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)

Cardiotoxicity in platinum-based chemotherapy: Mechanisms, manifestations, and management

Platinum-based chemotherapy, a cornerstone in the treatment of various malignancies, is often limited by its potential cardiotoxic effects. Understanding these effects is crucial for optimizing patient outcomes and guiding treatment decisions. This review explores the mechanisms, clinical manifestations, detection, management, and future directions in the research of cardiotoxicity associated with platinum-based chemotherapy. The mechanisms discussed here include oxidative stress, reactive oxygen species production, DNA damage, and alterations in signaling pathways. Clinical manifestations range from mild symptoms to severe complications, including Takotsubo cardiomyopathy, as highlighted by recent case studies. The role of diagnostic tools such as echocardiography, cardiac magnetic resonance imaging, and cardiac biomarkers in early detection is emphasized, underscoring the importance of regular cardiac monitoring. Management strategies focus on cardioprotective agents, alternative chemotherapy regimens, and emerging therapeutic approaches, including the potential of nano liposomal and cubosomal formulations. The review also delves into the future of personalized medicine in predicting and managing cardiotoxicity, advocating for ongoing research to mitigate these adverse effects. This comprehensive overview aims to enhance the understanding of cardiotoxicity in platinum-based chemotherapy, informing clinical practices and promoting patient-centric care.

Cardiac MRI for differentiating chemotherapy-induced cardiotoxicity in sarcoma and breast cancer

BACKGROUND

Over the past few decades, many studies have focused on anthracyclines effect on the heart (cardiotoxicity), but only a few have focused on sarcoma. In this study, we harness the capabilities of advanced cardiac magnetic resonance imaging (MRI) for characterizing anthracyclines-induced cardiotoxicity in sarcoma and compare the results to those from breast cancer patients.

PATIENTS AND METHODS

The patients receive an MRI exam at three timepoints: baseline (pre-treatment), posttreatment, and at 6-months follow-up.

RESULTS

The results demonstrated a differential response in sarcoma, characterized by increasing left-ventricular (LV) mass and decreasing right ventricular ejection fraction (RVEF). In all patients, left ventricular ejection fraction (LVEF) remained > 50% at all timepoints. Myocardial strain was always lower than the normal threshold values and showed small changes between different timepoints. Myocardial T2 and extracellular volume (ECV) showed increasing and decreasing patterns, respectively, in sarcoma, which were the opposite patterns of those in breast cancer. While myocardium T1 showed increasing values in breast cancer, T1 in sarcoma increased post-treatment and then decreased at the 6-months follow-up. The results showed inverse correlation between dose and different strain components in sarcoma, which was not the case in breast cancer. Certain myocardial segments showed high correlation coefficients with dose, which may reflect their increased sensitivity to cardiotoxicity.

CONCLUSIONS

Cardiac MRI proved to be a valuable technique for determining anthracycline-induced changes in cardiac function and myocardial tissue composition in sarcoma and differentiating it against breast cancer. It also provides a comprehensive assessment of heart health at baseline, which is important for risk stratification.

Cardiotoxicity of Breast Cancer Chemotherapy

Breast cancer is one of the leading causes of malignancy affecting women in the United States. Although many effective treatments are available, most come with notable side effects that providers and patients must take into consideration. Various classes of chemotherapeutic agents, including anthracyclines and human epidermal growth factor receptor-2 antagonists, are known to be toxic to myocardial tissue. In this review article, we discuss what is reported in the literature regarding the cardiotoxicity of these agents as well as how to monitor and prevent cardiac injury and dysfunction.

Cardiotoxicity following thoracic radiotherapy for lung cancer

Radiotherapy is the standard of care treatment for unresectable NSCLC, combined with concurrent chemotherapy and adjuvant immunotherapy. Despite technological advances in radiotherapy planning and delivery, the risk of damage to surrounding thoracic tissues remains high. Cardiac problems, including arrhythmia, heart failure and ischaemic events, occur in 20% of patients with lung cancer who undergo radiotherapy. As survival rates improve incrementally for this cohort, minimising the cardiovascular morbidity of RT is increasingly important. Problematically, the reporting of cardiac endpoints has been poor in thoracic radiotherapy clinical trials, and retrospective studies have been limited by the lack of standardisation of nomenclature and endpoints. How baseline cardiovascular profile and cardiac substructure radiation dose distribution impact the risk of cardiotoxicity is incompletely understood. As Thoracic Oncology departments seek to expand the indications for radiotherapy, and as the patient cohort becomes older and more comorbid, there is a pressing need for cardiotoxicity to be comprehensively characterised with sophisticated oncology, physics and cardio-oncology evaluations. This review synthesises the evidence base for cardiotoxicity in conventional radiotherapy, focusing on lung cancer, including current data, unmet clinical needs, and future scientific directions.

Imaging of the Acute and Chronic Cardiovascular Complications of Radiation Therapy

Chest radiotherapy (XRT) plays a crucial role in the treatment of a multitude of cancers including breast, lung, esophageal, and lymphoma. Although XRT enhances cancer survival rates, it may also expose healthy bystander tissues to radiation, potentially leading to severe complications. Initially considered relatively resistant to radiation damage, the heart has been shown over the past 4 decades to be susceptible to radiation-induced cardiovascular toxicity and despite advances in XRT which can minimize radiation exposure to heart tissue, no cardiac radiation dose is entirely safe. The clinical spectrum of radiation-induced cardiovascular toxicity is broad, encompassing coronary artery disease, myocardial dysfunction, valvular abnormalities, and pericardial disorders. Radiation-induced cardiovascular toxicity may manifest acutely or many years after XRT, with each condition more likely to present at certain time points post-XRT. Cardiac imaging is a crucial tool in both the screening and diagnosis of radiation-induced cardiovascular toxicity with an understanding of its pathophysiology, incidence, and progression required to implement a comprehensive, multimodality imaging approach to detect and manage these complications effectively.

Cancer, genetic susceptibility and risk of coronary artery disease: A prospective study

Objective

Cancer survivors have an increased risk of developing coronary artery disease (CAD). We introduce CAD polygenic risk scores (PRS) and examine associations with cancer status on CAD outcomes.

Methods

From the UK Biobank, we identified cancer survivors and CAD outcomes among 464,193 CAD-free participants using linked cancer registries, hospitalizations, and death records. CAD-PRS was categorized as low (lowest tertile), intermediate (tertile 2), and high (highest tertile). Adjusted Cox models assessed the joint and interaction effects of cancer status and CAD-PRS on CAD outcomes.

