Late Effects	Causative Treatment	Signs and Symptoms	Screening and Diagnostic Tests	Management and Intervention
aAdapted from Schwartz et al.[37]
Cardiomyopathy	Chemotherapy: Anthracycline >300 mg/m2, >200 mg/m2 and radiation therapy to mediastinum, high-dose cyclophosphamide, (bone marrow transplant), and possibly ifosfamide	Fatigue, cough, dyspnea on exertion, peripheral edema, hypertension, tachypnea/rales, tachycardia, cardiomegaly (S3/S4), hepatomegaly, syncope, palpitations, arrhythmias	ECG, echocardiogram/ radionuclear angiography and chest x-ray baselines, every 2–5 years (depending on risk factors), Holter monitor and exercise testing baseline, as needed for symptoms and after high cumulative anthracycline dose (>300 mg/m2)	Diuretics, digoxin, afterload reduction, antiarrhythmics, cardiac transplant, education regarding risks of: isometric exercises, alcohol consumption, drug use, smoking, pregnancy, anesthesia
	Radiation: >35 Gy
	Chemotherapy and Radiation: >25 Gy and anthracyclines
Valvular damage (mitral/tricuspid aortic)	Radiation: >40 Gy	Weakness, cough, dyspnea on exertion, new murmur, pulsating liver	Echocardiogram and chest x-ray (baseline), every 3–5 years then as needed for symptoms	Penicillin prophylaxis for surgery/dental procedures
Pericardial damage	Radiation: >35 Gy	Fatigue, dyspnea on exertion, chest pain, cyanosis, ascites, peripheral edema, hypotension, friction rub, muffled heart sounds, venous distension, pulsus paradoxus	ECG (ST-T changes, decreased voltage), echocardiogram, chest x-ray baseline, every 3–5 years	Pericardial stripping
Coronary artery disease	Radiation: >30 Gy	Chest pain on exertion (radiates to arm/neck), dyspnea, diaphoresis, pallor, hypotension, arrhythmias	ECG every 3 years, stress test (consider thallium scintigraphy) baseline, every 3–5 years or as needed for symptoms	Diuretics, cardiac medications, low-sodium, low-fat diet, conditioning regimens

References

37. Schwartz C L, Hobbie WL, Constine LS, et al., eds.: Survivors of Childhood Cancer: Assessment and Management. St. Louis, Mo: Mosby, 1994.