nationwide turkish registry (CARPE DIEM-TR)

Cardiovascular disease and cancer share common risk factors, and recent ESC cardio-oncology guidelines recommend HFA-ICOS risk stratification to define treatment-related cardiotoxicity risk. Beyond cardiotoxicity, assessment of individual baseline cardiovascular event risk is essential to guide appropriate preventive strategies. This study aimed to assess baseline estimated 10-year cardiovascular disease risk, anthracycline-related cardiotoxicity risk, and variations in these risk profiles according to disease stage and pathological subgroups in women with newly diagnosed breast cancer enrolled in the CARPE DIEM-TR registry. The Cardiovascular Risk Profile and Events During Treatment of Breast Cancer Patients in Türkiye (CARPE DIEM-TR) registry was initiated in 2024 to evaluate baseline cardiovascular risk factors and subsequent cardiovascular events in women with newly diagnosed BC. Patients with available data enrolled up to 15 January 2026 were included. Anthracycline (AC) cardiotoxicity risk was assessed using the HFA-ICOS risk calculator, while 10-year cardiovascular disease risk was estimated using SCORE2 and its derivatives (SCORE2-Diabetes and SCORE2-OP), as appropriate. The study included 333 women with BC and available SCORE2 data. Mean age was 53.2±12.8 years and mean BMI was 28.5±5.4 kg/m²; 29.4% had a smoking history. Hypertension was present in 30.9%, diabetes in 18.6%, and coronary artery disease in 2.7%. The median 10-year CVD risk was 3.3% (0–60.9%), with 54.4% classified as low risk, 6.3% moderate, 30.6% high, and 8.4% very high risk. No patients were at very high AC cardiotoxicity risk, while 58.6% were at low risk for AC cardiotoxicity. Concordance between AC cardiotoxicity risk and SCORE2 categories is shown in the Sankey plot (Figure 1). Patients with available data on cancer stage, hormone receptor status, and HER2 status were further analyzed. Patients with locally advanced disease had higher non-HDL cholesterol (144.5±42.1 vs. 160.2±44.0; p=0.021), LDL cholesterol (120.3±34.7 vs. 137.3±39.4; p=0.004), and 10-year CVD risk (2.1% vs. 4.9%; p=0.032) compared with those with early-stage disease. Body mass index was significantly higher in HER2-positive patients than in HER2-negative patients (29.8±6.2 vs. 27.8 ± 5.3; p=0.045), while all other variables were comparable. No significant differences were observed between hormone receptor–positive and –negative patients (Table 1). HFA-ICOS cardiotoxicity risk and SCORE2 cardiovascular risk showed modest concordance, with many low cardiotoxicity–risk patients having high or very high baseline cardiovascular risk. Cardiovascular risk varied by tumor characteristics, with higher lipid levels and 10-year CVD risk in locally advanced disease and higher BMI in HER2-positive patients. These findings highlight the need for early, systematic cardiovascular risk assessment and individualized cardio-oncology strategies.Figure 1  

Exercise for the mitigation of cancer therapy-related cardiac dysfunction in breast cancer patients treated with anthracyclines: a systematic review and meta-analysis

Comparative performance of biomarker-based and biomarker-free HFA-ICOS models for predicting anthracycline-related cardiotoxicity

Cardio-oncology patients face an increased risk of chemotherapy-related cardiotoxicity (CTRCD). The Heart Failure Association (HFA)/International Cardio-Oncology Society (ICOS) score is a validated tool for cardiovascular (CV) risk stratification. Although cardiac biomarkers play a key role in CTRCD risk assessment and diagnosis, their availability in routine clinical practice remains limited. We aimed to compare the performance of the full HFA-ICOS model, incorporating cardiac biomarkers, with biomarker-free models, including a simplified clinical model and a modified model integrating baseline global longitudinal strain (GLS), in anthracycline-treated patients. We retrospectively analyzed 316 patients treated with anthracyclines across three centers. Baseline CV risk was assessed using the HFA-ICOS score. Three models were evaluated: (1) the full HFA-ICOS model including cardiac biomarkers (troponin and NT-proBNP), (2) the mini-HFA-ICOS model excluding biomarkers, and (3) a modified biomarker-free HFA-ICOS model including baseline GLS. CTRCD was defined according to the 2022 ESC guidelines. Discriminative performance was assessed using recever operating characteristic (ROC) curves, and comparisons between models were performed using DeLong’s test. Risk reclassification analyses were also conducted. Asymptomatic (27%, 39%, 46%, and 60%; p 0.017) and symptomatic CTRCD (1.3%, 4.6%, 13%, and 40%; p < 0.001) were more frequent in higher risk groups. For all CTRCD definitions, the full HFA-ICOS model showed higher discrimination than the mini model (AUC 0.640 vs 0.604; p = 0.004). When baseline GLS was incorporated into the biomarker-free model, discrimination was numerically improved compared with the mini model (AUC 0.643 vs 0.604; p = 0.0004) and was comparable to the full HFA-ICOS model (AUC 0.643 vs 0.640; p = 0.75), although differences in AUC did not reach statistical significance. When excluding mild asymptomatic CTRCD to minimize biomarker-related circularity, the modified biomarker-free HFA-ICOS model including GLS demonstrated discrimination comparable to the full and mini models (AUC 0.622 vs 0.617; p = 0.87; AUC 0.622 vs 0.605; p = 0.39). Compared with the full HFA-ICOS model, the mini model resulted in risk reclassification in 7.6% of patients, entirely driven by downgrading, whereas inclusion of GLS reduced discordance with the full model (5.1%) and reclassified 3.8% of patients compared with the mini model. While integration of cardiac biomarkers improves CTRCD risk stratification within the HFA-ICOS framework, baseline GLS provides meaningful incremental value when biomarkers are unavailable or when biomarker-independent CTRCD definitions are applied. GLS may therefore represent a pragmatic alternative to biomarkers for refining cardiotoxicity risk assessment in routine cardio-oncology practice.

