2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS)

Racial and Ethnic Disparities in Cardiotoxicity in Patients With Cancer Treated With Anthracyclines

BACKGROUND

Cardiotoxicity in patients with cancer treated with anthracyclines is associated with increased morbidity and mortality. We aimed to examine the incidence of and risk factors for cardiotoxicity in a racially and ethnically diverse cohort with cancer treated with anthracyclines.

METHODS

We included consecutive adult patients who underwent anthracycline-based chemotherapy from 2016 to 2019 for any type of cancer. The end point was the development of cardiotoxicity (defined as clinical heart failure or drop in left ventricular ejection fraction ≥10% to ≤50%).

RESULTS

A total of 743 individuals were included (28.0% Non-Hispanic [NH] White, 30.5% NH Black, 38.5% Hispanic, 3.0% Asian). Hypertension, diabetes, hyperlipidemia, obesity, and low socioeconomic status were more common in NH Black and Hispanic individuals. During a median follow-up of 21 months, 98 individuals (13.2%) developed cardiotoxicity. The incidence of cardiotoxicity was significantly higher in NH Black (16.3%), Hispanic (14.7%) and Asian (18.2%) individuals than in NH White (7.2%) individuals (P=0.024). After adjusting for cardiovascular risk factors, socioeconomic status score, anthracycline dose, baseline left ventricular ejection fraction, and cancer type, being NH Black (hazard ratio [HR], 2.62 [95% CI, 1.23-5.56]) or Hispanic (HR, 2.37 [95% CI, 1.11-5.07]) was independently associated with a higher risk of cardiotoxicity. NH Black and Hispanic individuals had a greater decline in left ventricular ejection fraction compared with NH White and Asian counterparts. The associations between baseline characteristics and incident cardiotoxicity were similar across different racial and ethnic groups.

CONCLUSIONS

In a large retrospective multiracial and ethnic cohort treated with anthracyclines, NH Black, Hispanic, and Asian individuals had an increased risk of cardiotoxicity compared with their NH White counterparts.

Blood pressure elevations post-lenvatinib treatment in hepatocellular carcinoma: a potential marker for better prognosis

Lenvatinib is a tyrosine kinase inhibitor that effectively inhibits vascular endothelial growth factor signaling and is used for treating hepatocellular carcinoma. However, angiogenesis inhibitors often cause hypertension. Although lenvatinib-induced hypertension has been proposed as a potential surrogate marker for better prognosis, studies on blood pressure elevations and outcomes following lenvatinib initiation are limited. This study included 67 patients who underwent lenvatinib therapy at the Department of Gastroenterology, Kagoshima University Hospital, between May 2018 and December 2023. The median age of the cohort was 71 years, and 82.1% of the patients were male. The median blood pressure at admission was 128/73 mmHg, which significantly increased to 136/76 mmHg the day after lenvatinib administration. Grade 3 hypertension (≥160/100 mmHg) occurred in 37.3% of patients during hospitalization. The median increase in systolic blood pressure from admission to its peak during hospitalization was 26 mmHg. Patients who experienced an increase in blood pressure of ≥26 mmHg were classified into the blood pressure elevation group, which showed a significantly lower mortality rate than that of the blood pressure non-elevation group (35.3% vs. 81.8%, log-rank p = 0.007), even after adjusting for age, sex, disease stage, performance status, and liver reserve function. This study demonstrated that patients who experienced earlier blood pressure elevation after lenvatinib administration had lower overall mortality rates. These findings suggest that blood pressure elevations after lenvatinib initiation may serve as valuable prognostic indicators in patients with cancer undergoing lenvatinib therapy. • Early Blood Pressure Elevation Following Lenvatinib Administration Significant blood pressure elevation was observed from the day after Lenvatinib administration, with a median systolic blood pressure increase of 26 mmHg. Grade 3 hypertension (≥160/100 mmHg) was observed in 38% of patients during hospitalization. •Blood Pressure Control Antihypertensive therapy was intensified in 39% of patients during hospitalization, yet 12% still had Grade 3 hypertension the day before discharge. • Association Between Blood Pressure Elevation and Prognosis Even after adjusting for age, sex, disease stage, performance status, and liver function reserve, blood pressure elevation was suggested as a better prognostic factor.

Immune Checkpoint Inhibitor-Related Myocarditis With or Without Concomitant Myopathy: Clinical Findings and Cardiovascular Outcomes

BACKGROUND

Data on cardiovascular outcomes in patients with both immune checkpoint inhibitor-induced immune-related myocarditis (irMyocarditis) and immune-related myopathy (irMyopathy) are limited.

OBJECTIVES

The aim of this study was to describe clinical characteristics and cardiovascular outcomes in patients with isolated irMyocarditis vs those with concomitant irMyocarditis and irMyopathy.

METHODS

A retrospective cohort study was conducted among patients diagnosed with irMyocarditis at Massachusetts General Brigham between 2015 and 2023. Clinical, laboratory, and imaging characteristics were evaluated, and cardiovascular outcomes were compared between patients with and those without concomitant irMyopathy. The outcomes assessed included acute heart failure requiring diuresis, significant arrhythmias (ventricular arrhythmias and high-degree atrioventricular block), and cardiovascular and all-cause mortality during the index hospitalization.

RESULTS

Among 101 patients with irMyocarditis, 32 (31.7%) had concomitant irMyopathy. Patients with irMyocarditis and irMyopathy had higher high-sensitivity troponin T (median 716 ng/L vs 75 ng/L; P < 0.001) and creatine kinase levels (median 3441 U/L vs 232 U/L; P < 0.001) and were more likely to present with significant arrhythmias (HR: 2.12; 95% CI: 1.13-3.97; P = 0.019). Conversely, patients with isolated irMyocarditis had higher N-terminal prohormone of brain natriuretic peptide levels (median 2043 pg/mL vs 606 pg/mL; P = 0.007), lower left ventricular ejection fractions (median 56% vs 65%; P = 0.008), and a higher likelihood of acute decompensated heart failure (HR: 5.88; 95% CI: 1.45-25; P = 0.013). Cardiovascular and all-cause death during admission were numerically higher in patients with concomitant irMyopathy but were not significantly different between the 2 groups.

CONCLUSIONS

Patients with irMyocarditis and irMyopathy and those with isolated irMyocarditis have distinct biomarker profiles and cardiovascular complications. These differences should be confirmed in larger prospective cohorts to guide tailored management strategies.

Immune Checkpoint Inhibitor Myocarditis and Left Ventricular Systolic Dysfunction

BACKGROUND

Immune checkpoint inhibitors (ICIs) have transformed cancer treatment, but ICI myocarditis (ICI-M) remains a potentially fatal complication. The clinical implications and predictors of left ventricular ejection fraction (LVEF) <50% in ICI-M are not well understood.

OBJECTIVES

The aim of this study was to identify factors associated with LVEF <50% vs ≥50% at the time of hospitalization for ICI-M. A secondary objective was to evaluate the relationship between LVEF and 30-day all-cause mortality.

METHODS

The International ICI-Myocarditis Registry, a retrospective, international, multicenter database, included 757 patients hospitalized with ICI-M. Patients were stratified by LVEF as reduced LVEF (<50%) or preserved LVEF (≥50%) on admission. Cox proportional hazards models were used to assess the associations between LVEF and clinical events, and multivariable logistic regression was conducted to examine factors linked to LVEF.

RESULTS

Of 757 patients, 707 had documented LVEFs on admission: 244 (35%) with LVEF <50% and 463 (65%) with LVEF ≥50%. Compared with patients with LVEF ≥50%, those with LVEF <50% were younger (<70 years), had a body mass index of <25 kg/m2, and were more likely to have received chest radiation (24.2% vs 13.5%; P < 0.001). Multivariable analysis identified predictors of LVEF <50%, including exposure to v-raf murine sarcoma viral oncogene homolog B1/mitogen-activated protein kinase inhibitors, pre-existing heart failure, dyspnea at presentation, and at least 40 days from ICI initiation to ICI-M onset. Conversely, myositis symptoms were associated with LVEF ≥50%. LVEF <50% was marginally associated with 30-day all-cause mortality (unadjusted log-rank P = 0.062; adjusted for age, cancer types, and ICI therapy, HR: 1.50; 95% CI: 1.02-2.20).

CONCLUSIONS

Dyspnea, time from ICI initiation, a history of heart failure, and prior cardiotoxic therapy may be predictors of an initial LVEF <50% in patients with ICI-M.