Results

Over the follow-up (median 11.7 years), 36,332 participants developed CAD. Compared to low CAD-PRS, the hazard ratios (HRs) and 95% confidence intervals (CIs) for CAD was 1.35 (1.31-1.38) for intermediate and 1.86 (1.81-1.91) for high CAD-PRS. The HR (95% CI) for CAD in cancer survivors was 1.16 (1.13-1.19) compared to those without cancer. In the joint effect analysis, compared to participants with low CAD-PRS and no cancer, the HRs (95% CIs) for CAD were 1.37 (1.32-1.41) and 1.90 (1.84-1.96) for intermediate and high CAD-PRS without cancer, respectively. For those with cancer, the HRs (95% CIs) were 1.26 (1.19-1.33), 1.59 (1.51-1.67), and 2.13 (2.03-2.23) for low, intermediate, and high CAD-PRS, respectively. A significant multiplicative interaction (HR: 0.94, 95% CI: 0.91-0.98) was observed between CAD-PRS and cancer status on CAD. Additionally, a significant additive interaction between cancer and high CAD-PRS was found for fatal CAD.

Conclusion

Cancer was associated with a higher risk of CAD and may further increase the risk of CAD related to genetic factors.

Mobile/wearable digital devices for care of active cancer patients: a survey from the ESC Council of Cardio-Oncology

Aims

The Council of Cardio-Oncology of the European Society of Cardiology developed an on-line anonymous survey to provide an overall picture of the current practice on the use of mobile and wearable digital devices in cardio-oncology and the potential barriers to their large-scale applicability.

Methods and results

Between June 2023 and January 2024, an online anonymous questionnaire was completed by 220 healthcare professionals from 55 countries. The greatest number of respondents reported that mobile/wearable digital devices have a role in all active cancer patients for measuring heart rate (33.9%), blood pressure (34.4%), body temperature (32.0%), physical activity (42.4%), and sleep (31.2%). In the setting of atrial fibrillation detection, respondents were evenly split between applying these technologies in all patients (33.0%) or only in selected patients (33.0%). Regarding QTc interval monitoring, 30.6% reported that mobile/wearable digital devices play a role only in selected patients. The decision to use the device was taken by the patient in 56.6% of cases and the physician in 43.4%. The most important barrier reported to mobile/wearable device implementation in the setting of cardiac rhythm monitoring and QTc measurement was their cost (weighted average: 3.38 and 3.39, respectively).

Conclusion

Mobile/wearable digital devices are considered to play an important role in different settings of cardio-oncology, including monitoring of patients' parameters and arrhythmia detection. Their role in monitoring physical activity and QTc interval appears more nuanced. The most important perceived barrier to mobile/wearable digital device implementation is considered their high cost.

Echocardiographic findings of patients with transthyretin amyloid cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is becoming increasingly recognized with the aging population, advancements in understanding of disease pathobiology and the potential benefits of emerging therapies. Bone scintigraphy, including 99mTc-labeled pyrophosphate scintigraphy, is currently considered the first-line modality for identifying ATTR-CM. Therefore, it is important to increase the preset probability using inexpensive and simple tests including echocardiography. Although there were a lot of typical echocardiographic findings of amyloid cardiomyopathy, unexplained left ventricular (LV) wall thickness, LV apical sparing, and a discrepancy between LV wall thickness and QRS voltage were selected as red flags/clues for ATTR-CM in various current diagnostic algorithms. Although echocardiography is useful for ATTR-CM screening, there are several limitations. Therefore, it is important to perform echocardiography and combine it with physical examination, laboratory findings, and other imaging data.

Pathophysiology of dilated cardiomyopathy: from mechanisms to precision medicine

Dilated cardiomyopathy (DCM) is a complex disease with multiple causes and various pathogenic mechanisms. Despite improvements in the prognosis of patients with DCM in the past decade, this condition remains a leading cause of heart failure and premature death. Conventional treatment for DCM is based on the foundational therapies for heart failure with reduced ejection fraction. However, increasingly, attention is being directed towards individualized treatments and precision medicine. The ability to confirm genetic causality is gradually being complemented by an increased understanding of genotype-phenotype correlations. Non-genetic factors also influence the onset of DCM, and growing evidence links genetic background with concomitant non-genetic triggers or precipitating factors, increasing the extreme complexity of the pathophysiology of DCM. This Review covers the spectrum of pathophysiological mechanisms in DCM, from monogenic causes to the coexistence of genetic abnormalities and triggering environmental factors (the 'two-hit' hypothesis). The roles of common genetic variants in the general population and of gene modifiers in disease onset and progression are also discussed. Finally, areas for future research are highlighted, particularly novel therapies, such as small molecules, RNA and gene therapy, and measures for the prevention of arrhythmic death.

Effect of Sacubitril/Valsartan or Enalapril on Left Ventricular Function in Patients With Hematologic Malignancies Treated With Bone Marrow Transplantation: A Randomized Controlled Trial

BACKGROUND

In patients with bone marrow transplantation (BMT) for hematologic malignancies, evidence for prevention of cancer therapy-related cardiac dysfunction (CTRCD) remains limited.

OBJECTIVES

The authors investigated whether early initiation of sacubitril/valsartan or enalapril could be helpful to prevent CTRCD in patients undergoing BMT.

METHODS

We randomized 90 patients with preserved left ventricular ejection fraction (LVEF) after BMT to sacubitril/valsartan, enalapril, or no cardioprotective medication (controls). The primary endpoints included i) LVEF, ii) LV global longitudinal strain (GLS), iii) myocardial wasted work (GWW), and work efficiency (GWE) by speckle tracking echocardiography. Secondary endpoints included changes in LV volumes.

RESULTS

Patients treated with sacubitril/valsartan or enalapril for 6 months did not show a deterioration of LV GLS or LVEF (P > 0.05). Conversely, controls showed impaired LV GLS (-20.9% ± 2.1% vs -18.8% ± 2.6%, P = 0.001) and reduced LVEF (P = 0.045) at 6 months post-BMT. The percent improvement of GWW and GWE was greater in the sacubitril/valsartan compared to enalapril or control group (P = 0.044 and P = 0.011, respectively) at 6 months. Conversely, in controls, GWW increased (80.7 ± 60.6 vs 115.3 ± 52.1 mm Hg%, P = 0.045), and GWE was compromised (P = 0.030) at 6 months post-BMT. Among the 3 treatment groups, only sacubitril/valsartan group showed a reduction in LV end-diastolic and systolic volume compared to baseline (102.3 ± 26.9 vs 93.2 ± 18.9 mL, P = 0.042 and 44.5 ± 15.4 vs 39.1 ± 10.1 mL, P = 0.012, respectively).

