Cardio-oncology emerged from a clinical necessity recognised decades ago, tracing its roots to the discovery of anthracycline-induced cardiomyopathy in the 1970s.1 Initially focused on dose-dependent myocyte injury, cardio-oncology expanded as novel cancer therapies induced diverse cardiovascular toxicities. It now includes the biunivocal relationship between the heart and cancer. Milestones include the world’s first dedicated cardio-oncology unit at MD Anderson Cancer Center in 2000 and the establishment of the International Cardio-Oncology Society in 2009.2,3
Today, approximately 15–20 million cancer survivors live in Europe, where cardiovascular disease has become a leading cause of long-term morbidity and mortality.4 The evolving oncology landscape – ranging from vascular endothelial growth factor and Bruton’s tyrosine kinase inhibitors inducing hypertension and AF to immune checkpoint inhibitors, causing T-cell-mediated myocarditis – has underscored the need for structured surveillance and prevention strategies.5,6
In response, major international societies, including the American Society of Clinical Oncology and the European Society of Cardiology (ESC), have issued comprehensive practice guidelines to standardise patient care.7–9 A key advance is the move beyond left ventricular ejection fraction (LVEF) alone towards subclinical detection using global longitudinal strain (GLS) and high-sensitivity troponins.10 Yet, implementation remains inconsistent. In US real-world practice, only about one-third of anthracycline-treated breast cancer and lymphoma survivors receive cardiac surveillance, leaving many at-risk patients unmonitored.11 In contrast, 76% of ESC 2022 recommendations are based on level of evidence c.9 Uncertainty also persists regarding primary prevention. Major trials of neurohormonal blockers have shown mixed benefits, prompting interest in alternative strategies such as statins and sodium–glucose cotransporter 2 inhibitors.11–13 Limited standardisation of biomarker assays further complicates uniform practice.14
The integration of cardio-oncology guidelines into routine care remains essential, but is uneven, shaped by socioeconomic and institutional disparities.
To evaluate regional practice, a national online survey of Romanian physicians caring for patients with cancer collected data on demographics, institutional settings and cardio-oncology clinical practices.15
The survey was conducted from September to November 2024 among Romanian physicians in cardiology, internal medicine, oncology and haematology. The 21-question survey (15 single-response, 6 multiple-response) was distributed by email to members of National Cardiology Society and National Oncology and Hematology professional groups. Responses were anonymous, and no identifying information was stored. The survey was completed by 190 respondents (150 women, 40 men). Of these, most were cardiologists (139 respondents), 39 were oncologists/haematologists and the remaining 12 were internal medicine specialists or had other medical specialties. The detailed questionnaire has been previously published.15 The results provide a snapshot of guideline implementation, highlighting both progress and persistent gaps.
This viewpoint discusses determinants of guideline-adherent surveillance and prevention strategies in Romanian cardio-oncology practice.
Risk Stratification and Primary Prevention
The 2022 ESC guidelines define structured risk assessment, stratifying patients into low, moderate, high or very high categories based on patient- and therapy-related factors.16 Data from more than 1,000 patients in the CARDIOTOX registry confirmed progressive HRs of 1.0, 3.2, 10.3, and 28.7, respectively, for symptomatic or moderate/severe cancer therapy-related cardiac dysfunction, with mortality also increasing accordingly.17
Data from the Romanian dataset indicate that centres with cardio-oncology expertise are more likely to implement preventive pharmacotherapy (statins, angiotensin-converting enzyme inhibitors/ angiotensin II receptor blockers, β-blockers) and lifestyle counselling, even in lower-risk patients, whereas oncologists and non-cardiology clinicians generally defer prevention to higher-risk categories.15 This reflects an ongoing gap between validated risk tools and real-world practice (Figures 1 and 2).
Traditional risk factors and emerging molecular markers (around 80 single nucleotide polymorphisms) are key determinants of cardiotoxicity.18 The observation that prior cardiology exposure predicted uptake of preventive strategies supports the need for more personalised risk stratification. Meanwhile, suboptimal baseline control of hypertension, dyslipidaemia and glycaemia remains common.19
Surveillance and Early Detection of Cardiotoxicity
The 2022 ESC guidelines on cardio-oncology recommend echocardiography (LVEF, GLS), biomarkers (troponin, natriuretic peptides), and individualised follow-up. However, advanced modalities, which detect early cancer therapy-related cardiac dysfunction, are inconsistently implemented.20 This is also true for Romanian centres, where cardiology involvement and university affiliation seem to be predictors for a higher likelihood of employing GLS and biomarker monitoring in clinical practice. In contrast, smaller centres rely predominantly on LVEF (Figure 3).