Blood pressure variability as predictor of cancer therapy-related cardiovascular toxicity in patients with Multiple Myeloma

Blood pressure (BP) variability (BPV) is an independent predictor of cardiovascular (CV) events. The role of BPV in defining risk of cancer therapy-related cardiovascular toxicity (CTR-CVT) is currently unknown. The aims of this study were: (i) to evaluate BPV in a population of patients with Multiple Myeloma, undergoing proteasome inhibitors therapy; (ii) to assess the predictive value of BPV for CTR-CVT; (iii) to analyze clusters of subjects based on BPV. One hundred twenty-four patients underwent a baseline evaluation, including Ambulatory Blood Pressure Monitoring (ABPM), PWV, and Echocardiography. BPV was assessed through ABPM-based standard deviation (SD), weighted standard deviation (wSD), coefficient of variation (CoV), average real variability (ARV), and variability independent of the mean (VIM). Individuals who developed CTR-CVT had a higher baseline BPV. Furthermore, night-time BPV was associated with CTR-CVT, independently of age, smoking, BP, diabetes, dyslipidemia, and kidney function (night-time systolic CoV: adjusted OR 1.09 [1.01-1.21]; night-time systolic VIM: adjusted OR 1.18 [1.01-1.39]). Cut-offs for these BPV parameters were identified as predictors of CTR-CVT occurrence: 10.5 for night-time systolic CoV; 7.8 and 6.4 for systolic and diastolic night-time VIM. Clustering analysis identified subgroups of subjects characterized by the highest BPV, who had a greater prevalence of events, but no differences in other CV risk determinants. Short-term BPV is an independent predictor of CTR-CVT. BPV may enhance the precision of risk stratification in cancer patients, enabling identification of individuals at higher risk who would not be recognized, if traditional prognostic indicators were the sole applied criteria. On the left panel in the figure, the distribution of blood pressure variability (BPV) in the population according to cancer therapy-related cardiovascular toxicity occurrence; in the central panel, association of blood pressure variability with events and cutoffs values; in the right panel, clustering analysis results based on BPV levels. Histogram and radar plot represent events and BPV indexes distribution in the three clusters, respectively. ARV, average real variability; BPV, Blood Pressure Variability; CTR-CVT, cancer therapy-related cardiovascular toxicity; CoV, coefficient of variation; DBP, Diastolic blood pressure; SBP, Systolic blood pressure; SD, standard deviation; VIM, variability independent of the mean; wSD, weighted standard deviation.

A Multicenter Prospective Observational Study to Examine the Experience of Using Phosphocreatine in Combination Therapy for Heart Failure Caused by Cancer Treatment. Rationale and Design of the Study

Enhanced cancer treatment efficacy has resulted in a significant increase in the number of cancer survivors after the cure of malignant tumors. However, cardiovascular morbidity, including chronic heart failure, has become the leading cause of death and decreased life expectancy among cancer survivors. This is due, in particular, to the cardiotoxic effects of anticancer drugs and associated factors. Cardioprotective approaches aim to reduce the incidence and severity of cardiotoxicity through the use of cardioprotective agents (e.g., dexrazoxane), liposomal drug delivery systems (e.g., liposomal doxorubicin), and optimization of drug administration schedules. Reducing the cardiotoxicity of cancer treatments is a clinically important goal. Phosphocreatine-based therapy represents a potentially valuable new strategy in this area. In this regard, the study "Multicenter prospective observational study to investigate the experience of using phosphocreatine in combination therapy for heart failure caused by cancer treatment" was initiated. This publication presents the protocol of the observational non-interventional NEOCARD study.

Subclinical B-type Natriuretic Peptide Elevation 24 Months After Anthracycline-Containing Chemotherapy

The incidence of anthracycline-induced cardiotoxicity typically occurs within the first year after chemotherapy, but the changes in cardiac function and biomarkers beyond this initial year have not been adequately investigated. We analyzed 105 consecutive patients followed for 24 months after anthracycline-containing chemotherapy at Fukushima Medical University Hospital from June 2018 to April 2021. Echocardiography and blood tests for cardiac troponin I and B-type natriuretic peptide (BNP) were conducted at baseline, and 3, 6, 12, and 24 months after chemotherapy initiation. In the whole patient cohort, BNP levels increased from 10.5 [6.3-18.3] pg/mL at baseline to 19.2 [12.1-34.5] pg/mL at 24 months after chemotherapy (P < 0.01). Based on BNP levels at 24 months, the patients were divided into 2 groups: a BNP-elevated group (n = 57) and a BNP-normal group (n = 48). In the BNP-elevated group, time-course changes revealed that BNP levels remained stable until 12 months, but increased at 24 months. Multivariate logistic analysis identified age, total anthracycline dose, and baseline BNP levels as predicting factors for elevated BNP levels at 24 months. Subclinical BNP elevation was observed at 24 months of follow-up after initiation of anthracycline-containing chemotherapy.

A new online dynamic nomogram based on the inflammation burden index to predict cardiac injury after antitumor therapy in lung cancer patients

INTRODUCTION

Cardiotoxicity has become a major concern in cancer patients, especially those with lung cancer, as anti-tumor therapies can significantly affect patient survival and quality of life. This study aims to develop and validate a dynamic nomogram based on the Inflammation Burden Index (IBI) to predict the risk of cardiac injury within one year after anti-tumor treatment in lung cancer patients.

METHODS

This single-center, retrospective study included 1386 lung cancer patients who underwent myocardial enzyme testing between July 2018 and January 2023. The IBI was calculated as: IBI = (CRP (mg/dL) × Neutrophils (/μL)) / Lymphocytes (/μL). Statistical analysis using SPSS 22.0 and R 4.4.1, including machine learning algorithms and multivariate logistic analysis, identified independent predictors of cardiac injury. An online dynamic nomogram was developed and validated using internal validation, ROC curves, and decision curve analysis (DCA).

RESULTS

The average age of the 1386 patients was 61.98 ± 9.22 years. Significant independent predictors included age, BMI, hypertension, immunotherapy, D-dimer, LDH, NSE, CKMB, and IBI. The nomogram showed strong discriminative ability with AUC-ROC values of 0.85 for the training set and 0.86 for the validation set. Calibration curves confirmed good fit, and DCA showed high clinical utility.

CONCLUSION

An online dynamic nomogram based on clinical and inflammatory markers was developed to predict cardiac injury in lung cancer patients following anti-tumor therapy. The model shows strong discriminative ability and potential clinical value, which can provide vital information for oncologists when designing customized clinical treatments.

Fluoropyrimidine Chemotherapy and the Risk of Death and Cardiovascular Events in Patients With Gastrointestinal Cancer

BACKGROUND

Fluoropyrimidine chemotherapy is administered first-line for many gastrointestinal cancers. However, patients with cardiovascular disease commonly receive alternative treatment due to cardiotoxicity concerns.

OBJECTIVES

The study sought to assess the risks of all-cause mortality and acute cardiovascular events with fluoropyrimidine treatment.

METHODS

We conducted an observational cohort study applying a target trial emulation framework to linked national cancer, cardiac, and hospitalization registry data from the Virtual Cardio-Oncology Research Initiative. Adults diagnosed with tumors eligible for fluoropyrimidine-based chemotherapy as first-line therapy were included. All-cause mortality and a composite of hospitalization for acute cardiovascular events (acute coronary syndrome, heart failure, cardiac arrhythmia, cardiac intervention, cardiac arrest, and cardiac death) were compared in patients treated with fluoropyrimidine-based chemotherapy vs alternative management. Adjusted, weighted pooled logistic regression models were used to estimate the 1-year risk difference (RD).

RESULTS

Among 103,110 patients (mean age 69.7 years, 59% male), the absolute risk of death at 1 year was significantly lower in fluoropyrimidine-treated patients (RD: -7.7%; 95% CI: -8.7% to -6.7%) with a small increased risk of acute cardiovascular events (RD: 0.9%; 95% CI: 0.0% to 1.9%). This was primarily due to arrhythmias (RD: 0.8%; 95% CI: 0.1% to 1.6%) and cardiac arrest (RD: 0.3%; 95% CI: 0.1% to 0.5%), with no increased risk of acute coronary syndromes including in the subgroup of patients with pre-existing coronary artery disease.

CONCLUSIONS

The markedly improved overall survival with fluoropyrimidines in patients with gastrointestinal cancer significantly outweighs the small risk of cardiac arrhythmia and arrest. Oncologists should take this into consideration for decision making to avoid undue clinical conservatism, particularly in patients with cardiovascular disease.

Systematic Review and Meta-analysis of Right Ventricular Changes in Cancer-therapy - The Forgotten Ventricle in Cardio-Oncology

INTRODUCTION

Cancer therapy-induced cardiotoxicity (CTRCD) is a significant adverse effect of oncologic treatment, associated with considerable morbidity and mortality. Among CTRCD, heart failure stands out in prevalence and severity, with left ventricular dysfunction being the focus of most studies. Right ventricle (RV) may also be damaged by CTRCD, however the effects of CTRCD on RV function (RVF) have not been elucidated.

OBJECTIVE

We aimed to conduct a systematic review and meta-analysis evaluating RV echocardiographic parameters in patients undergoing chemotherapy.

METHODS

PubMed, Embase and Cochrane were searched for studies that evaluated RV parameters during cancer therapy. Statistical analysis was performed using the R statistical software. We computed pooled mean differences (MD), adopting a random-effects model, with a significance level of 0.05. A correlation coefficient of 0.5 was assumed for paired measurements. Heterogeneity was assessed using the I² statistic.