CONCLUSIONS

Treatment with sacubitril/valsartan or enalapril prevented deterioration of myocardial function at 6 months in patients with hematologic malignancies treated with BMT. Moreover, sacubitril/valsartan showed a more favorable effect on myocardial work indices. (Effect of Angiotensin Converting Enzyme and Sacubitril Valsartan in Patients After Bone Marrow Transplantation; NCT04092309).

Reviewing the path to balance: mechanisms and management of hypertension associated with targeting vascular endothelium in cancer therapy

Contemporary anticancer drugs are often accompanied by varying degrees of cardiovascular toxicity, with hypertension emerging as one of the most prevalent side effects, particularly linked to inhibitors of vascular endothelial growth factor receptor (VEGFR) and tyrosine kinase inhibitors (TKIs). Hypertension induced by cancer therapies contributes to increased cardiovascular mortality in cancer patients and survivors. Given the shared common risk factors and overlapping pathophysiological mechanisms, hypertension is also a prevalent comorbidity in this patient population. The mechanisms underlying hypertension induced by therapies targeting the vascular endothelial growth factor (VEGF) signaling pathway primarily involve reduced nitric oxide (NO) synthesis, increased endothelin-1 (ET-1) production, oxidative stress, microvascular rarefaction and dysfunction, decreased natriuresis, activation of the renin-angiotensin system (RAS), and partial endothelial cell death. Research into hypertension associated with therapies targeting the VEGF signaling pathway (VSP) could facilitate the optimization of cancer treatments, improve the evaluation and management of hypertension during targeted therapy, and help to reduce cardiovascular event rates and overall patient mortality. This review aims to provide a comprehensive summary of the current advancements in this area.

Impact of oncologic diseases on outcome in patients with severe isolated tricuspid regurgitation

BACKGROUND

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Isolated TR, defined as TR without overt heart disease, is typical and offers limited cardiac treatment options other than interventional repair or replacement. Survival history of cancer or active cancer treatment may lead to an unnecessary delay of TR treatment.

METHODS

We included all patients diagnosed with severe TR at the Medical University of Vienna between 2003 and 2016 who had normal left ventricular function and no other valvular lesions. Outcome analysis was performed on cancer type, status and the number of organs affected by cancer.

RESULTS

A total of 973 patients were included. 182 (19%) patients had cancer, 52 were active and 130 had a history of cancer at the time of TR diagnosis. Oncologic patients were divided into subgroups of gastrointestinal, skin, glands, gynaecological, breast, urogenital, lung and other cancers. Ten-year mortality of patients with cancer was higher than those without cancer (p < 0.001). Multivariate analysis adjusting for age did not reveal significantly higher mortality in patients with a history of cancer compared to patients without cancer (p = 0.59). Patients with lung, active, or multi-organ cancer showed the highest mortality.

CONCLUSIONS

Mortality in patients with severe isolated TR is high and increased by active or multi-organ cancer but not by a history of cancer. These patients should be discussed in interdisciplinary cardio-oncology teams to avoid delaying life-saving treatment of TR and cancer.

Cardio-oncology rehabilitation and exercise: evidence, priorities, and research standards from the ICOS-CORE working group

The aim of this whitepaper is to review the current state of the literature on the effects of cardio-oncology rehabilitation and exercise (CORE) programmes and provide a roadmap for improving the evidence-based to support the implementation of CORE. There is an urgent need to reinforce and extend the evidence informing the cardiovascular care of cancer survivors. CORE is an attractive model that is potentially scalable to improve the cardiovascular health of cancer survivors as it leverages many of the existing frameworks developed through decades of delivery of cardiac rehabilitation. However, there are several challenges within this burgeoning field, including limited evidence of the efficacy of this approach in patients with cancer. In this paper, a multidisciplinary team of international experts highlights priorities for future research in this field and recommends standards for the conduct of research.

Immune checkpoint Inhibitor related myocarditis reported through the FDA adverse event reporting system: pharmacovigilance trends in reporting and outcomes

Introduction

As the use of immune checkpoint inhibitors (ICIs) continues to expand, it is important to be mindful of rare but serious side effects such as myocarditis. Multiple analyses of adverse effect databases have demonstrated an association between ICIs and myocarditis; however, given the rapid implementation of therapeutic use, introduction of multiple new ICIs, and expanding indications, it is unclear if trends are evolving in reporting and outcomes.

Methods

We analyzed the FDA Adverse Event Reporting System to investigate the association between ICIs and myocarditis and trends in myocarditis outcomes among reports submitted between 2012 and the first quarter of 2023.

Results

After removal of duplicate cases, 1,326 myocarditis cases were reported to the database in patients receiving ICIs. Of these, the majority of reported cases were in males (62%) and the median age was 69 years. Consistent with the increase in utilization, the number of cases reported per year increased with each passing year. The reporting odds ratio (ROR) for all ICI drugs included in the analysis was 30.1 (95% confidence interval: 28.4-32.0). RORs for the individual drugs ranged from 12.3 for durvalumab to 168.5 for nivolumab/ relatlimab. The overall fatality rate of all cases was 37%. A significant difference in fatality rate among reported cases was present when comparing outcomes in 2018 and 2022 (45% vs 33%, respectively, p=0.017).

Discussion

Myocarditis continues to be associated with immune checkpoint inhibitors, with the number of reported cases increasing consistent with increasing utilization; however, the outcomes may be improving with less cases being reported as fatal.

The predictive value of changes in 18F-FDG PET/CT cardiac uptake patterns and metabolic parameters for anthracycline based chemotherapy induced cardiac toxicity in lymphoma patients

OBJECTIVE

This study aims to examine alterations in positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) heart uptake patterns and metabolic factors before and after anthracycline-based chemotherapy in lymphoma patients, and to investigate the added benefit of oncological 18F-FDG PET/CT in chemotherapy-induced heart damage.

MATERIALS AND METHODS

Between July 2017 and December 2022, lymphoma patients diagnosed at the Second Affiliated Hospital of Dalian Medical University who underwent 6 cycles of anthracycline-based chemotherapy and had baseline and 6-cycle oncological 18F-FDG PET/CT scans were included. A total of 366 patients with complete data sets were enrolled. Relevant parameters including blood tests, lipid profile, cardiac biomarkers, lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), albumin (ALB), β2-microglobulin (β2-MG), and cardiac ultrasound findings were collected. Patients were monitored from the initiation of chemotherapy until January 2024, and the occurrence of cancer therapy-related cardiovascular toxicity (CTR-CVT) was documented. Changes in PET/CT heart uptake patterns pre- and post-treatment, along with the presence or absence of CTR-CVT, were used to analyze alterations in left ventricular and epicardial adipose tissue metabolic parameters, as well as changes in echocardiographic parameters. Logistic regression analysis was employed to identify risk factors for CTR-CVT.

