HFA-ICOS anthracycline baseline risk: how the risk level is set
The HFA-ICOS anthracycline proforma sorts a patient into a low, medium, high or very high baseline cardiovascular risk level before anthracycline chemotherapy. Any very high factor sets very high. Otherwise any high factor, or 5 or more medium points, sets high. Medium points of 2 to 4 set medium, and anything less is low.
Not a medical device. Not a diagnosis or dosing recommendation.
What is the HFA-ICOS anthracycline risk tool?
Anthracyclines are a group of chemotherapy drugs that can harm the heart. In 2020 the Heart Failure Association (HFA) Cardio-Oncology Study Group of the European Society of Cardiology and the International Cardio-Oncology Society (ICOS) published baseline risk proformas for several groups of cancer drugs, led by Lyon. This page covers the anthracycline proforma.
Magent's calculator takes age, left ventricular ejection fraction (LVEF) and the yes/no factors, and returns the risk level, the medium points and the paper's expert-opinion guide for that level.
This page explains the logic. It doesn't say what a risk level means for a particular person.
The HFA-ICOS anthracycline logic
very high heart failure or cardiomyopathy
high any high factor, or medium points ≥ 5
high factors: severe valvular heart disease; myocardial infarction or
coronary revascularization; stable angina; LVEF < 50%; age ≥ 80;
previous anthracycline; prior left chest or mediastinal radiotherapy
medium medium points 2 to 4
low medium points 0 or 1
medium points:
2 each LVEF 50–54%; age 65–79
1 each elevated troponin; elevated BNP or NT-proBNP; hypertension; diabetes;
chronic kidney disease; previous non-anthracycline chemotherapy;
current or significant smoker; obesityExact expression the calculator uses:
very_high if heart_failure_or_cardiomyopathy; else high if any High factor (severe_valvular_heart_disease, mi_or_coronary_revascularization, stable_angina, lvef_percent<50, age_years>=80, previous_anthracycline, prior_left_chest_or_mediastinal_rt) OR medium_points>=5; else medium if medium_points in 2..4; else low (no factors or one Medium 1). medium_points sums Medium 1 (=1: elevated_troponin, elevated_bnp, hypertension, diabetes, ckd, previous_non_anthracycline_chemo, current_or_significant_smoker, obesity) and Medium 2 (=2: lvef_percent 50-54, age_years 65-79) only. Age and LVEF use the highest matching printed band. Lyon 2020 HFA-ICOS anthracycline table. cardiotoxicity_guide is that paper's expert-opinion guide: low <2%, medium 2-9%, high 10-19%, very high >=20%Inputs
| Input | Meaning | Tier |
|---|---|---|
age_years | Age in years | High at 80 or above; 2 points at 65 to 79 |
lvef_percent | Left ventricular ejection fraction, % | High below 50; 2 points at 50 to 54 |
heart_failure_or_cardiomyopathy | Heart failure or cardiomyopathy | Very high |
severe_valvular_heart_disease, mi_or_coronary_revascularization, stable_angina, previous_anthracycline, prior_left_chest_or_mediastinal_rt | Yes/no factors | High |
elevated_troponin, elevated_bnp, hypertension, diabetes, ckd, previous_non_anthracycline_chemo, current_or_significant_smoker, obesity | Yes/no factors | 1 medium point each |
How the calculation works
- Check for very high. Heart failure or cardiomyopathy sets very high straight away.
- Check for high. Any high factor sets high.
- Count medium points. Add 2 for each Medium 2 factor and 1 for each Medium 1 factor. High and very high factors don't add medium points.
- Set the level. 5 or more medium points is high, 2 to 4 is medium, and 0 or 1 is low.
Age and LVEF use the highest band that applies. An age of 80 or above counts as a high factor and doesn't also add the 2 medium points for age 65 to 79.
Units
Age is in whole years and LVEF in whole percent. The other inputs are yes or no, assigned from the paper's definitions. The guide figure returned with each level is a percentage band from the paper's expert opinion.