RESULTS

We included 1,520 patients from 25 studies, 73% of whom were women and with a mean age of 51.1±16.5 years. RVF was significantly lower after CTRCD, with reduction in fractional area change (MD=-2.29% [95% CI: -3.63,-0.95]), RV global longitudinal strain (MD=2.49% [95% CI: 1.73, 3.25]), and RV free wall strain (MD=3.21% [95% CI: 2.32, 4.11]). Additionally, tricuspid annular plane systolic excursion was significantly reduced (MD=-1.44mm [95% CI: -1.94, -0.95]) and pulmonary artery systolic pressure was significantly higher (MD=1.60mmHg [95% CI: 0.64, 2.56]) after chemotherapy.

CONCLUSION

The assessment of RVF is important in CTRCD, and its quantification should be included in clinical follow-up during cancer treatment. Further research is needed to elucidate the underlying factors contributing to RV dysfunction and to develop methods for its early detection.

Diagnostic accuracy of ECG and N-terminal pro B-type natriuretic peptide for cardiac dysfunction among asymptomatic long-term breast cancer survivors

BACKGROUND

With a growing population of breast cancer survivors, it is important to acknowledge long-term consequences of breast cancer treatment, including left ventricular systolic dysfunction (LVSD). Although echocardiography is a reliable technique to diagnose LVSD, its limited accessibility in primary care poses challenges.

METHODS

A cross-sectional diagnostic accuracy study among 350 long-term breast cancer survivors, at least 5 years after breast cancer diagnosis, comparing the diagnostic performance of index tests ECG and N-terminal pro B-type natriuretic peptide (NT-proBNP) to the reference test echocardiography. LVSD was defined as left ventricular ejection fraction (LVEF) less than 54% or LVEF less than 50% on echocardiography.

RESULTS

The median age at time of investigation was 63 years (IQR 57-68), with a median follow-up duration since breast cancer diagnosis of 10 years (IQR 7-14). An abnormal ECG demonstrated a sensitivity of 63.0% (IQR 48.7-75.7), a corresponding specificity of 51.7 (IQR 45.8-57.6) and a negative likelihood ratio of 0.7 (IQR 0.5-1.0) for detecting a LVEF less than 54%. An abnormal ECG showed a sensitivity of 75.0 (IQR 47.6-92.7), a corresponding specificity of 50.6 (IQR 45.1-56.2) and a negative likelihood ratio of 0.5 (0.2-1.2) for detecting LVSD defined as LVEF less than 50%. The area under the curve for NT-proBNP was 0.59 (95% confidence interval: 0.50-0.68) for detecting LVEF less than 54% and 0.56 (95% confidence interval: 0.39-0.74) for detecting LVEF less than 50%.

DISCUSSION

ECG and NT-proBNP are inadequate diagnostic tools to screen for LVSD among asymptomatic long-term breast cancer survivors.

Comparison of the diagnostic and prognostic value of criteria for immune checkpoint inhibitor related myocarditis

BACKGROUND

Myocarditis is a dreaded complication of immune-checkpoint inhibitor (ICI) therapy but challenging to diagnose. There are no published data comparing the two leading diagnostic criteria for ICI-related myocarditis (ICIrM) and their association with cardiovascular events.

METHODS

In this retrospective cohort study, we reviewed all patients who underwent ICI therapy and had cardiac troponin assessment for possible myocarditis across three tertiary institutions from 2011 to 2022. ICIrM was adjudicated by the Bonaca et al. criteria and the ESC-ICOS guidelines. A propensity matched control group was identified of patients treated with ICI without developing myocarditis. Baseline characteristics and long-term outcomes, including cardiac death, MACE (myocardial infarction, TIA/stroke, heart failure), and arrhythmias data were curated, and patients diagnosed with ICIrM by each criteria were compared to controls for cardiovascular events.

RESULTS

A total of 59 patients (mean age was 73.1 ± 10.2 years, 60.1% male) were identified as having a diagnosis of ICIrM by Bonaca criteria (16 definite, 13 probable and 30 possible myocarditis). Forty-seven of these patients met the ESC-ICOS guidelines criteria, and all patients meeting either set of ICIrM criteria were treated with steroid therapy. At 3-year follow up, patients diagnosed with ICIrM by the Bonaca criteria had a high risk of cardiac mortality (HR 17.84, 95%CI 2.36-134.62, p = 0.005), MACE (HR 4.90, 95%CI 2.40-10.02, p < 0.001) and arrhythmias (HR 3.33, 95%CI 1.78-6.21, p < 0.001) when compared to matched controls. ICIrM by ESC-ICOS criteria was similarly predictive of cardiac mortality, MACE, and arrhythmias (HR 15.01, 95%CI 1.96-114.76, p = 0.009, HR 5.18, 95%CI 2.33-11.53, p < 0.001, and HR 3.41, 95%CI 1.73-6.70, p < 0.001 respectively).

CONCLUSION

The ESC-ICOS guidelines were more restrictive than the Bonaca et al. criteria for the diagnosis of ICIrM but similar in terms of prognostic value.

Toxicities and management strategies of emerging antibody-drug conjugates in breast cancer

Antibody-drug conjugates (ADCs) offer a promising therapeutic approach for various cancers, enhancing the therapeutic window while mitigating systemic adverse effects on healthy tissues. ADCs have achieved remarkable clinical success, particularly in treating breast cancer, becoming a standard therapy across all subtypes, including hormone receptor-positive, human epidermal growth factor receptor 2-positive, and triple-negative breast cancer. Although designed to selectively target antigens via monoclonal antibodies, ADCs can exhibit toxicity in normal tissues, often due to off-target effects of their cytotoxic payloads. Understanding and managing these toxicities according to established guidelines are crucial for enhancing ADC clinical efficacy, minimizing adverse events, and ultimately improving patient outcomes. This review comprehensively examines the toxicities of ADCs employed in breast cancer treatment and explores their management strategies. Furthermore, we investigate novel ADCs beyond trastuzumab deruxtecan and sacituzumab govitecan, evaluating their potential efficacy and corresponding safety profiles.

Cardiotoxicity induced by chemotherapy and immunotherapy in cancer treatment: a bibliometric analysis

OBJECTIVE

New chemotherapy and immunotherapy agents have revolutionized cancer treatment, significantly improving patient survival rates and quality of life while extending lifespans. However, these therapies often come with severe side effects, particularly cardiotoxicity. Over the past few decades, this field has seen steady growth. To better understand current trends, research hotspots, and collaborative networks in this area, a bibliometric analysis of relevant literature was conducted.

METHODS

A comprehensive search was performed in the Web of Science for articles on cardiotoxicity induced by chemotherapy and immunotherapy in cancer treatment, published in SSCI and SCI-EXPANDED up to October 21, 2024. Using software tools such as GraphPad Prism, CiteSpace, and VOSviewer, we analyzed various parameters including publication year, countries, institutions, journals, authors, and references. Additionally, co-occurrence analyses, cooperation relationship assessments, co-citation networks, keyword maps, clustering analyses, and keyword emergence evaluations were conducted.

RESULTS

As of October 21, 2024, a total of 5290 articles from 5674 institutions and 27,528 authors across 114 countries and regions were collected. The annual publication frequency and rate steadily increased. The United States emerge as the leading country in terms of publication volume, with the University of Texas System being the most prolific and frequently cited institution. "Breast Cancer Research and Treatment" was among the journals with revelant publications. Notable contributors included Ky bonnie and Thavendiranathan Paaladinesh, while Cardinale D achieved the highest average citation count per publication. Current research hotspots included echocardiography, trastuzumab, doxorubicin, radiotherapy, myocarditis, and 5-fluorouracil. The trend suggests that cardiotoxicity is expected to play an increasingly critical role in chemotherapy and immunotherapy for cancer treatment.

CONCLUSION

This study provides a bibliometric visualization analysis of cardiotoxicity induced by chemotherapy and immunotherapy in the cancer treatment. It highlights current developments, collaborative efforts, and research hotspots within this field, offering essential scientific reference value for Cardio-Oncology.

Primary mediastinal B-cell lymphoma (PMBCL): The LYSA pragmatic guidelines

Primary mediastinal B-cell lymphoma (PMBCL) is a distinct subtype of large B-cell lymphoma with unique clinical, histopathological, and molecular characteristics. Despite its aggressive nature, PMBCL has a high cure rate when managed appropriately. Advances in the understanding of PMBCL biological characteristics, coupled with improvements in diagnostic tools and therapeutic approaches, have significantly improved patient outcomes in recent years. In this article, we present a set of pragmatic guidelines developed by the Lymphoma Study Association (LYSA) for the management of PMBCL. These guidelines address key aspects of diagnosis, staging, response evaluation, and treatment, integrating the latest evidence from clinical trials, expert consensus, and real-world practice. The aim of the guidelines is to provide clinicians with a clear, practical framework to optimize care for patients with PMBCL, ensuring that the best available evidence is translated into clinical practice.

