Cardiovascular care in adult cancer survivorship post-therapy: a cross-sectional analysis of clinical practice guidelines.

Background/objective Cardiovascular disease (CVD) is a major and potentially life-threatening late effect in cancer survivors, in some populations surpassing the risk of cancer recurrence as a leading cause of mortality. The aim of this study was to compare and critically appraise existing guidelines on CVD in cancer survivorship and to synthesize evidence-informed recommendations for the management of cardiovascular health in this population. Methods A systematic search was conducted on 16 January 2025 across PubMed, the Cochrane Library, and professional society websites. We included guidelines from professional oncology societies addressing CVD management in adult cancer survivors, published in English between 2000 and 2024. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Recommendations, levels of evidence, and strengths of recommendations were extracted and standardized into the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Screening, grading, and data extraction were performed independently by two reviewers. Results Of 524 screened references, twelve guidelines from seven professional societies met the inclusion criteria and were analyzed. Of the twelve guidelines, two were rated as high quality and ten as moderate quality. Risk stratification emerged as the foundation of follow-up care, with most guidelines considering baseline cardiovascular risk, type and cumulative dose of specific cancer therapy, and treatment-related cardiotoxicity. The ESC 2022 guideline proposed the most detailed tiered model (very high risk, early high risk, late high risk, moderate risk and low risk), while others such as ASCO 2017 and NCCN 2024 guidelines used simpler schemes based on anthracycline dose, age, or pre-existing CVD. Follow-up strategies, including surveillance, pharmacologic therapy, lifestyle counseling, and specialist referral were linked to risk category. However, substantial variation existed in the timing and frequency of cardiac imaging, use of biomarkers, and thresholds for initiating cardio-protective medication. Lifestyle modification and multidisciplinary care were consistently recommended, but detail and supporting evidence varied across guidelines. Structured implementation of cardio-oncology rehabilitation models was limited. Pregnancy-related cardiovascular surveillance and long-term implications of novel oncologic therapies were inconsistently addressed. Several recommendations were strongly endorsed despite limited prospective outcome data, highlighting a gap between recommendation strength and evidence level. Conclusion In long-term survivorship, CVD represents a major determinant of morbidity and mortality beyond cancer surveillance. In this analysis, there was a consensus across guidelines on the central role of risk stratification encompassing pre- and post-treatment cardiovascular risk, treatment-related cardiotoxicity, and cardiac dysfunction during therapy in guiding follow-up care. However, the guidelines differed across oncology, cardiology, and general medicine. This variation poses a challenge, as clinicians in one field may be unfamiliar with guidelines from another. Our analysis aimed to address this gap by highlighting the coexistence of multiple, specialty-specific guidelines for the same clinical issues, such as cardiovascular disease. As guidelines reflect the evidence available at the time of publication, many do not yet account for newer oncologic therapies or the importance of structured rehabilitation programs. Harmonized, regularly updated, and evidence-based interdisciplinary recommendations are essential for the cardiovascular management of cancer survivors.