RESULTS

Among lymphoma patients who received 6 cycles of anthracycline-based chemotherapy, compared to their initial state, there was a notable decrease in white blood cell count (WBC), neutrophil-to-lymphocyte ratio (NLR), erythrocyte sedimentation rate (ESR), and β2-microglobulin (β2-MG) levels post-treatment. Conversely, albumin (ALB) levels and blood lipid levels significantly rose after treatment. Post-treatment, the maximum standardized uptake value (SUVmax) and mean standardized uptake value (SUVmean) of the left ventricle significantly increased, and the percentage of patients exhibiting no uptake pattern in the left ventricle significantly decreased, while those with diffuse uptake pattern notably increased. Moreover, the count of patients with abnormal cardiac uptake significantly rose post-treatment. Analyzing changes in uptake patterns, the group displaying abnormal changes exhibited an increase in left atrial diameter and a decrease in left ventricular ejection fraction compared to the group with normal changes. The SUVmax of the epicardial adipose tissue was notably higher in the abnormal change group compared to the normal change group. Based on the presence or absence of CTR-CVT, the CTR-CVT group showcased higher left atrial diameter and left ventricular end-systolic diameter, and lower left ventricular ejection fraction compared to the non-CTR-CVT group. Additionally, the SUVmax and SUVmean of the epicardial adipose tissue were higher in the CTR-CVT group than in the non-CTR-CVT group. Left atrial end-systolic diameter, left ventricular ejection fraction, SUVmax of the epicardial adipose tissue, and change in uptake pattern were identified as risk factors for CTR-CVT.

CONCLUSION

In lymphoma patients treated with anthracycline-based chemotherapy, alterations in 18F-FDG PET/CT cardiac uptake patterns and metabolic parameters observed during the follow-up period before and after treatment, as well as changes in epicardial adipose tissue metabolic parameters post-treatment, could serve as predictors for the occurrence of CTR-CVT.

Characterizing Cardiotoxicity of FDA-Approved Soft Tissue Sarcoma Targeted Therapies and Immune Checkpoint Inhibitors: A Systematic Review

Background: Soft tissue sarcomas (STS) are aggressive cancers that show increasing response to novel targeted-therapies and immune-checkpoint-inhibitors. Despite anecdotal reports of cardiovascular adverse events (AEs) and major adverse cardiovascular events (MACE) potentially hindering their utility, the true cardiotoxic profile of these novel-therapies in STS has been largely understudied. Methods: We assessed the incidence and severity of AEs and MACE of contemporary FDA-approved targeted and immune-based therapies for STS, using data from landmark clinical trials supporting FDA-approval. We also analyzed data from the FDA adverse-event-reporting-system-(FAERS) for FDA-approved STS targeted and immune-based therapies for comparative real-world validation. Results: Overall, 12 clinical trials supporting FDA-approval of STS targeted-therapies and immune-checkpoint-inhibitors, incorporating 1249 patients, were identified. These clinical trials revealed 751 AEs including, hypertension (382, 50.87%), atrial fibrillation (3, 0.40%), myocardial infarction (2, 0.27%), cardiac failure (congestive included) (9, 1.20%), and cardiac failure (heart failure included) (7, 0.93%). Compared to placebo, those treated saw higher MACE (OR: 3.27, p < 0.001). The FAERS data showed 489 reported AEs including hypertension (275, 56.24%), atrial fibrillation (31, 6.34%), myocardial infarction (15, 3.07%), and cardiac failure (congestive included) (30, 6.13%). Programmed death-ligand 1 (PD-L1) inhibitors had the highest probability of AEs (0.65, 1.17), followed by tyrosine kinase inhibitors (0.66, 0.11), tropomyosin receptor kinase inhibitors (0.25, 0.13), mammalian target of rapamycin inhibitors (0.21, 0.09), and enhancer of zeste homologue 2 inhibitors (0.11, 0.06). Proportions were calculated from the samples in clinical trials supporting FDA-approval and FAERS, respectively. Conclusions: In this investigation, contemporary FDA-approved therapies for STS are associated with increased risk of AEs.

Revolutionising Cardio-Oncology Care with Precision Genomics

Cardiovascular disease is the worldwide leading cause of mortality among survivors of cancer due in part to the cardiotoxicity of anticancer therapies. This paper explores the progress in precision cardio-oncology, particularly in genetic testing and therapeutics, and its impact on cardiovascular diseases in clinical and laboratory settings. These advancements enable clinicians to better assess risk, diagnose conditions, and deliver personalised, cost-effective therapeutics. Through case studies of cancer-therapy-related cardiac dysfunction, clonal haematopoiesis of indeterminate potential, and polygenic risk scoring, we demonstrate the benefits of incorporating precision genomics in individualised care in cardio-oncology. Furthermore, leveraging real-world genomic data in clinical settings can advance our understanding of long noncoding RNAs and microRNAs, which play important regulatory roles in cardio-oncology. Additionally, employing human-induced pluripotent stem cells to stratify risk and guide prevention strategies represents a promising avenue for modelling precision cardio-oncology. While these advancements showcase the significant progress in genetic approaches, they also raise substantial ethical, legal, and societal concerns. Regulatory oversight of genetic and genomic technologies should therefore evolve suitably to keep up with rapid advancements in technology and analysis. Provider education is crucial for the appropriate use of new genetic and genomic applications, including on the existing protection available for patients regarding genetic information. This can provide confidence for diverse study groups to advance genetic studies looking to develop a comprehensive understanding and effective clinical applications for heterogeneous populations. In clinical settings, the implementation of genetic and genomic applications within electronic medical records can offer point-of-care clinical decision support, thus providing timely information to guide clinical management decisions.

Upfront fixed-duration treatment strategies for chronic lymphocytic leukemia in Arab populations: a position statement from the Gulf region

The treatment landscape for chronic lymphocytic leukemia (CLL) has expanded dramatically over the last decade, with a wide range of effective treatments now available. Clinical management of CLL varies widely depending on patient profile, meaning the optimal treatment in Arab patients, who tend to be young and often present with comorbidities, including diabetes and obesity, requires specific considerations. In the absence of regional guidelines, a group of experts from across the Gulf region and one international expert from Germany convened to discuss and agree upon a position statement for venetoclax-based fixed-duration treatment strategies for Arab patients with CLL. Our position is that ibrutinib-venetoclax should be the first choice as first-line therapy for all fit CLL patients in the region, regardless of age. The advantages of an all-oral, fixed-duration treatment are discussed in the context of a young Arab patient population, including excellent patient and physician convenience, limited accumulative risk of toxicities, uncomplicated logistics, and low burden of healthcare administration costs. Finally, we discuss the management of key safety considerations in Arab populations including ethnic neutropenia, risk of cardiotoxic events, considerations during intermittent fasting, and avoiding adverse drug-drug interactions, e.g., with anti-tuberculosis or anti-obesity medications.