Protocol of the follow-up of patients with transthyretin amyloid cardiomyopathy by multimodality imaging (FAITH) study: a prospective observational study in patients with ATTR-CM undergoing treatment with tafamidis

INTRODUCTION

This prospective observational study of patients with transthyretin amyloid cardiomyopathy (ATTR-CM) undergoing treatment with tafamidis aims at identifying quantitative image markers and comparing imaging modalities regarding the follow-up and prognostication of these patients, with the goal of providing a multiparametric score to predict treatment response.

METHODS AND ANALYSIS

Patients with a board-approved decision to receive tafamidis will undergo, in addition to standard of care, baseline and follow-up cardiovascular magnetic resonance (CMR) scans at 9 and 18 months. In total, the study plans to recruit and scan 60 patients. A blinded read will take place in a CMR research core laboratory. The final statistical analysis will be based on developing a multiparametric score for the prediction of treatment response. The study will be managed through the Amyloidosis Center Charité Berlin, a clinical unit formed from the three clinical campus sites of the Charité in Berlin, using the Berlin Research Network for CMR.

ETHICS AND DISSEMINATION

The study was approved by the Charité-Universitätsmedizin Berlin ethics committee EA1/262/23. The results of the study will be disseminated through international peer-reviewed publications and congress presentations.

TRIAL REGISTRATION NUMBER

Approved WHO primary register: German Clinical Trials Register: https://www.drks.de/DRKS00033884. WHO International Clinical Registry Platform: https://trialsearch.who.int/?TrialID=DRKS00033884. Recruitment started on 1 July 2024.

Cardio-oncology: Emerging Concepts in Cardiovascular Sequelae of Cancer Therapies, Translational Research and Reverse Cardio-oncology

Cardio-oncology was established with the aim of defining primary and secondary prevention approaches through surveillance and the use of tools to stratify and diminish the cardiovascular risk to cancer patients. This branch of medicine also contributes to establishing a new field in translational medicine for cardiovascular disease by focusing on the interplay between cancer and heart disease. In this first article in the new cardio-oncology section of the journal, we explore the main concepts of emerging anti-cancer therapies and their plausible cardiotoxic effects and we will describe advances and gaps in knowledge, highlighting how cardio-oncology is contributing to translational cardiology. We will speculate on the complex interplay between cancer and heart failure and discuss an emerging concept known as reverse cardio-oncology. We also present the perspective that cardio-oncology represents a promising platform area of research, allowing the discovery of novel pathways involved in cardiovascular disease through the identification of toxicities induced by targeted cancer therapies.

Severe Late-Onset Anthracycline-Induced Cardiotoxicity in Breast Cancer Survivor Patient: Importance of Post-Chemotherapy Surveillance

BACKGROUND

Left ventricular (LV) dysfunction is a common and serious complication from cancer treatment. One of the common regimens that can cause cardiotoxicity is anthracycline, and anthracycline-induced cardiotoxicity may manifest after several years.

CASE SUMMARY

A 32-year-old woman presented with heart failure syndrome late after chemotherapy administration for breast cancer therapy. Several months after chemotherapy completion, patient presented with overt LV dysfunction. The guideline-directed medical treatment was initiated. Patient demonstrated gradual recovery and progressive improvement of myocardial systolic performance with LV thrombus resolution after 5-month evaluation.

DISCUSSION

The recognition of cancer therapy-related cardiac dysfunction (CTRCD) is important since early detection and treatment with heart failure treatment provide a good functional recovery and long-term prognosis. The clinical application of longitudinal strain and myocardial work echocardiography in CTRCD cases for therapeutic response tracking and prognostication purposes is recommended.

TAKE-HOME MESSAGE

Long-term postchemotherapy echocardiography evaluation especially in high-risk CTRCD criteria is of utmost importance due to the possibility of late-onset CTRCD.

Simultaneous Transcatheter Pulmonary and Tricuspid Valve Replacement in Carcinoid Heart Disease

BACKGROUND

Neuroendocrine tumors can cause carcinoid heart disease, often presenting with pulmonary and tricuspid regurgitation. Valvular pathology and right heart failure can influence prognosis more than the tumor itself. Given high surgical risk, prolonged recovery, and limited life expectancy, interventional valve replacement is a strong alternative.

CASE SUMMARY

We present a patient with severe pulmonary and torrential tricuspid regurgitation caused by carcinoid heart disease. Despite stable neuroendocrine tumor control, the patient developed progressive right heart failure, requiring urgent valve therapy. Simultaneous transcatheter pulmonary and tricuspid valve replacements were performed, almost eliminating tricuspid and pulmonary regurgitation.

DISCUSSION

Right heart valve failure is frequent in carcinoid heart disease and significantly impacts outcomes. Although surgical valve replacement remains the standard, transcatheter approaches provide an effective, less invasive alternative for high-risk patients, offering symptom relief and excellent results.

TAKE-HOME MESSAGE

Simultaneous interventional valve replacement in carcinoid heart disease is feasible and effective.

Dexrazoxane makes doxorubicin-induced heart failure a rare event in sarcoma patients receiving high cumulative doses

Doxorubicin remains a cornerstone in sarcoma treatment, but its dose-dependent cardiotoxicity limits its clinical use and therapeutic potential. Dexrazoxane, the only FDA-approved cardioprotective agent, has demonstrated substantial efficacy in preventing doxorubicin-induced cardiotoxicity. However, despite its proven benefits, dexrazoxane remains underutilized not only in clinical practice but also in contemporary trials. This review examines the role of dexrazoxane in recent oncology trials involving sarcoma patients treated with high cumulative doses of doxorubicin. The LMS 04 trial, a contemporary phase 3 sarcoma trial in which dexrazoxane use was prohibited, reported a 5.4% heart failure incidence at cumulative doxorubicin doses of 360-450 mg/m². In contrast, the trials, where dexrazoxane was used early or upfront, demonstrated rare heart failure incidences even at cumulative doses exceeding 600 mg/m², which is well beyond the conventional maximal limit. Additionally, dexrazoxane enables the safe administration of cumulative doxorubicin doses exceeding 1000 mg/m² without increasing cardiotoxicity. Concerns about secondary malignancies and reduced anti-tumor efficacy have not been supported by clinical trials and meta-analyses. The routine upfront use of dexrazoxane should be considered with doxorubicin treatment, especially in those requiring high cumulative doses or patients at high risk of cardiotoxicity, as each dose of doxorubicin incrementally contributes to the development of cardiotoxicity. Dexrazoxane not only mitigates cardiotoxicity but also allows for extended doxorubicin dosing, maximizing its therapeutic potential. Awareness and guideline updates are necessary to ensure its broader adoption in clinical practice.

Utility of global longitudinal strain in early identification of chronic cardiotoxicity in asymptomatic long-term malignant lymphoma survivors with normal left ventricle ejection fraction

Malignant lymphoma survivors are at increased risk for anthracycline and/or radiotherapy-induced chronic cardiotoxicity. Proper long-term follow-up is essential for malignant lymphoma survivors after-care. This study aimed to assess TTE parameters of potential subclinical cardiotoxicity and to examine their utility in diagnosing chronic cardiotoxicity. Improvement of the diagnostic process may precede the manifestation of cardiac adverse events. Main objective of the study was to improve the identification of cancer survivors in increased risk of treatment cardiotoxicity. To achieve this goal, utility of various echocardiography parameters was examined.In this retrospective study we analysed TTE of 167 subjects with speckle tracking according to the European Society of Echocardiography guidelines during the follow-up period. 88 of them were long-term lymphoma survivors diagnosed with malignant lymphoma between the years 1994-2015. Minimum follow up period was 5 years with the median of 10 years after anti-cancer treatment cessation. TTE were performed between the years 2017-2022 at cardio-oncology outpatient office during regular follow-up period. A total of 79 volunteers with no history of chronic heart failure (CHF) or decline in LVEF, 51 (64.6%) of whom were males, with the median age of 46 (16-58) years were included in the analysis as control group. Control subjects had various indications for TTE (e.g. preoperative examination, benign palpitations, or with well controlled arterial hypertension taking two antihypertensives at most). Ischemic heart disease was ruled out by stress test. None of the control subjects had history of stroke or chronic lower limb ischemia. All control subjects were considered clinically stable with no sign of cardiac impairment caused by primary disease. Both cancer survivors and control group were divided into subgroups based on LVEF: lower normal LVEF (53-61%), and higher normal LVEF (> 61%). Survivors with lower normal LVEF (53-61%) had a statistically significant decline in GLS compared to those with higher normal LVEF (> 61%). This phenomenon was not observed in control group indicating a possible additional diagnostic value of this parameter. Inclusion of GLS assessment in follow-up TTE examination of subjects with lower normal LVEF may improve the sensitivity of detection of chronic cardiotoxicity. Patients with declined GLS and lower normal LVEF are candidates for intensified follow-up to precede manifestation of cardiac adverse events.

