ESC Cardio-Oncology 2026: Heart Failure Phenotyping in Cancer

The intersection of oncology and cardiology presents unique challenges, particularly in the management of heart failure (HF) in cancer patients. Cardiotoxicity, a common adverse effect of many cancer treatments, can manifest as various HF phenotypes, including heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and stress-induced cardiomyopathy.¹ Accurate phenotyping is essential for tailoring treatment, as therapies effective for one HF phenotype may be ineffective or even harmful for another.²

Traditional methods of HF diagnosis, such as left ventricular ejection fraction (LVEF) assessment, may not fully capture the spectrum of myocardial dysfunction in cancer patients. For instance, LVEF can remain within normal limits despite significant subclinical myocardial injury, particularly in HFpEF.³ The ESC Cardio-Oncology 2026 session highlighted the need for more sophisticated diagnostic tools to identify specific HF phenotypes early, thereby enabling proactive management and potentially mitigating disease progression.⁴

Imaging Findings and Clinical Decisions

The session emphasized the role of advanced cardiac imaging techniques in characterizing myocardial changes in cancer patients. Echocardiography, particularly speckle-tracking echocardiography for global longitudinal strain (GLS), was presented as a sensitive marker for detecting subclinical myocardial dysfunction before changes in LVEF become apparent.⁵ A reduction in GLS by >10-15% from baseline, or an absolute GLS value of <-19%, has been identified as an early predictor of cardiotoxicity in patients receiving anthracyclines or trastuzumab.⁶ This early detection allows for the initiation of cardioprotective therapies, such as beta-blockers or ACE inhibitors, potentially preventing overt HF.⁷

Cardiac magnetic resonance imaging (CMR) offers comprehensive tissue characterization, providing insights into myocardial fibrosis, inflammation, and edema, which are critical for differentiating HF phenotypes.⁸ For example, late gadolinium enhancement (LGE) on CMR can identify areas of myocardial fibrosis, which is common in HFpEF and can be exacerbated by certain cancer treatments.⁹ CMR also provides accurate and reproducible measurements of ventricular volumes and function, which are particularly valuable in complex cases or when echocardiographic windows are suboptimal.¹⁰

Beyond imaging, the session discussed the integration of clinical biomarkers and risk stratification models. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin (hs-cTn) can indicate myocardial stress and injury, respectively.¹¹ Serial monitoring of these biomarkers, in conjunction with imaging, can help identify patients at highest risk for developing HF and guide the intensity of surveillance and intervention.¹² The discussion underscored that a multidisciplinary approach, involving cardiologists, oncologists, and imaging specialists, is paramount for optimal patient care.¹³

Limitations in current practice include the variability in imaging protocols across institutions and the lack of standardized guidelines for integrating advanced imaging into routine cardio-oncology care.¹⁴ The cost and accessibility of advanced imaging modalities like CMR also present barriers. Future directions involve developing more precise risk prediction models that combine clinical, imaging, and biomarker data, as well as exploring novel imaging techniques and artificial intelligence applications to automate and standardize the assessment of myocardial function and tissue characteristics.¹⁵