Among asymptomatic patients with structurally normal TTE undergoing treatment with anthracyclines or alkylating agents that develop mildly elevated BNP and/or troponin levels, would you consider referring them for cardiac MRI to evaluate for subclinical cardiotoxicity?

If TTE images are adequate and the echo is entirely normal, but BNP and/or troponin levels are mildly elevated after anthracyclines or alkylating agents, differential diagnosis includes HFPEF, ischemia, or subclinical cardiotoxicity. If Echo shows unexplained significant LVH, CMR is reasonable to rule out cardiac amyloidosis or other infiltrative process. The best measure of subclinical cardiotoxicity is LV GLS. A relative reduction in GLS of > 15% compared to pre-chemo values suggests subclinical cardiotoxicity. BNP measurement is not uniformly recommended with anthracyclines because there are conflicting data on the role of BNP in predicting LV dysfunction or subsequent heart failure after anthracyclines. If TTE images are technically lim...