Developing a simple clinical risk score for ibrutinib-associated atrial fibrillation

BACKGROUND

Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, is used in the treatment of B-cell malignancies (e.g., chronic lymphocytic leukemia [CLL]). Initial risk stratification of ibrutinib-associated atrial fibrillation (IAAF) may inform atrial fibrillation (AF) surveillance strategies. The performance of existing AF risk scores to predict incident AF among patients newly treated with ibrutinib is unknown.

METHODS

We conducted a single-center retrospective study of all patients without a history of AF who were treated with ibrutinib (2012-2016). Patient demographics were compared between cohorts by the presence of IAAF within 24 months of treatment initiation. First, the predictive ability of established AF risk models was assessed. Secondly, univariate and multivariate analyses were used to create a new IAAF risk model which was compared to established AF risk models by area under the curve (AUC) analysis.

RESULTS

Of 167 patients (66 ± 11 years, 70% male), 24 (14.4%) developed incident IAAF (mean time to IAAF, 7.1 ± 6.3 months). Univariate analysis showed that hypertension (HTN), diabetes (DM), systolic heart failure (HFrEF), and obstructive sleep apnea (OSA) were associated with IAAF. Logistic regression analysis of variables of interest and those with p < 0.1 on univariate analysis demonstrated that left atrial diameter (LAD) > 43 mm and obstructive sleep apnea were independently associated with IAAF. Existing AF risk scores had reasonable performance (AUC, 0.68-0.72). A new simple clinical risk score was developed: OSA 5 points, HFrEF 3 points, DM 2 points, and hyperlipidemia 2 points. This simple IAAF risk score achieved a numerically greater AUC than that of established risk models (AUC = 0.77). There was no statistically significant difference in the AUC performance between risk scores.

CONCLUSION

Among 167 ibrutinib naïve patients, risk factors for incident AF development resemble those of the general population. However, common AF risk models have moderate predictive ability. Large validation studies are needed to confirm the superior IAAF predictive ability of this simple risk score and investigate the incremental predictive value of echocardiographic variables.

Principles of optimal multidisciplinary management of prostate cancer in clinical practice

Advances in the diagnosis and management of prostate cancer have significantly changed the disease landscape. While benefiting from better oncological outcomes, patients are now experiencing higher rates of non-cancer comorbidities, including cardiovascular disease. The increasing impact of cardiovascular disease in those with prostate cancer led to the expanding role of cardio-oncology professionals in enhancing the multidisciplinary care of these patients. As a result, the International Cardio-Oncology Society (IC-OS) launched a 4-webinar series in collaboration with the European Association of Urology and the Canadian Urology Association to inform best practices in the multidisciplinary care of patients with prostate cancer. This program highlighted currently recommended diagnostic and treatment strategies from urology, oncology, and cardiology and emphasized knowledge gaps and future directions. In this article, which is the second in a 2-part series, we review challenging cases that were presented and discussed among a multidisciplinary international panel and highlight ongoing research and future directions from both urology/oncology and cardio-oncology.

Comparison of cardiac computed tomography recommendations in recent ESC vs. ACC/AHA guidelines

Cardiac computed tomography (CCT) continues to expand with increasing applications and technological advancements. Growing evidence on the clinical utility of CCT necessitates evaluating how this knowledge is incorporated into European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. We aimed to provide a comprehensive comparison of CCT indications between ESC and ACC/AHA guidelines to identify areas of consensus and divergence in the current landscape of CCT utilization. ESC and ACC/AHA guidelines were systematically reviewed for CCT recommendations. The class of recommendation (COR) and level of evidence (LOE) were compared using χ2 or Fisher exact tests. The latest ESC guidelines included 40 recommendations regarding CCT: 18 (45%) COR-I, 14 (35%) COR-IIa, 6 (15%) COR-IIb, and 2 (5%) COR-III. Two (5%) recommendation had LOE-A, 20 (50%) had LOE-B, and 18 (45%) had LOE-C. The latest ACC/AHA guidelines consisted of 54 recommendations: 18 (33.3%) COR-I, 28 (51.9%) COR-IIa, 6 (11.1%) COR-IIb, and 2 (3.7%) COR-III. Two recommendations were assigned LOE-A (3.7%), 30 (55.6%) were classified as LOE-B, and 22 (40.7%) as LOE-C. ACC/AHA guidelines had a significantly higher proportion of COR-IIa recommendations (P = 0.04) and similar proportions of COR-I and COR-IIb recommendations (P = 0.28; P = 0.76), compared to ESC guidelines. The proportion of LOE-B and LOE-C recommendations weren't statistically different (P = 0.54; P = 0.84). ACC/AHA guidelines included more CCT recommendations with a higher COR and LOE than ESC guidelines. These findings highlight the need for continued research and consensus-building to establish standardized, evidence-based CCT recommendations in clinical practice.

Immuno-inflammatory mechanisms in cardio-oncology: new hopes for immunotargeted therapies

Cardio-oncology is an emerging interdisciplinary field concerned with cancer treatment-related cardiovascular toxicities (CTR-CVT) and concomitant cardiovascular diseases (CVD) in patients with cancer. Inflammation and immune system dysregulation are common features of tumors and cardiovascular disease (CVD). In addition to the mutual exacerbating effect through inflammation, tumor treatments, including immunotherapy, chemotherapy, radiation therapy, and targeted therapy, may induce immune inflammatory reactions leading to cardiovascular damage. Cancer immunotherapy is currently a new method of cancer treatment. Immunotherapeutic agents, such as immune checkpoint inhibitors (ICIs), chimeric antigen receptor T cell immunotherapy (CAR-T), mRNA vaccines, etc., can induce anti-tumor effects by enhancing the host immune response to eliminate tumor cells. They have achieved remarkable therapeutic efficacy in clinical settings but lead to many immune-related adverse events (irAEs), especially CTR-CVT. Establishing specific evaluation, diagnostic, and monitoring criteria (e.g., inflammatory biomarkers) for both immunotherapy and anti-inflammatory therapy-related cardiovascular toxicity is vital to guide clinical practice. This article explores the role of immune response and inflammation in tumor cardiology, unravels the underlying mechanisms, and provides improved methods for monitoring and treating in CTR-CVT in the field of cardio-oncology.

Oxidative Stress Biomarkers Predict Myocardial Dysfunction in a Chemotherapy-Induced Rat Model

Objectives: Chemotherapy improves survival in breast cancer patients but increases the risk of myocardial dysfunction and heart failure. Since early prediction of cardiomyopathy remains difficult, biomarkers are needed for detecting myocardial damage before heart failure develops. This study examines the association between oxidative stress biomarkers and myocardial dysfunction in a chemotherapy-induced rat model. Methods: Forty-two rats were randomized into four groups: control (n = 7), doxorubicin only (n = 7), doxorubicin plus trastuzumab (n = 7), and doxorubicin plus trastuzumab with cardioprotective intervention (n = 21). Doxorubicin and trastuzumab were administered sequentially over 28 days. Echocardiography with speckle-tracking was utilized to measure longitudinal strain (LS, -%). Reduced LS was defined by a LS with a median value less than 23% on day 28. Blood samples were collected for biomarker analysis, focusing on superoxide dismutase (SOD) and glutathione (GSH). Myocardium fibrosis was assessed using Masson's trichrome staining. Results: Thirty-four rats survived and underwent LS analysis. All rats treated with doxorubicin and trastuzumab exhibited reduced LS, while those receiving cardioprotective intervention maintained preserved LS on day 28. The reduced LS group had significantly lower SOD and higher GSH levels compared to the preserved LS group. SOD and GSH correlated strongly with LS (SOD, r = 0.590, p = 0.001; GSH, r = -0.590, p = 0.003), and LS correlated with fibrosis area (r = -0.660, p < 0.001). SOD and GSH effectively predicted reduced LS. Conclusions: In a rat model of chemotherapy-induced cardiomyopathy, oxidative stress biomarkers correlated with myocardial dysfunction, as indicated by LS. These findings highlight the potential of biomarker monitoring to improve early detection and prevention strategies for chemotherapy-induced cardiomyopathy.

Understanding Mortality Patterns in Elderly Cancer Patients with Atrial Fibrillation: A Comprehensive Data Analysis

BACKGROUND

Atrial Fibrillation (AF) among patients with cancer is a significant health concern for older adults in the United States. This study analyzes trends and demographic disparities in mortality rates related to AF in patients with cancer aged 65+.

METHODS

The CDC WONDER database was used to analyze Age-adjusted mortality rates (AAMRs) for to AF in patients with cancer (ICD-10 I48, C00- C97) from 1999 to 2023, stratified by sex, race, geography, and metropolitan status. Average Annual Percentage Changes (AAPCs) and Annual Percentage Changes (APCs) per 100,000 with 95 % confidence intervals (CI) calculated using Joinpoint regression.

