HFA-ICOS Cardiovascular Toxicity Risk Stratification
Definition
The HFA-ICOS (Heart Failure Association–International Cardio-Oncology Society) risk stratification tool categorises patients with cancer into Low / Moderate / High / Very High baseline cardiovascular toxicity risk before initiating potentially cardiotoxic anticancer therapy. It is applied separately for six treatment categories: anthracyclines, HER2-targeted therapies, VEGFi (vascular endothelial growth factor inhibitors), BCR-ABL TKIs, multiple myeloma therapies, and RAF/MEK inhibitors.
Key Concepts
Scoring Logic
- Very High (VH): Any single VH risk factor (e.g. pre-existing HF/cardiomyopathy/CTRCD, prior trastuzumab for HER2 therapy, cardiac amyloidosis in MM). (sources/Cardio-Oncology-ESC-2022, rating: very high)
- High (H): Any single H risk factor (e.g. LVEF <50%, age ≥80 for anthracyclines, prior mediastinal RT, MI/PCI/CABG for VEGFi, severe VHD).
- Moderate (M): Risk factors scored M1 (1 point) or M2 (2 points). 2–4 points total = Moderate. ≥5 points total = High.
- Low: No risk factors OR one M1 risk factor.
Key Risk Factors by Category (Anthracyclines)
- VH: Pre-existing HF/cardiomyopathy/CTRCD
- H: LVEF <50%; age ≥80; prior anthracycline; severe VHD; MI/PCI/CABG; prior mediastinal RT
- M2 (2 pts): LVEF 50–54%; elevated baseline NP; elevated baseline cTn; prior arrhythmia; prior trastuzumab
- M1 (1 pt): Age 65–79; hypertension; CKD; DM; obesity; smoking; prior non-anthracycline chemotherapy
Key Risk Factors by Category (HER2-Targeted Therapies)
- VH: Prior trastuzumab; pre-existing CTRCD/HF
- H: LVEF <50%; age ≥80; prior anthracycline (current protocol); severe VHD; MI/PCI/CABG
- High risk if anthracycline + trastuzumab given concurrently
- M2: LVEF 50–54%; elevated NP/cTn; prior arrhythmia
- M1: Hypertension; CKD; DM; obesity; smoking; prior mediastinal RT
Anthracycline Cumulative Dose Threshold
- Cumulative doxorubicin-equivalent dose ≥250 mg/m² = higher risk category. (sources/Cardio-Oncology-ESC-2022)
- Anthracycline equivalence dose ratios (vs. doxorubicin): Epirubicin ×0.8; Daunorubicin ×0.6; Mitoxantrone ×10.5; Idarubicin ×5.
Clinical Integration
- Risk stratification result must be communicated to the patient and documented (Class I). (sources/Cardio-Oncology-ESC-2022)
- Low risk → proceed with anticancer therapy without delay (Class I).
- Moderate risk → consider cardiology referral without delaying cancer treatment (Class IIb).
- High/VH risk → mandatory cardiology referral before starting treatment (Class I) + MDT risk/benefit discussion (Class I) + cardioprotective strategies (Class IIa).
Contradictions / Open Questions
- HFA-ICOS tools are based on retrospective data and have not been prospectively validated in large RCTs. (sources/Cardio-Oncology-ESC-2022)
- Tool applicability across different cancer types (developed for specific cancer groups) requires caution when extrapolating.
- Traditional CV risk calculators (SCORE2, ASCVD) were not designed for cancer populations; cancer itself increases CVD risk beyond what these scores capture.
Connections
- Related to concepts/Cardio-Oncology
- Related to concepts/Cancer-Therapy-Related-CV-Toxicity
- Related to entities/Heart-Failure
- Related to sources/Cardio-Oncology-ESC-2022