key: cord-0976743-5rbowj73 authors: Farmakis, Dimitrios; Keramida, Kalliopi; Filippatos, Gerasimos title: Cardio‐Oncology services during the COVID‐19 pandemic: Practical considerations and challenges date: 2020-05-22 journal: Eur J Heart Fail DOI: 10.1002/ejhf.1898 sha: 23086e400b26cb6ee14d240dc1600478ee714a83 doc_id: 976743 cord_uid: 5rbowj73 nan 3 to secure a separate and protected access to oncology, haematology and cardiooncology departments and clinics. For the public spaces and other departments that may be used by cancer patients like the radiology department, all the general prophylactic measures should be applied. Cardiotoxicity risk stratification before the initiation of anticancer therapy is now more crucial than ever. To minimize the risk of exposure, baseline cardiological evaluation can be omitted in patients with low or very low cardiotoxicity risk, including those with no history of CV disease, CV risk factors, previous cardiotoxicity or previous cardiotoxic therapies and those not being scheduled for anticancer regimens with established cardiotoxicity profile (Table 1 ). In contrast, medium and high-risk patients should be assessed according to current guidelines and local practices. During cancer therapy, the regular CV follow-up of patients should be modified in a way that mitigates the risk of not identifying and treating cardiotoxicity on time while attenuating the potential exposure to COVID-19. Biomarkers, including cardiac troponins (cTn) and natriuretic peptides (NP), have proven their role in early identification of cardiotoxicity in the form of myocardial dysfunction and can replace follow-up echocardiographic studies in asymptomatic patients during this period. These biomarkers can be assessed during scheduled cancer therapy, without the need for additional hospital visits as in the case of imaging. It should be stressed though that cardiotoxicity is not only about myocardial dysfunction and biomarkers are not always available and cannot identify other toxicities. Imaging and mainly echocardiography is a pillar of cardio-oncology, but its reasonable and modified use will minimise the exposure of patients and physicians. Follow up appointments for cancer survivors should be deferred, prioritising patients' safety and allocating appropriately the existing health care resources. Cancer patients under treatment and cancer survivors should be well informed and updated through all available resources and maintain contact with the cardiooncology team through telephone calls, mobile applications and smart digital webbased applications [10] . Telecommunication-based consultation between physicians and patients and among physicians can help to continue many of the cardiooncology service functions to promote safe delivery of cancer care without disruption while limiting the patients' exposure. Cardiovascular complications of COVID-19 include myocardial injury, acute myocardial infarction, heart failure, fulminant myocarditis, takotsubo syndrome, arrhythmias, conduction disturbances, cardiogenic shock and venous thromboembolism. In a cancer patient, these events can also represent CV toxicity of anticancer treatments, thus creating important diagnostic and therapeutic dilemmas Accepted Article This article is protected by copyright. All rights reserved. [11] . Acute cardiac injury, presenting as cTn or NP elevation, is the most commonly reported COVID-19-related CV complication, with an incidence of 8-12% in the general population [12] . Although an advisory by the American College of Cardiology discourages random measurement of cardiac biomarkers [13] , this cannot be applied in many cancer patients, in whom these biomarkers can be used for cardiotoxicity surveillance, attenuating the need for echocardiography or other imaging modalities. The COVID-19 pandemic imposes the implementation of strategies that will limit exposure of the vulnerable cardio-oncology patient population without compromising the essentials of their healthcare. Cardio-oncology services need to adapt efficiently to deal with the unprecedented challenges in everyday clinical practice during the present and future pandemics (Figure 1 ). At the same time, this outbreak can pave the road to shape specific disciplines and establish mechanisms that would be useful for every similar crisis in the future. This article is protected by copyright. All rights reserved. Characteristics of and Important Lessons From the COVID-19) Outbreak in China: Summary of a Report of American College of Radiology (ACR) COVID-19 pandemic: guidance for nuclear medicine departments Cancer Care During the COVID-19 Pandemic: An ESMO Guide for Patients ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC) Cardiovascular disease and COVID-19 ACC clinical bulletin focuses on cardiac implications of coronavirus Figure 1: Main adaptations and challenges in Cardio-Oncology services during the COVID-19 pandemic (created using artwork provided by Servier Medical Art This article is protected by copyright. All rights reserved.