RESULTS

From 1999 to 2023, AF in patients with cancer caused 421,247 deaths among U.S. adults 65+. The overall AAMR rose from 24.1 in 1999 to 61.1 in 2023, with a 3.92 AAPC (95 % CI: 3.81 to 4.05). AAMR increased significantly from 1999 to 2018 (APC: 3.12), surged from 2018 to 2021 (APC: 10.93), then rose slightly until 2023 (APC: 1.40), all p <0.01. From 1999 to 2023, Men had higher AAMRs than women (53.8 vs. 27.2) while NH Whites had the highest AAMRs (42.2), followed by NH Blacks (23.1). Vermont has the highest AAMR (60.0), Nevada the lowest (17.3), and the Western region had the highest AAMR (40.8), while rural areas had slightly higher AAMRs than urban areas (39.1 vs 34.8).

CONCLUSION

The AAMR for AF in patients with cancer in the U.S. has doubled over the past two decades, particularly during the COVID-19 pandemic. These findings highlight the urgent need for targeted interventions and enhanced access to care.

Mapping clinical and imaging factors that might predict cardiac events in breast cancer patients

Background

Breast cancer is the most common in women, with a 90% overall survival at 5 years. Cardiotoxicity is a side effect that can modify their morbidity and mortality. Its low prevalence and long latency period have challenged the establishment of a strategy for early detection and prevention.

Objectives

To investigate the association between coronary artery calcium (CAC) in planning computed tomography (CT) and cardiac events.

Methods

Retrospective cohort of 873 breast cancer patients (460 right-side; 413 left-side) treated with radiotherapy (2013-2022). We extract the Hounsfield Unit to quantify the CAC degree from the heart structure in the planning CT. We used IBM-SPSS software (V 29.0 Armonk, NY) for the statistical analysis.

Results

After a median follow-up of 4.52 years (range: 2.42-6.22 years), the cardiac events incidence was 1.95% vs 5.1% in right and left breast cancer, respectively. The mean heart dose was higher in cases with cardiac events (6.74Gy vs 2.28Gy; p<0.01). CAC score>0 was detected in 32.76% of planning CT and was more frequent in the elderly and those with cardiovascular risk factors (p<0.01). Patients with cardiac events presented a CAC score>0 in 41.4% of cases. However, the overall survival in these patients did not differ from those without CAC (p=0.58).

Conclusions

Patients with cardiovascular risk factors and a mean cardiac dose greater than 5 Gy are at increased risk of cardiotoxicity and should be referred for Cardio-Oncology evaluation. The application of the CAC score in CT planning could be a valuable screening test that requires further study.

Early prediction of cardiovascular events following treatments in female breast cancer patients: Application of real-world data and artificial intelligence

•Application of real-world data and artificial intelligence in detecting cardiotoxicity following cancer treatment. •Clinical features have been used to develop prediction models. •Important features include age, tumor size, hypertension, HbA1c, HDL, creatinine, bilirubin, BUN, ALT, and diabetes. •This study offers potential approaches for cardio-oncology clinical practice.

Potent P2Y12 Inhibitors vs Clopidogrel in Cancer Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Patients with cancer undergoing percutaneous coronary intervention (PCI) experience a higher risk of both ischemic and bleeding events. The aim of this study was to assess ischemic and bleeding risks after PCI in cancer patients treated with potent P2Y12 inhibitors (P2Y12i; prasugrel and ticagrelor) compared with clopidogrel.

METHODS

Consecutive patients with cancer undergoing PCI at a tertiary center between 2012 and 2022 and discharged on P2Y12i were included in this study. Propensity score covariate adjustment was used to account for baseline differences between patients treated with potent P2Y12i and clopidogrel. Key clinical endpoints included major adverse cardiac and cerebrovascular events (MACCEs---composite of death, myocardial infarction, or stroke) and major bleeding.

RESULTS

Of the 1702 included patients, 373 (21.9%) were treated with potent P2Y12i and 1329 (78.1%) with clopidogrel. Factors associated with potent P2Y12i use were acute coronary syndrome presentation and lesion length, whereas clopidogrel use was associated with active cancer status, thrombocytopenia, older age, and femoral access. MACCEs at 1 year occurred in 3.5% of patients treated with potent P2Y12i vs 6.8% of those receiving clopidogrel (log-rank test, P = 0.035; adjusted hazard ratio [adj HR] 0.53, 95% confidence interval [CI] 0.26-1.10), but no differences in bleeding risk were detected (5.5% vs 7.0%, adj HR 0.92, 95% CI 0.53-1.60). The reduction in MACCEs was significant in patients with remission but not active cancer (Pinteraction = 0.011).

CONCLUSIONS

Among cancer patients undergoing PCI, potent P2Y12i use was associated with similar bleeding risk and lower incidence of ischemic events compared with clopidogrel, but with no significant difference after propensity score adjustment.

Phenotypes of Myocardial Dysfunction on Serial Echocardiography and CMR in Women With Early-Stage Breast Cancer

BACKGROUND

Understanding phenotypic variations in left ventricular (LV) dysfunction during cancer therapy may allow for tailored surveillance and prevention.

OBJECTIVES

The study sought to determine LV dysfunction phenotypes during cancer therapy and their interrelated-ness and association with cancer therapy-related cardiac dysfunction (CTRCD), myocardial tissue changes, and blood biomarkers.

METHODS

This is a secondary analysis of the EMBRACE-MRI (Evaluation of Myocardial Changes During BReast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI) study in which women with early-stage HER2+ breast cancer were recruited prospectively. High-sensitivity troponin I, B-type natriuretic peptide, and echocardiography were obtained pre-anthracycline and every 3 months with measurement of systolic and diastolic function and left atrial reservoir strain (LARS). Cardiac magnetic resonance (CMR) was performed at baseline and follow-ups with quantification of myocardial T1, T2, and extracellular volume (ECV). Diastolic dysfunction (DD) was graded using American Society of Echocardiography guidelines ("conventional") and regraded by replacing left atrial volume with LARS <24% ("modified"). Relative reduction in global longitudinal strain (GLS) >15% was considered "worsening GLS," and CTRCD was defined using CMR-derived left ventricular ejection fraction.

RESULTS

Among 136 women (51.1 ± 9.2 years), CTRCD developed in 37 of 136 (27%) and worsening GLS in 53 of 126 (42%) with analyzable studies. Incident DD occurred in 25 (19.4%) of 129 and 19 (14.4%) of 132 patients by conventional and modified grading, respectively. Using LARS improved the ability to classify DD. Transition state analysis demonstrated that the first abnormal state during cancer therapy could be worsening GLS, DD, CTRCD, or a combination. A greater proportion of patients who first transition to DD vs worsening GLS developed subsequent CTRCD (5 of 8 [63%]) vs 7 of 39 [18%]). Worsening DD was associated with higher odds of subsequent CTRCD (OR: 20.9, 95% CI: 3.4-129.5) vs worsening GLS (OR: 4.9, 95% CI: 2.6-9.4). DD was significantly associated with radiation dose and ECV but not with blood biomarkers.

CONCLUSIONS

Patients receiving breast cancer therapy can develop significant GLS change, DD, or CMR-defined CTRCD that can occur in isolation, concurrently, or sequentially. Development of DD is associated with ECV and higher risk for subsequent CTRCD. (Evaluation of Myocardial Changes During BReast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI [EMBRACE-MRI]; NCT02306538).

Serum Albumin-Creatinine Ratio and Anthracycline Cardiotoxicity in Patients with Cancer

Background: Several studies have suggested that the serum albumin-creatinine ratio (sACR) is a useful marker for the early risk stratification of patients with cardiomyocyte injury. This study aims to evaluate the relationship between sACR and anthracycline-related cardiotoxicity. Methods: This study included patients who had received anthracycline-based chemotherapy between 2014 and 2023 and had undergone baseline and follow-up echocardiography after the treatment. The level of sACR was calculated using serum albumin and creatinine values obtained before the chemotherapy. The definition of cardiotoxicity was based on the criteria of the European Society of Cardiology (ESC) for ejection fraction and the American Society of Echocardiography (ASE) for diastolic dysfunction. The patients were categorized into either the high or low sACR group based on the cut-off value obtained from the receiver operating characteristic (ROC) curve analysis. Results: In total, 525 patients (159 males, 366 females) were included. Multivariate analysis after adjustment for age, body mass index (BMI), cardiovascular disease, hemoglobin, anthracycline dose, and gender showed that sACR (HR = 1.85% 95 CI 1.12 to 3.06 p = 0.016), cardiovascular disease (HR = 1.97% 95 CI 1.08 to 3.61 p = 0.027), BMI (HR = 1.86% 95 CI 1.12 to 3.10 p = 0.017), and age (HR = 1.02% 95 CI 1.001 to 1.04 p = 0.036) were significantly associated with an increased risk of cardiotoxicity. Conclusions: This study is the first to show a significant relationship between sACR and cardiotoxicity related to anthracycline use. Routine laboratory tests that are conducted before anthracycline therapy can aid clinicians in identifying high-risk patients who may require closer follow-up or cardioprotective measures.

Rivaroxaban for 18 Months Versus 6 Months in Patients With Cancer and Acute Low-Risk Pulmonary Embolism: An Open-Label, Multicenter, Randomized Clinical Trial (ONCO PE Trial)

BACKGROUND

The optimal duration of anticoagulation therapy for patients with cancer and acute low-risk pulmonary embolism (PE) is clinically relevant, but evidence is lacking. Prolonged anticoagulation therapy could have a potential benefit for prevention of thrombotic events; however, it could also increase the risk of bleeding.

