**5. Coronary artery disease (CAD)**

*Advanced Concepts in Endocarditis - 2021*

dial contrast agents is recommended [13].

Simpson's technique by 2D echocardiography, with an LVEF of ≥55% as a normal reference range. Calculation of LVEF should be also combined with assessment of the wall motion score index, which is based on a 16-segment model of the left ventricle [11]. Resting wall motion score index based on a 16-segment model of the left ventricle has been demonstrated to be a more sensitive marker of anthracyclineinduced CTRCD than relying on the LVEF alone [12]. When two contiguous LV segments are not well visualised on non-contrast apical images, the use of myocar-

Although LVEF is a commonly accepted measure of cardiac systolic function and an accepted indicator of prognosis in patients with heart failure [14], it has low sensitivity for the detection of small changes in LV function. LVEF measurement using the 2D biplane technique has a temporal coefficient of variation of 7.4% [15], which is important to highlight because the measurement variability is close to the definition of CRTCD (drop in LVEF of 10% or more). This variability is the result of a number of factors including the operator's skills and the geometric assumptions used to estimate three-dimensional (3D) volumes from 2D images. 3D echocardiography has been shown to be more accurate than the 2D echocardiography in the measurement of the LV volumes [16]. However, the feasibility of the 3D technique can be reduced in some cancer patients because of the negative influence of factors such as concomitant radiotherapy (breast cancer and lymphoma) and surgery (mastectomies of left breast cancer, breast expanders or implants), which makes the ultrasound windows under these circumstances suboptimal [17]. The ASE recommends 3D echocardiography as the preferred technique for monitoring LV function and detecting CRTCD. However, it is important to realise that this technology has several limitations as well. It is recommended that calculation of LVEF by 2D biplane Simpson's method also be included in all the oncologic patients echocardiographic report to allow comparison with previous studies if this method

To minimise the risk of irreversible cardiomyopathy, the goal is to identify signs

A comprehensive assessment of LV diastolic function, including grading of diastolic function and providing an estimate of LV filling pressure (by using the E/e′ ratio), should be performed in addition to the assessment of LV systolic function [19]. Although abnormal diastolic function parameters may reflect subclinical LV dysfunction, it has not been found to be prognostic of cardiotoxicity, and its clinical

The frequency of the RV dysfunction during cancer therapy-related cardiotoxicity has not been accurately examined. As early studies of CRTCD included

of toxicity as early as possible. Echocardiography-based deformation imaging techniques (strain) have become an essential tool to detect CRTCD. Changes in strain are more sensitive, appear prior to LVEF reduction and before the CRTCD manifests as symptomatic heart failure. Global longitudinal strain (GLS) is of particular interest because it can be incorporated into a clinical echocardiographic examination relatively efficiently with currently available technology [18]. The EACVI and ASE recommend assessing GLS as a routine component of clinical echocardiograms in patients at risk for type 1 or type 2 cardiotoxicity [6]. A relative percentage decrease in GLS > 15% is indicative of subclinical LV dysfunction and could be utilised as the starting point for timely cardio protection therapy.

**64**

was used.

**4.2 LV diastolic function**

significance remains uncertain.

**4.3 Right ventricular (RV) function**

The diagnostic capability of rest echocardiography in CAD is limited to the assessment of the presence and magnitude of regional wall motion abnormalities.

Stress echocardiography, an established technique for the detection and prognostication of stable CAD as recommended by guidelines, may be useful in the evaluation of patients who are undergoing regimens that may be associated with ischemia, as fluoropyrimidines, platinum compounds (cisplatin), vascular endothelial growth factor inhibitors and radiotherapy.

Stress echocardiography is also being used to unmask subclinical abnormalities of the LV function induced by chemotherapeutic agents. Although both exercise [12] and dobutamine stress echocardiography [21–23] have been applied to patients with cancer for the identification of anthracycline-induced CTRCD, the results of these studies appear to be inconclusive and contradictory. Further studies are needed to better understand the prognostic role of stress echocardiography, before can be routinely used into clinical practice.