Cardiac monitoring and incidence of cardiotoxicity cardiomyopathy among breast cancer patients undergoing anthracycline regimen chemotherapy: insight from a single centre study

Anthracyclines remain a cornerstone of breast cancer therapy but carry a significant risk of cancer therapy-related cardiac dysfunction (CTRCD). This study evaluates the incidence of CTRCD in an Indonesian setting using the latest 2022 ESC Cardio-Oncology guidelines, focusing on subclinical markers such as high-sensitivity Troponin I (hs-cTnI), Global Longitudinal Strain (GLS) and Mechanical Dispersion (MD). This retrospective analytical cohort study involved 98 breast cancer patients treated with anthracyclines at a national referral hospital in Indonesia from July 2018 to February 2020. Clinical assessments, hs-cTnI, and echocardiography (LVEF, GLS, and MD) were performed at baseline, 1, 3, and 6 months. CTRCD was defined per the 2022 ESC criteria. CTRCD occurred in 74.5% of patients, predominantly as asymptomatic mild cases (63.26%). While symptomatic CTRCD was relatively low (7.14%), asymptomatic dysfunction was detected as early as one-month post-chemotherapy. A significant progressive decline was observed in LVEF (68.2 ± 6.2% to 61.3 ± 8.8%, p  < 0.001) and GLS (-19.7 ± 2.9% to -17.1 ± 3.5%, p  < 0.001). Notably, mechanical dispersion significantly increased over time ( p  = 0.029), and median hs-cTnI surged from 1.6 ng/L to 82.2 ng/L ( p  < 0.001) by month 6. The high incidence of asymptomatic CTRCD underscores the inadequacy of relying on clinical symptoms alone. Integration of hs-cTnI, GLS, and mechanical dispersion monitoring is may be essential for early detection and enables timely cardioprotective intervention.

Impact of adjuvant hormone therapy on cardiac function and lipid profiles in breast cancer patients: a prospective cohort study

Advances in oncological treatment have improved survival in breast cancer patients, yet treatment-related cardiovascular (CV) toxicity remains a significant concern. Hormone therapy (HT) is a cornerstone of treatment for hormone receptor-positive breast cancer, but its direct effects on cardiac structure, function, and metabolic parameters are not fully understood. This study aimed to evaluate the impact of HT on longitudinal changes in cardiac function, assessed by echocardiography, and metabolic parameters in breast cancer patients who had complete cardiotoxic chemotherapy. A single-centre, prospective cohort study was conducted at a tertiary referral cancer centre between March 2015 and April 2022. We enrolled 579 breast cancer patients who completed chemotherapy (anthracycline or HER2-targeted agents) and underwent serial echocardiography and lipid profile testing. Patients were divided into two groups; those receiving adjuvant HT (n=297) and those who did not (n=282). The primary outcome was the change in left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), and serum lipid levels from baseline in final follow-up (median 372 days). Baseline characteristics and cumulative anthracycline doses were comparable between groups. At the final follow-up, the HT group demonstrated a significantly greater decline in LVEF (59.9±7.2% vs. 62.0±6.4%, P <0.001) and more impaired GLS (-16.8±3.3% vs. -18.5±3.1%, P <0.001) compared to the non-HT group. Cancer therapeutics-related cardiac dysfunction (CTRCD) occurred more frequently in the HT group (12.5% vs. 7.1%, P=0.030). Furthermore, HT was associated with significant increase in total cholesterol and low-density lipoprotein (LDL) cholesterol (estimated mean difference 6.16 mg/dL, P <0.001). Longitudinal changes in LDL-cholesterol were inversely correlated with LVEF changes (partial γ=-0.151, P <0.001) and positively correlated with GLS changes (partial γ=0.209, P <0.001). No significant difference was observed in the 2-year incidence of heart failure hospitalization or urgent visits between the groups (4.7% vs. 3.2%, P=0.335). Adjuvant HT in breast cancer patients is associated with significant elevations in LDL-cholesterol and a subclinical deterioration in cardiac systolic function. These findings suggest that HT-induced dyslipidaemia may contribute to subclinical cardiac dysfunction, highlighting the need for proactive CV monitoring and metabolic management in this population.Relation between lipid and systolic func  Clinical outcome