METHODS

In a multicenter, open-label, adjudicator-blinded, randomized clinical trial at 32 institutions in Japan, we randomly assigned patients with cancer and acute low-risk PE of the simplified version of the Pulmonary Embolism Severity Index score of 1, in a 1:1 ratio, to receive either an 18-month or a 6-month rivaroxaban treatment. The primary end point was recurrent venous thromboembolism (VTE) at 18 months. The major secondary end point was major bleeding at 18 months according to the criteria of the International Society on Thrombosis and Hemostasis. The primary hypothesis was that an 18-month treatment was superior to a 6-month treatment in terms of the primary end point.

RESULTS

From February 2021 to March 2023, 179 patients were randomized, and after the exclusion of one patient who withdrew consent, 178 were included in the intention-to-treat population: 89 patients in the 18-month rivaroxaban group and 89 in the 6-month rivaroxaban group. The mean age was 65.7 years; 47% of the patients were men, and 12% had symptoms of PE at baseline. The primary end point of recurrent VTE occurred in 5 of the 89 patients (5.6%) in the 18-month rivaroxaban group and in 17 of the 89 (19.1%) in the 6-month rivaroxaban group (odds ratio, 0.25 [95% CI, 0.09-0.72]; P=0.01). Among 22 recurrent VTE, 5 patients presented with a symptomatic recurrent VTE; recurrent PE occurred in 11 patients, including 2 with main and 4 with lobar PEs; and recurrent deep vein thrombosis was seen in 11 patients, including 3 with proximal deep vein thromboses. The major secondary end point of major bleeding occurred in 7 of the 89 patients (7.8%) in the 18-month rivaroxaban group and in 5 of the 89 patients (5.6%) in the 6-month rivaroxaban group (odds ratio, 1.43 [95% CI, 0.44-4.70]; P=0.55).

CONCLUSIONS

In patients with cancer and acute low-risk PE of the simplified version of the Pulmonary Embolism Severity Index score of 1, the 18-month rivaroxaban treatment was superior to the 6-month rivaroxaban treatment with respect to recurrent VTE events.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04724460.

Management of Stable Coronary Artery Disease and Acute Coronary Syndrome in Patients with Cancer

PURPOSE OF REVIEW

This review examines the current evidence and management strategies for stable coronary artery disease (CAD) and acute coronary syndrome (ACS) in patients with cancer. We outline the unique challenges, optimal treatment approaches, and outcomes in this growing population.

RECENT FINDINGS

First-line medications for CAD management are consistently underutilized in cancer patients despite serving as standard of care. As a corollary, medical optimization in CAD management in general is less likely to occur in patients with cancer. Early invasive strategies in ACS show improved survival, yet cancer patients receive percutaneous coronary intervention less frequently than non-cancer patients. Optimization of medical management should be prioritized in stable CAD; revascularization with PCI is first line for most patients presenting with ACS. Modification of risk factors contributing to both CAD and cancer is of utmost importance. Cancer survivors should receive vigilant, long-term monitoring for the development of signs of CAD.

Clinical Outcomes and Prognostic Implications of TAVR in Patients With Active Cancer: A Meta-Analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for high-risk patients with severe aortic stenosis (AS). However, the clinical outcomes and prognostic implications of TAVR in patients with active cancer remain uncertain. This meta-analysis evaluates procedural success, complications, and survival outcomes of TAVR in patients with and without active cancer.

METHODS

A comprehensive literature search was conducted across PubMed, Scopus, and Web of Science databases. Statistical analysis was performed using a random-effects model. Statistical analyses were conducted using STATA version 18.0.

RESULTS

The results of the meta-analysis showed no significant difference in in-hospital mortality between cancer and non-cancer patients (OR = 1.17; 95% CI: 0.83, 1.65; p = 0.27). Similarly, 30-day mortality did not differ between the two groups (OR = 0.93; 95% CI: 0.72, 1.19; p = 0.49). However, 1-year mortality was significantly higher in cancer patients (OR = 1.93; 95% CI: 1.45, 2.56; p < 0.01). Two-year mortality was also higher in cancer patients (OR = 2.65; 95% CI: 1.79, 3.93; p < 0.01). No significant differences were observed in major bleeding, acute kidney injury, stroke, or permanent pacemaker implantation between the groups.

CONCLUSION

While TAVR offers comparable in-hospital and short-term survival outcomes for cancer and non-cancer patients, long-term mortality is significantly higher in those with active cancer. These findings suggest that TAVR is a viable option for cancer patients with severe AS but requires careful long-term prognostic considerations. Further studies are needed to optimize management strategies for this complex population.

Expert Opinion on Managing Adverse Reactions Associated With Acalabrutinib Therapy: A Delphi Consensus From France

Acalabrutinib, a second-generation Bruton's tyrosine kinase inhibitor (BTKi), offers an improved safety profile compared to first-generation inhibitors like ibrutinib. While BTKi guidelines exist, practical differences between BTKis-such as drug interactions and tolerance-are not fully addressed. Therefore, a consensus on acalabrutinib use would benefit the medical community. This 2-round Delphi study involved hematologists, pharmacists, cardiologists, dermatologists, and nurse practitioners throughout France to establish consensus-based practical guidance on managing adverse events (AEs) associated with acalabrutinib in chronic lymphocytic leukemia. Key findings highlighted the need for a hospital pharmacist to analyze drug interactions before starting acalabrutinib. Additionally, the experts' opinion was to avoid the concomitant use of acalabrutinib with strong CYP3A inhibitors due to an increased risk of toxicity and with strong CYP3A inducers due to potential efficacy concerns. Importantly, our study did not find contraindications for acalabrutinib in patients with current or previous atrial fibrillation. The panel emphasized the importance of measuring blood pressure at every clinical visit for patients treated with acalabrutinib and opposed the initiation of acalabrutinib in patients on both aspirin and clopidogrel. For invasive dermatological or dental procedures, acalabrutinib should be discontinued 4 days prior and resumed 48 hours postprocedure in the absence of bleeding. Additionally, patients should be informed about the risk of headaches, particularly during the first month of treatment, and paracetamol use in combination with caffeine is recommended for managing grade ≥ 2 headaches under acalabrutinib treatment. This Delphi study underscored the effectiveness of a collaborative process in enhancing the management of acalabrutinib-associated AEs.

Management and mitigation of metabolic bone disease and cardiac adverse events throughout the prostate cancer pathway: clinical review and practical recommendations

Some current prostate cancer (PCa) treatment regimens are known to have adverse effects on bone, for example androgen deprivation therapy (ADT), and on cardiovascular health, for example ADT and antiandrogen therapy. Strengthened recommendations for the practical assessment and management of bone and cardiovascular health in men with PCa are needed. This review aims to provide practical guidance for healthcare providers along the continuum of patient care on the management of bone and cardiovascular health in men with PCa undergoing ADT and antiandrogen therapy based on real-world evidence. Evidence was identified by searching PubMed for publications that reported the effects of PCa treatment on bone or cardiovascular health in a real-world setting and were published between January 2017 and August 2023. Review articles were excluded. The evidence identified indicates that ADT decreases bone mineral density (BMD) and increases the risk of osteoporosis and fractures. Bone-protecting agents (BPAs) are effective at improving bone health in patients undergoing ADT and antiandrogen therapy at all stages of the PCa pathway. Despite this, the use and timing of initiation of BPAs are variable. Furthermore, real-world studies have confirmed an association between ADT and cardiovascular risk. As survival outcomes improve, maintenance of bone and cardiovascular health is increasingly important in men with PCa. Risk is a continuous variable that must be assessed throughout the continuum of PCa treatment. Therefore, all men starting ADT should be assessed for bone and cardiovascular risk. Lifestyle adjustments, dietary supplementation and pharmacological intervention may be advised.

Diagnosis of cancer therapy-related cardiovascular toxicities: A multimodality integrative approach and future developments

Diagnosing cancer therapy-related cardiovascular toxicities may be a challenge. The interplay between cancer and cardiovascular diseases, beyond shared cardiovascular and cancer risk factors, and the increasingly convoluted cancer therapy schemes have complicated cardio-oncology. Biomarkers used in cardio-oncology include serum, imaging and rhythm modalities to ensure proper diagnosis and prognostic stratification of cardiovascular toxicities. For now, troponin and natriuretic peptides, multimodal cardiovascular imaging (led by transthoracic echocardiography combined with cardiac magnetic resonance or computed tomography angiography) and electrocardiography (12-lead or Holter monitor) are cornerstones in cardio-oncology. However, the imputability of cancer therapies is sometimes difficult to assess, and more refined biomarkers are currently being studied to increase diagnostic accuracy. Advances reside partly in pathophysiology-based serum biomarkers, improved cardiovascular imaging through new technical developments and remote monitoring for rhythm disorders. A multiparametric omics approach, enhanced by deep-learning techniques, should open a new era for biomarkers in cardio-oncology in the years to come.