Large left atrial myxoma with synchronous laryngeal squamous cell carcinoma: A case report

BACKGROUND

Cardiac myxoma is a benign neoplasm and one of the most common types of primary cardiac tumors. Synchronous cardiac myxoma and other malignancies are extremely rare, and only limited cases have been reported.

CASE SUMMARY

We describe a young patient with newly diagnosed locally advanced laryngeal cancer, with a synchronous cardiac tumor detected on staging scans. An echocardiogram showed the typical appearance of myxoma in the left atrium. Early cardiac surgery was performed in view of its obstructive features and post cardiac surgery recovery was uneventful. The patient was scheduled for subsequent oncological treatment for the laryngeal cancer. However, due to rapid progression of the advanced laryngeal malignancy, he was placed on supportive care.

CONCLUSION

To our knowledge, this is the first reported case of synchronous cardiac myxoma with laryngeal malignancy. Individualized treatment strategy should be adopted to manage synchronous tumors in a multidisciplinary approach. The most life-threatening condition needs be treated first. Single resection, staged operations or simultaneous resection of both tumors have been reported with good outcomes.

Cardiology involvement and mortality in adult patients with advanced solid cancer complicated by atrial fibrillation

BACKGROUND

The association between comorbid atrial fibrillation (AF) and survival in adult patients with advanced solid cancer, as well as the impact of cardiology involvement in such patients, remains unclear.

METHODS

This retrospective cohort study included adult patients diagnosed with advanced solid cancers. We calculated prevalence of AF in different cancer types and compared all-cause mortality between patients with and without AF. We further examined the association between cardiology involvement and mortality in the subset of participants with AF.

RESULTS

Among the 1,349 adult patients with advanced solid cancer, 122 (9.0%) had AF. The risk of AF was the highest in lung and mediastinal cancer (15.6%). AF was associated with higher all-cause mortality, which became neutral after adjustment for age, sex, comorbidities, cancer types and cancer treatments (crude hazard ratio [HR] 1.39, 95% confidence interval [CI] 1.11-1.75, p =  0.004; adjusted HR 1.08, 95%CI 0.84-1.39, p =  0.552). In those with AF, cardiology involvement was independently associated with lower all-cause mortality (age, sex, comorbidities, cancer types and cancer treatments-adjusted HR 0.50 [95%CI 0.28-0.88], p =  0.017), though the cumulative incidence of neither cardiovascular nor non-cardiovascular death differed significantly between patients who received cardiology care and those who did not.

CONCLUSIONS

In adult patients with advanced solid cancer, AF per se was not independently associated with increased mortality. Cardiology involvement in patients with advanced solid cancer and AF was linked to a better overall survival, but with low certainty that this finding is not attributable to unmeasured confounding.

Survivorship clinic attendance improves completion but not timeliness of cardiac surveillance post anthracyclines

BACKGROUND

Anthracycline induced cardiomyopathy (AIC) is an important complication of cancer management. Recent findings showed that with early identification and intervention, AIC may be fully or partially reversible. European society of cardiology (ESC) guidelines recommend a risk-stratified monitoring approach, including transthoracic echocardiogram (TTE) for all patients within 12 months post-treatment.

AIM

Investigate the impact of a survivorship clinic on TTE follow up for AIC.

METHODS

Over a 5 year span, 235 patients with haematological malignancies received anthracycline chemotherapy ≥ 250mg/m2. The electronic medical records of these patients were reviewed. TTE outcomes were compared between survivorship and non-survivorship patients.

RESULTS

Survivorship patients received TTE in 88.6% of cases, whereas non-survivorship patients received TTE in 30.9% of cases. In survivorship patients, TTE was indicated for asymptomatic screening in 92.3% of cases. In non-survivorship patients the majority of TTE were for symptom investigation (78.0%). Chi-squared analysis found these results to be statistically significant (p value < 0.05).

DISCUSSION

Survivorship patients are nearly three times more likely to receive TTE monitoring for AIC. However, due to delayed clinic referral/attendance, only 36.4% received TTE within 1 year of treatment completion, in line with ESC guidelines.

CONCLUSION

Survivorship clinics improve TTE monitoring for AIC, allowing early identification and potential intervention. However, reliance on this model alone may risk inadequate surveillance for patients who do not attend and delays in referral/attendance may impact monitoring timeliness.

Artificial Intelligence Applications in Cardio-Oncology: A Comprehensive Review

PURPOSE OF REVIEW

This review explores the role of artificial intelligence (AI) in cardio-oncology, focusing on its latest application across problems in diagnosis, prognosis, risk stratification, and management of cardiovascular (CV) complications in cancer patients. It also highlights multi-omics analysis, explainable AI, and real-time decision-making, while addressing challenges like data heterogeneity and ethical concerns.

RECENT FINDINGS

AI can advance cardio-oncology by leveraging imaging, electronic health records (EHRs), electrocardiograms (ECG), and multi-omics data for early cardiotoxicity detection, stratification and long-term risk prediction. Novel AI-ECG models and imaging techniques improve diagnostic accuracy, while multi-omics analysis identifies biomarkers for personalized treatment. However, significant barriers, including data heterogeneity, lack of transparency, and regulatory challenges, hinder widespread adoption. AI significantly enhances early detection and intervention in cardio-oncology. Future efforts should address the impact of AI technologies on clinical outcomes, and ethical challenges, to enable broader clinical adoption and improve patient care.

Prevention of cancer-therapy related cardiac dysfunction

PURPOSE OF REVIEW

Introduction of modern cancer therapies has led to increased survival of affected patients. With this advantage, the incidence of cancer therapy-related cardiac dysfunction (CTRCD) has increased and reasonable prevention strategies become necessary. This review outlines the major approaches to limit development and progression of CTRCD.