Evidence continues to question a ‘one-size-fits-all’ model, with GLS and biomarker changes predicting later dysfunction, but incremental prognostic and cost-effectiveness value remains uncertain.18 This observed heterogeneity reinforces the need for context-specific, resource-aligned surveillance strategies, reserving advanced imaging for higher-risk groups.
Therapeutic Management of Cardiovascular Toxicity
Although guidelines recommend cardioprotective therapy (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, β-blockers, statins) in high-risk or early dysfunction patients, and close interdisciplinary coordination, evidence remains largely consensus-based.16,20 Key knowledge gaps include optimal timing, thresholds for therapy, and standardised surveillance intervals.
Survey data revealed that Romanian cardiologists are significantly more likely to initiate cardioprotective agents upon GLS decline, troponin rise, or reduced LVEF, while oncologists often continue cancer therapy without modification or referral. This reflects global tensions between oncologic efficacy and cardiovascular risk.15,18 Poorer outcomes after withdrawal of cardioprotective therapy have been documented, consistent with the survey’s finding of inconsistent long-term follow-up.21 Structured follow-up was defined as long-term care delivered according to current international cardio-oncology and oncology guideline recommendations, including risk factor management, lifestyle counselling and coordination with primary care.
Recent algorithms provide practical guidance on therapy continuation, cardioprotection and treatment reinitiation.22 However, frequent continuation of oncological treatment without cardiology input in this national cohort highlights persisting implementation barriers and the need for better-integrated multidisciplinary workflows.
Survivorship and Long-term Follow-up
Post-treatment surveillance is increasingly recognised as a critical step in patient management. Current literature highlights that patients receiving cardiotoxic therapy require long-term follow-up for heart failure, coronary disease, valvular abnormalities, and arrhythmias.16 In a cohort of approximately 36,000 adult cancer survivors, those with cardiovascular disease had markedly lower survival (60% versus 81%, p<0.01).23 Romanian centres with structured cardio-oncology programmes are more likely to assign cardiologists to oversee long-term follow-up, while those without such programmes delegate care to general practitioners, illustrating fragmented survivorship and the absence of integrated care pathways.15 The survey defined the existence of cardio-oncology programmes as the availability of dedicated teams consisting of oncologists and cardiologists, with multidisciplinary regular meetings, following standardised risk stratification and surveillance protocols in accordance with current international guidelines.
Integrating National Findings with the Evidence Base
The national survey findings align closely with global data: physicians with cardio-oncology experience show higher adherence to recommended risk stratification and prevention strategies, whereas disparities between cardiologist-led and non-cardiology-led centres persist worldwide.17 Cardio-oncology experience was defined in the survey as self-reported duration of involvement in cardio-oncology care, categorised by years of practice.
This study brings a valuable perspective from an Eastern European context, where real-world cardio-oncology data are scarce.
Despite recognition of these issues, many institutions lack standardised protocols for baseline risk stratification and serial monitoring. The use of GLS and biomarkers remains variable, limited by resources, training, and cost. Preventive and therapeutic interventions are inconsistently applied, and structured long-term follow-up is often absent, underscoring the urgent need for cohesive, multidisciplinary care models beyond the acute treatment phase.
This analysis captures real-world cardio-oncology practice in Romania, revealing both progress and persistent gaps in guideline implementation. However, a limitation of this survey is that the response rate could not be calculated; therefore, the representativeness of the respondents remains uncertain.
Conclusion
The survey provides important insight into cardio-oncology practice in an Eastern European setting, revealing heterogeneity in adherence to international guidelines. Specialised training, institutional expertise and access to resources strongly influence implementation. Persistent challenges include limited availability of advanced imaging and biomarkers, inadequate integration of cardioprotective measures, and fragmented survivorship structures. Addressing these gaps will require regional strategies that emphasise standardisation, interdisciplinary collaboration and scalable, resource-sensitive models of care.