A longitudinal study of right ventricular function of patients with multiple myeloma treated with carfilzomib

A particular focus on right ventricular function should be suggested in patients during treatment with carfilzomib due to potential RV side-effects. TAPSE follow-up appears to be an interesting tool for close monitoring of these patients. https://bit.ly/4dTedb9.

Long-term and short-term cardiovascular disease mortality among patients of 21 non-metastatic cancers

INTRODUCTION

Previous studies on cardiovascular disease (CVD) death risk in cancer patients mostly focused on overall cancer, age subgroups and single cancers.

OBJECTIVES

To assess the CVD death risk in non-metastatic cancer patients at 21 cancer sites.

METHODS

A total of 1,672,561 non-metastatic cancer patients from Surveillance, Epidemiology, and End Results (SEER) datebase (1975-2018) were included in this population-based study, with a median follow-up of 12·7 years. The risk of CVD deaths was assessed using proportions, competing-risk regression, absolute excess risks (AERs), and standardized mortality ratios (SMRs).

RESULTS

In patients with localized cancers, the proportion of CVD death and cumulative mortality from CVD in the high-competing risk group (14 of 21 unique cancers) surpassed that of primary neoplasm after cancer diagnosis. The SMRs and AERs of CVD were found higher in patients with non-metastatic cancer than the general US population (SMR 1·96 [95 %CI, 1·95-1·97]-19·85[95 %CI, 16·69-23·44]; AER 5·77-210·48), heart disease (SMR 1·94[95 %CI, 1·93-1·95]-19·25[95 %CI, 15·76-23·29]; AER 4·36-159·10) and cerebrovascular disease (SMR 2·05[95 %CI, 2·02-2·08]-24·71[95 %CI, 16·28-35·96]; AER 1·01-37·44) deaths. In the high-competing risk group, CVD-related SMR in patients with localized stage cancer increased with survival time but followed a reverse-dipper pattern in the low-competing risk group (7 of 21 cancers). The high-competing risk group had higher CVD-related death risks than the low-competing risk group.

CONCLUSION

The CVD death risk in patients with non-metastatic cancer varied by cancer stage, site and survival time. The risk of CVD mortality is higher in 14 out of 21 localized cancers (high-competing cancers). Targeted strategies for CVD management in non-metastatic cancer patients are needed.

Effectiveness of exercise-based interventions in preventing cancer therapy-related cardiac dysfunction in patients with breast cancer: A systematic review and network meta-analysis

BACKGROUND

Despite advances in cancer treatment that have improved survival rates among patients with breast cancer, they are at high risk of developing cancer therapy-related cardiac dysfunction, which typically manifests as heart failure. Although exercise improves cardiorespiratory fitness in these patients, its effectiveness in preventing cancer therapy-related cardiac dysfunction remains unclear.

OBJECTIVE

To assess the effectiveness of exercise-based interventions using cardiac function parameters and to identify the optimal exercise modality for preventing cancer therapy-related cardiac dysfunction.

DESIGN

A systematic review and network meta-analysis.

METHODS

A comprehensive search was conducted across PubMed, Embase, Scopus, Web of Science, and the Cochrane Library databases, covering all records from their inception through August 6, 2024. Studies that used exercise-based interventions, either exercise alone or with other interventions, were included. Those with insufficient data for the primary and secondary outcomes were excluded. Quality appraisal was evaluated using the risk of bias tool (RoB-2). All statistical analyses were conducted using the meta (version 7.0-0) and gemtc (version 1.0-2) packages in R software (version 4.3.3). For continuous outcomes, pairwise and network meta-analysis were employed to estimate mean differences (MDs) and 95 % confidence intervals (CI). The Surface Under the Cumulative Ranking Curve (SUCRA) was employed to rank treatments. The study protocol has been registered on PROSPERO (ID: CRD42024501160).

RESULTS

In total, 13 randomized controlled trials involving 1122 participants were included in the review. There was low-to-high risk of bias across thirteen studies. Compared to usual care, exercise-based interventions significantly improved left ventricular ejection fraction (MD, 1.68; 95 % CI, 0.59-2.77) and global longitudinal strain (MD, 1.40; 95 % CI, 0.59-2.21). Based on the ranking probabilities, combined aerobic and resistance exercise was the most efficacious method for improving left ventricular ejection fraction (four studies; SUCRA, 0.96), followed by exercise-based cardio-oncology rehabilitation (two studies; SUCRA, 0.45) and aerobic exercise (four studies; SUCRA, 0.42). In terms of improving global longitudinal strain, combined aerobic and resistance exercise also ranked highest (three studies; SUCRA, 0.88). However, exercise-based cardio-oncology rehabilitation (two studies; SUCRA, 0.47) and aerobic exercise (one study; SUCRA, 0.45) were less effective.

CONCLUSIONS

This network meta-analysis showed very low certainty for the prospective efficacy of exercise-based interventions, especially the combined aerobic and resistance exercise, in preventing cancer therapy-related cardiac dysfunction. Further rigorous studies are required to confirm the effectiveness of exercise-based interventions in preventing cancer therapy-related cardiac dysfunction among patients with breast cancer.

Ischaemic and bleeding risk after ST-elevation myocardial infarction in patients with active cancer: a nationwide study

Aims

Treatment of patients with cancer presenting with ST-elevation myocardial infarction (STEMI) is complex given the increased risk of both thrombotic and major bleeding complications.

Methods and results

A nationally linked cohort of STEMI patients between January 2005 and March 2019 was obtained from the UK Myocardial Infarction National Audit Project and the UK National Hospital Episode Statistics Admitted Patient Care registries. The primary outcomes were major bleeding and re-infarction at 1 year following admission with STEMI. Major bleeding was defined as bleeding events that require hospital admission. Re-infarction was defined as acute MI according to the fourth Universal Definition of Myocardial Infarction. A total of 322 776 STEMI-indexed admissions were identified between January 2005 and March 2019. Of those, 7050 (2.2%) patients were diagnosed with active cancer. Cancer patients were older with more cardiovascular comorbidities. Cancer patients received invasive coronary angiography (62.2% vs. 72.7%, P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%, P < 0.001) less often compared with patients without cancer and were less likely to be prescribed dual antiplatelet therapy (85% vs. 95.4%, P < 0.001). The incidence of major bleeding (6.5% vs. 3.5%, P < 0.001) and re-infarction (cancer 5.7%, no cancer 5.1%, P = 0.01) was higher in cancer patients at 1 year. After adjustment for differences in baseline covariates, a similar risk of re-infarction (sub-hazard ratios (SHR) 1.10, 95% CI 0.94-1.27) and a 50% increased risk of major bleeding (SHR 1.49, 95% CI 1.30-1.71) were observed in cancer patients.

Conclusion

Compared with non-cancer patients, cancer patients have a higher risk of major bleeding but not of re-infarction. Mitigating bleeding risk in STEMI patients with cancer is of paramount importance to improve outcomes.

Clinical profile and cardiovascular events in patients with atrial fibrillation and hematologic malignancies with recent initiation of targeted therapy: Real-life data from CANAC-FA registry

BACKGROUND

"Real-life" data on cardiovascular management and clinical outcomes in patients with atrial fibrillation (AF) and hematologic malignancies are limited.

AIM

To describe the clinical profile and incidence of cardiovascular events in this population.

METHODS

Data were obtained from the CANAC-FA Registry, an observational, multicenter and retrospective study. A review of the medical records of patients who had consulted for chronic lymphocytic leukemia (CLL) or multiple myeloma (MM) between 2017 and 2019 was conducted in five hospitals in Spain. Patients with atrial fibrillation (AF) were identified, and the initial visit during which specific treatment for the neoplasm was administered was considered the baseline visit. The follow-up period concluded in 2021. Events of interest included major bleeding, cardiovascular events (hospital admission for cardiovascular causes or cardiovascular death), and death from any cause.

RESULTS

A total of 7,793 patients were reviewed, of whom 1,189 (15%) had AF and 81 (1%) had AF and had initiated a specific hematological treatment within the previous year. Of these patients, 48 (59%) had MM and 33 (41%) had CLL. The mean values for the Charlson, CHA2DS2-VASc and HAS-BLED indices were 5.3 ± 1.7, 3.4 ± 1.5 and 2.4 ± 1.1, respectively. Anticoagulants were prescribed to 85% of patients, with a majority (42%) receiving direct anticoagulants. After a maximum follow-up period of 59 months, the incidences of events at 1, 2 and 3 years of follow-up were: 1.2±1.2%, 1.2±1.2 and 3.5±2.5% for major bleeding; 11.6±3.7%, 11.6±3.7 and 17.2±5.3% for cardiovascular events; and 27.6±5.0%, 41.5±6.3 and 51.3±6.9% for all-cause mortality.

CONCLUSIONS

The incidence of cardiovascular events was high in this population, suggesting the need to implement more effective preventive strategies.