RECENT FINDINGS

A broad range of cancer therapies can provoke CTRCD ranging from mild asymptomatic forms to severe heart failure. Profound cardiological assessment of cardiovascular comorbidities before initiation of cancer therapy allows identification of cancer patients at higher risk developing CTRCD which may also require closer surveillance. Cardioprotective adjustment of cancer therapy and initiation of cardioprotective medication and lifestyle optimization prior to anti-cancer treatment additionally limit the risk of CTRCD. During therapy, regular examination of cancer patients using high-sensitive cardiological diagnostic tools as three-dimensional (3D) echocardiography and global longitudinal strain (GLS) enables early detection of mild forms of CTRCD. This allows appropriate adjustment of cancer therapy and initiation of CTRCD treatment to prevent further progression to severe forms. Cardiological risk stratification before treatment initiation, cardioprotective interventions before and during cancer therapy, along with regular monitoring of treated cancer patients, can help prevent the development of CTRCD. This maintains the antitumor effects of cancer therapy while limiting cardiotoxic side effects resulting in improved quality of life and mortality of affected cancer patients.

Early cardio-oncology intervention in thoracic radiotherapy: prospective single-arm pilot study

BACKGROUND

While there is increasing recognition of the morbidity of cardiovascular disease in cancer survivors, including accelerated atherosclerosis following thoracic radiotherapy, patients are frequently under-optimized for cardiovascular risk.

METHODS

In this prospective single-arm cohort pilot study, patients were treated with high-dose thoracic radiotherapy and had early consultation with cardio-oncology. Twenty patients were enrolled. The primary endpoint was adherence to cardio-oncology consultation. Secondary endpoints were cardiovascular medication intervention rate and patient-reported intervention perspectives. Clonal hematopoiesis of indeterminate potential, a major cardiovascular risk marker enriched in patients with cancer and induced by radiation exposure, was measured as an exploratory endpoint.

RESULTS

The cohort median age is 71 years. Most patients are female (13/20), have primary lung or esophageal carcinoma (16/20), and 7/20 have pre-existing cardiovascular disease. We show that cardio-oncology consultation adherence is high (19/20) and results in cardiovascular medication optimization changes in most patients (12/19), most commonly to initiate or intensify statin therapy (8/12). 8/12 patients with a primary cardiologist prior to enrollment have medication changes recommended. Most (12/17) participants are glad to learn about their heart health during cancer treatment. Clonal hematopoiesis is detectable prior to treatment in 8/20 patients and three develop new variants after treatment (1/3 de novo).

CONCLUSIONS

We observe that early cardio-oncology consultation is feasible, leads to cardiovascular medication optimization in the majority (>60%) of participants, most commonly to initiate or intensify statin therapy. New clonal hematopoiesis variants are detectable early after radiotherapy and the impact on post-treatment cardiovascular risk is worthy of further study.

Genetic Background in Patients with Cancer Therapy-Induced Cardiomyopathy

Emerging evidence indicates that specific genetic variants are associated with an increased risk of toxicity from anticancer treatments and cancer-related cardiovascular complications. These genetic factors influence drug metabolism, efficacy, and susceptibility to adverse effects. For cancer patients, the genetic background can have two major cardiovascular implications, namely therapy-related cardiotoxicity and cancer-related cardiovascular complications. Baseline risk stratification is essential to identify higher-risk individuals and ensure they receive appropriate preventive and therapeutic interventions and more frequent follow-up. Current guidelines recommend stratification based on cardiovascular risk factors, but these factors alone cannot accurately define individual risk. Genetic background has been shown to enhance risk stratification. Beyond rare genetic variants, recent genome-wide association studies have identified single nucleotide polymorphisms implicated in cancer therapy toxicity. Despite their current limitations, polygenic risk scores are expected to play a significant role in risk stratification. This review aims to summarize the current evidence on the role of the genetic background of patients with cancer treated with potentially cardiotoxic drugs who develop cardiotoxicity, aiming to provide insights to refine risk stratification further and tailor the management of these patients.

Macrotroponin interference and association with cardiotoxicity in patients receiving cardiotoxic breast cancer therapy: a pilot study

BACKGROUND

Cancer therapy-related cardiac dysfunction (CTRCD) is an important adverse effect in patients receiving potential cardiotoxic cancer therapies. Interpretation of cardiac troponin results can be affected by presence of macrotroponin, which can complicate CTRCD assessment. We aimed to assess whether macrotroponin is detectable in women with ERBB2 + breast cancer receiving sequential therapy with anthracyclines and trastuzumab.

METHODS

A total of 20 serum samples from 12 ERBB2 + breast cancer patients (median age: 55 years, range: 30-69 years) who exhibited a significant increase in high-sensitivity cardiac troponin I (hs-cTnI) from baseline to post-anthracycline (~ 2 months after therapy initiation) and/or 3-months into trastuzumab therapy (~ 5 months after therapy initiation) and/or who had at least one hs-cTnI value above the female-specific 99th percentile (hs-cTnI > 16 ng/L) and had available banked blood for analysis were included in this pilot study. Samples were analyzed using the Abbott STAT High-Sensitive Troponin-I and Roche Elecsys Troponin T hs STAT assays. Macrotroponin was detected by treating the sample with protein G and re-measuring hs-cTn. Macrotroponin presence was defined as a hs-cTnI or hs-cTnT recovery of < 40% or 85%, respectively.

RESULTS

Macrotroponin was not identified after anthracycline treatment but was present in four patients 3-months into trastuzumab therapy, two of which had hs-cTnI concentrations above the 99th percentile. None of these patients exhibited a significant reduction in LVEF and/or GLS despite having significant elevations in hs-cTnI.

CONCLUSIONS

Clinicians should be cautious of benign hs-cTn elevations resulting from macrotroponin presence, as it can complicate CTRCD assessment.

Applications of Artificial Intelligence for the Prediction and Diagnosis of Cancer Therapy-Related Cardiac Dysfunction in Oncology Patients

Cardiovascular diseases and cancer are the leading causes of morbidity and mortality in modern society. Expanding cancer therapies that have improved prognosis may also be associated with cardiotoxicity, and extended life span after survivorship is associated with the increasing prevalence of cardiovascular disease. As such, the field of cardio-oncology has been rapidly expanding, with an aim to identify cardiotoxicity and cardiac disease early in a patient who is receiving treatment for cancer or is in survivorship. Artificial intelligence is revolutionizing modern medicine with its ability to identify cardiac disease early. This article comprehensively reviews applications of artificial intelligence specifically applied to electrocardiograms, echocardiography, cardiac magnetic resonance imaging, and nuclear imaging to predict cardiac toxicity in the setting of cancer therapies, with a view to reduce early complications and cardiac side effects from cancer therapies such as chemotherapy, radiation therapy, or immunotherapy.