Worked examples
These use Magent's own expected values for the calculator.
Example 1: no factors
- Age 50, LVEF 60%, every factor no.
- Medium points 0. Level: low. Guide: under 2%.
Example 2: age 70
- Age 70 falls in the 65 to 79 band: 2 medium points.
- Medium points 2. Level: medium. Guide: 2–9%.
Example 3: LVEF 45%
- LVEF below 50% is a high factor.
- Medium points 0. Level: high. Guide: 10–19%.
Example 4: five 1-point factors
- Hypertension, diabetes, chronic kidney disease, smoking and obesity: 1 point each.
- Medium points 5. Level: high. Guide: 10–19%.
Example 5: heart failure
- Heart failure or cardiomyopathy is the very high factor.
- Medium points 0. Level: very high. Guide: 20% or more.
History of the HFA-ICOS proformas
The calculator cites Lyon and colleagues, European Journal of Heart Failure, 2020 (volume 22, issue 11, pages 1945–1960). The abstract describes a position statement from the HFA Cardio-Oncology Study Group of the European Society of Cardiology with the International Cardio-Oncology Society. It presents baseline risk proformas for oncologists, haemato-oncologists and cardiologists, covering anthracyclines and several other groups of cancer drugs, with patients sorted into low, medium, high and very high risk of cardiovascular complications.
When it's used
The proforma describes a baseline risk level before anthracycline chemotherapy starts.
Where it's used
The inputs come from the history, blood pressure, blood tests and an LVEF measurement, gathered in oncology or cardio-oncology clinics.
Who uses it
The person using the calculator enters age, LVEF and the yes/no factors. The calculator applies the proforma's rules.
Limits of the calculation
- The calculator doesn't examine the patient, read imaging, run blood tests or compute BMI. Every input comes from the person entering it.
- The guide percentages are the paper's expert opinion, not an absolute risk measured in a study.
- The result is a baseline risk level. It isn't an order for chemotherapy, imaging or heart-protective medicines, and this page doesn't say what to do with a level.
Clinical decisions belong to a qualified clinician who knows the patient.
How it differs from related calculators
- HFA-ICOS BCR-ABL proforma comes from the same paper but uses a different factor list for BCR-ABL kinase inhibitors.
- ACC/AHA heart failure stages stage heart failure itself. The HFA-ICOS proforma sets a baseline risk level before chemotherapy.
- NYHA class grades symptoms in known heart failure.
- MAGGIC estimates survival in known heart failure.
Glossary
- Anthracycline: a group of chemotherapy drugs, such as doxorubicin, that can damage heart muscle.
- LVEF: left ventricular ejection fraction, the share of blood the left ventricle pumps out with each beat.
- Proforma: a structured checklist used to assign a risk level.
- Cardio-oncology: the care of heart problems in people with cancer.
Common mistakes
- Adding high factors into the medium points. High and very high factors set the level directly.
- Counting age twice. An age of 80 or above is a high factor and doesn't also add the 65 to 79 points.
- Reading the guide as a measured risk. The percentages are expert opinion.
- Using this factor list for a BCR-ABL inhibitor. That drug group has its own proforma.
Source
Lyon AR, et al. Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies: a position statement and new risk assessment tools from the Cardio-Oncology Study Group of the Heart Failure Association of the European Society of Cardiology in collaboration with the International Cardio-Oncology Society. Eur J Heart Fail. 2020;22(11):1945-1960. DOI: 10.1002/ejhf.1920. PMID: 32463967
Frequently asked questions
What are the HFA-ICOS risk levels?
Low, medium, high and very high.
What sets very high risk on the anthracycline proforma?
Heart failure or cardiomyopathy.
Do high-risk factors add to the medium points?
No. They set the level to high directly.
How many medium points make high risk?
5 or more.
What does the guide percentage mean?
It is the paper's expert-opinion band for each level, not a measured risk.