Cardiotoxicity is a therapy-limiting toxicity with anthracyclines. Keefe proposed an algorithm for monitoring anthracycline chemotherapy in order to minimize the risk of cardiotoxicity. The author is from Memorial Sloan Kettering Cancer Center in New York City.



(1) body surface area in square meters

(2) cumulative dose of anthracycline in doxorubicin equivalents

(3) risk status


A patient is considered high risk for cardiotoxicity if the patient has any of the following:

(1) pre-existing heart disease

(2) radiation therapy to left lung or mediastinum

(3) hypertension


Monitoring is done with:

(1) echocardiography

(2) radionuclide angiography



High Risk

Low Risk

start monitoring

200 mg per square meter

300 mg per square meter

need for closer monitoring (monitor after every 2 cycles)

300 mg per square meter

400 mg per square meter

need for very close monitoring (monitor after every cycle)

400 mg per square meter

NA (consider after 500 mg per square meter)

followup after therapy completed

every 3 months

every 3 months


Endpoint to stop anthracycline therapy based on cardiotoxicity is based upon the left ventricular ejection fraction

(1) caution should be used if < 50%

(2) anthracycline chemotherapy should be discontinued when < 45%


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