PET/CT-derived coronary calcium score may predict cardiac complications in anthracycline-treated patients with lymphoma

ABSTRACT

Anthracycline-mediated cardiotoxicity is a common concern after lymphoma therapy, particularly in patients with high cardiovascular risk (CVR). In noncancer populations, coronary artery calcium scoring (CACS) effectively identifies individuals who may benefit from aggressive CVR modification to lower the risk of cardiovascular events. Emerging evidence suggests that CACS can also predict cancer therapy-related cardiotoxicity, potentially identifying candidates for cardioprotective strategies. Our study aimed to evaluate whether CACS obtained from pretreatment positron emission tomography (PET)/computed tomography (CT) scans could stratify cardiac event risk in patients with lymphoma receiving anthracycline-based chemotherapy. We enrolled 358 consecutive patients with lymphoma treated between 2012 and 2022, calculating the CACS from their pretreatment PET/CT. We reviewed medical records to identify pre-existing cardiac conditions, CVR, and posttreatment cardiac events, including coronary events, heart failure (HF), and arrhythmias. Logistic and Cox regression models were used to assess associations between CVR, CACS categories (CACS = 0, CACS 1-400, CACS >400), and new cardiac events. At a median follow-up of 27 months (95% confidence interval [CI], 22.3-31.7) in patients without cardiac history, 10% experienced posttreatment cardiac events (HF, 14; arrhythmias, 9; coronary event, 1; combination, 8). Patients with a CACS >0 had more events (21 total, 20% vs 11 total, 5.4% for CACS = 0; P < .001). Elevated CACS was independently associated with HF (CACS 1-400: odds ratio [OR], 3.73; 95% CI, 1.21-11.43; P = .022; CACS >400: OR, 5.43; 95% CI, 1.47-20.03; P = .011) and any cardiac event (CACS 1-400: OR, 2.48; 95% CI, 1.02-6.04; P = .045; CACS >400: OR, 3.28; 95% CI, 0.91-10.68; P = .029). CACS may effectively stratify patients with lymphoma at risk of cardiac complications, thereby identifying a group poised to benefit from targeted preventive strategies.

Comorbidity trajectories before and after the diagnosis of heart failure: A UK Biobank cohort study

AIMS

Heart failure (HF) is frequently associated with multiple comorbidities. We aimed to define their trajectory of accrual to identify opportunities for disease prevention.

METHODS AND RESULTS

We identified all participants in the UK Biobank cohort study diagnosed with HF prior to enrolment or during follow-up, who had disease occurrence data available from both primary and secondary care records (n = 9824). We established the time between diagnosis of HF and 16 common comorbidities to determine the rate and sequence of comorbidity accrual in relation to HF. Stratified analyses considered associations with sex and age at diagnosis of HF. In chronological sequence, HF was the median fourth diagnosis for men and women. As the age at HF diagnosis increased, HF came later in the sequence of diseases (median second in under 50 years to fifth in those aged 80-90 years). In all age strata, comorbidities accumulated for over a decade before HF and this accelerated in the years immediately before HF. The median time between comorbidity and HF diagnoses ranged from depression preceding HF by 10.7 years to dementia proceeding HF by 0.7 years; all comorbidities presented earlier in women. Atrial fibrillation/flutter was the commonest disease to immediately precede HF, followed by hypertension, cancer, myocardial infarction and osteoarthritis.

CONCLUSION

Heart failure is most often diagnosed in people with established multiple long-term conditions. There is a protracted window of opportunity during which interventions to prevent HF could be applied, often in disease contexts where this is not routine care, such as cancer and osteoarthritis.

Cardiotoxicity Beyond Cardiomyocytes-Focus on the Role of Cardiac Fibroblasts and Endothelial Cells

INTRODUCTION

Anti-cancer treatments frequently have serious adverse effects on the cardiovascular system. Understanding the mechanisms underlying these cancer therapy-related cardiovascular toxicities is essential for their prevention and potential treatment. While research often centres on cardiomyocyte damage as the primary cause of cardiac injury, the roles of cardiac fibroblasts and endothelial cells are often neglected. In this study, we aimed to investigate the direct toxicity in cardiac fibroblast and endothelial cells of 35 FDA-approved anti-cancer drugs, of which the effects previously only had been explored in cardiomyocytes.

METHODS AND RESULTS

Metabolic cell viability in cardiac fibroblasts and endothelial cells was first determined using the CellTiter-Glo luminescence assay. If metabolic cell viability was reduced, lactate dehydrogenase was measured in the supernatant to assess cytotoxicity. Interestingly, certain anti-cancer treatments were able to increase metabolic cell viability. For these drugs, gene expression analysis assessing for myofibroblast differentiation and endothelial-to-mesenchymal transition was performed.

CONCLUSION

Our study demonstrates that anti-cancer therapies indeed exhibited different toxicity profiles in cardiac fibroblasts and endothelial cells compared to cardiomyocytes and triggers specific pathophysiological transformations in response to anti-cancer drug exposure.

SGLT2 inhibitors for prevention and management of cancer treatment-related cardiovascular toxicity: a review of potential mechanisms and clinical insights

More evidence-based strategies are needed for preventing and managing cancer treatment-related cardiovascular toxicity (CTR-CVT). Owing to the growing body of evidence supporting their cardioprotective role in several cardiac injury scenarios, sodium-glucose cotransporter 2 inhibitors (SGLT2i) may be beneficial for preventing and treating CTR-CVT. In October 2024, a search was conducted of the PubMed database to review full studies investigating the cardioprotective role of SGLT2i against CTR-CVT. We identified 44 full published/pre-print studies and 3 ongoing randomised controlled trial across eight types of cancer treatment (anthracyclines, platinum-containing therapy, immune checkpoint inhibitors, HER2-targeted therapies, kinase inhibitors, androgen deprivation therapies, multiple myeloma therapies and 5-fluorouracil). Most studies used animal models and focussed on primary prevention. 43 of the 44 studies found some cardioprotective effect of SGLT2i against CTR-CVT, which in some cases included preventing ejection fraction decline and aberrations in cardiac electrophysiological parameters. Some studies also observed beneficial effects on mortality. A central triad of anti-inflammatory, anti-oxidative and anti-apoptotic mechanisms likely underlie SGLT2i-mediated cardioprotection against CTR-CVT. Overall, this growing body of research suggests that SGLT2i may be a promising candidate for preventing CTR-CVT either as monotherapy or in combination with other cardioprotective drugs. However, the literature is limited in that no prospective randomised controlled trials investigating SGLT2i for the prevention and management of CTR-CVT exist and most existing human retrospective data is based on diabetic populations. Future work must focus on addressing these limitations of the current literature.

Integration and Potential Applications of Cardiovascular Computed Tomography in Cardio-Oncology

PURPOSE OF REVIEW

Cardiovascular computed tomography (CCT) is a versatile, readily available, and non-invasive imaging tool with high-resolution capabilities in many cardiovascular diseases (CVD). Our review explains the increased risk of CVD among patients with cancer due to chemoradiotherapies, shared risk factors and cancer itself and explores the expanding role of CCT in the detection, surveillance, and management of numerous CVD among these patients.

