The utility of serial global longitudinal strain and biomarkers in identifying subclinical cardiotoxicity in cancer patients receiving anthracycline or trastuzumab therapy

Abstract Background Cancer therapy–related cardiac dysfunction (CTRCD) has become an increasingly common clinical concern due to the growing use and effectiveness of cancer treatments that may adversely affect cardiac function. Transthoracic echocardiography (TTE) remains the primary and most widely utilized non-invasive imaging modality for the routine screening and assessment of CTRCD. The primary objective in clinical practice is to facilitate the early identification of subclinical cardiac dysfunction. Early detection is critical, as it enables timely intervention to prevent the progression of cardiac damage and supports the continuation of potentially life-saving cancer therapies with minimal cardiovascular compromise. Purpose Evaluate the role of risk stratification, imaging and biomarkers in cardio-oncology patients. Methods A total of eighty-eight cancer patients scheduled to receive Anthracycline and/or Trastuzumab (AC/TZB) therapy were prospectively enrolled. Baseline cardiovascular evaluation included two-dimensional transthoracic echocardiography (2D TTE), global longitudinal strain (GLS), and measurement of cardiac biomarkers—troponin I and N-terminal pro-B-type natriuretic peptide (NT-proBNP)—prior to initiation of cancer therapy. Follow-up assessments were conducted at three and six months intervals using the same imaging and biomarkers. The aim was to facilitate the early detection of CTRCD and to initiate cardioprotective therapy (CPT) at the earliest signs of cardiac impairment. Results Out of the 88 patients, 26 of them (29.5%) developed cancer therapy–related cardiac dysfunction (CTRCD). Among them, 18 patients exhibited mild asymptomatic dysfunction, while 8 developed moderate asymptomatic CTRCD, defined by relative reductions in global longitudinal strain (GLS) and left ventricular ejection fraction (LVEF). The relative percentage change in GLS from the baseline was a reliable marker for early detection of CTRCD. At 3 months, a GLS reduction greater than 16.6% was significantly associated with the development of CTRCD (P 0.001; 95% CI: 0.783–0.934). At 6 months, a reduction exceeding 10.1% maintained its predictive value (P 0.001; 95% CI: 0.765–0.935). Patients with mild asymptomatic CTRCD demonstrated approximately twofold higher NT-proBNP levels compared to those without dysfunction, with a median value of 99.50 pg/mL at the 3-month follow-up (P = 0.037). These levels returned to the baseline by 6 months. Conclusions Baseline GLS alone was insufficient to predict CTRCD. A combined approach using serial imaging, cardiac biomarkers, and baseline risk factors improves early detection and risk stratification. In patients receiving Anthracycline therapy, a relative GLS reduction alongside elevated NT-proBNP effectively identified subclinical CTRCD. Early cardioprotective therapy (CPT) allowed continuation of chemotherapy and prevented progression to significant left ventricular dysfunction.Patients selection flowchart GLS estimation using 2D STE