RECENT FINDINGS

Recent research has highlighted the versatility and enhanced resolution capabilities of CCT in assessing a wide range of cardiovascular diseases. Early detection of cardiac changes and monitoring of disease progression in asymptomatic patients with cancer may lessen the severity of CVD. It offers an essential means to assess for coronary artery disease when patients are either unable to safely undergo stress testing for ischemia evaluation or at risk of complications from invasive coronary angiography. Furthermore, CCT extends its utility to valvular diseases, cardiomyopathies, pericardial diseases, cardiac masses, and radiation-induced cardiovascular diseases, allowing for a comprehensive, noninvasive assessment of the entire spectrum of cancer treatment associated CVD. Looking to the future, the integration of artificial intelligence and machine learning algorithms holds potential for automated image interpretation, improved precision and earlier detection of subclinical cardiac deterioration, allowing opportunities for earlier intervention and disease prevention. CCT is a useful imaging modality for assessing the myriad cardiovascular manifestations of diseases such as coronary artery disease, cardiomyopathies, pericardial disesaes, cardiac masses and radiation-induced cardiovascular diseases. CCT has several advantages. Readily available non-cardiac chest CT scans of patients with cancer may help with improved cardiovascular care, enhanced ASCVD risk stratification and toxicity surveillance.

Acute vascular and cardiac effects of lenvatinib in mice

BACKGROUND

Tyrosine kinase inhibitors (TKIs) targeting vascular endothelial growth factor (VEGF) receptor signalling are used in cancer therapy to inhibit angiogenesis. Unfortunately, VEGF inhibitors are known to induce severe hypertension in patients. This study aimed to elucidate the impact of the TKI lenvatinib on blood pressure, arterial stiffness, vascular reactivity, as well as cardiac function in a short-term murine model to shed light on potential contributors to cardiovascular (CV) toxicities associated with VEGF inhibition.

METHODS

Male C57BL/6J mice were randomly divided into 2 cohorts, either treated for 4 days with lenvatinib 4 mg/kg/day or 40% hydroxypropyl β-cyclodextrin as control. In an additional study, mice were subjected to a 4-day treatment followed by a 4-day wash-out, with echocardiography and blood pressure measurements performed on day 2 and 7. Subsequently, ex vivo vascular reactivity of thoracic aortic segments was determined.

RESULTS

Lenvatinib induced hypertension and arterial stiffness (i.e., increased pulse wave velocity), starting from day 2 of treatment. Further, left ventricular ejection fraction was reduced and the ventricle dilated upon treatment. Lenvatinib induced neither endothelial dysfunction nor impaired vascular smooth muscle cell reactivity to nitric oxide (NO). Interestingly, lenvatinib demonstrated a concentration-dependent increase in ATP-mediated relaxation. In addition, after the 4-day wash-out period, lenvatinib-treated mice did not show complete remission of hypertension. However, arterial stiffness, ATP-mediated relaxation and cardiac adaptation were recovered.

CONCLUSION

This comprehensive investigation provides valuable insights into the interplay between VEGF inhibition, vascular function and cardiac outcomes, emphasising the need for nuanced understanding and further exploration of the differential effects of lenvatinib on the CV system. Additionally, the study proposes a synergistic formation between VEGF and ATP, indicating an enhanced response via P2Yx receptor signalling.

Role of Cardio-Oncology Rehabilitation in Hematopoietic Stem Cell Transplantation and Chimeric Antigen Receptor T-Cell (CAR-T) Therapy

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) and chimeric antigen receptor T-cell (CAR-T) therapy often lead to severe sarcopenia and cachexia during treatment, making it difficult to maintain exercise tolerance. Consequently, "cancer rehabilitation" programs have been implemented to sustain and improve physical activity and motor function. Hematologic malignancies often involve the use of cardiotoxic drugs. Moreover, graft-vs.-host disease associated with allo-HSCT and the cytokine release syndrome in CAR-T therapy elevate the risk of cardiovascular complications. Thus, establishing "cardio-oncology rehabilitation" (CORE) is essential to support cancer patients and survivors. CORE is expected to enhance quality of life, improve cardiopulmonary function, reduce cancer and cardiac events recurrence, and prolong survival. Our institution conducts cardiopulmonary exercise testing before HSCT and CAR-T therapy, with exercise prescriptions based on heart rate at the anaerobic threshold and guidance on resistance exercises. This report discusses current trends in CORE for patients undergoing HSCT and CAR-T therapy, along with future challenges.

Long-term cardiac MRI follow up of MANTICORE (Multidisciplinary Approach to Novel Therapies in Cardio-Oncology REsearch)

BACKGROUND

This study investigates the long-term cardiac effects of trastuzumab-based chemotherapy in early breast cancer (EBC) survivors. We extend the original MANTICORE trial which showed that angiotensin-converting enzyme inhibitors (ACEI) and beta-blockers (BB) could mitigate the decline in left ventricular (LV) ejection fraction (EF) during the first year of trastuzumab treatment.

OBJECTIVES

We hypothesized that, over time, cardiac function would decline further and adverse changes in cardiac geometry would occur due to the aging of the population and prior treatment.

METHODS

The study enrolled 52 participants from the original MANTICORE trial cohort, with cardiac magnetic resonance (CMR) imaging conducted at a median of 6.5 years post randomization to treatment.

RESULTS

We found that, contrary to the hypothesis, participants maintained LV EF over the follow-up period. Specifically, the placebo group exhibited a recovery in LV EF to levels comparable with the treatment groups, suggesting no long-term differential impact on cardiac function. However, a significant reduction in LV mass was observed across all groups, the clinical implications of which remain unclear.

CONCLUSIONS

The findings suggest that in a selected population receiving trastuzumab-based chemotherapy, extended cardiac imaging surveillance beyond one-year post-treatment may be unnecessary. We posit that the presence of HER2 overexpressing breast cancer influenced hypertrophic changes to cardiac geometry observed at baseline and one year, which resolved after completing HER2-blocking treatment. The study also highlights the need for further research to understand the significance of changes in cardiac geometry during and after breast cancer treatment​.

Cardiopulmonary Functional Profiles in Cancer Therapy-Related Cardiac Dysfunction Among Patients with Non-Hodgkin Lymphoma

Background: Non-Hodgkin lymphoma (NHL) is associated with significant cardiovascular risks due to treatment-related toxicities, including cancer therapy-related cardiac dysfunction (CTRCD). While multimodality imaging, particularly echocardiography, is pivotal in monitoring cardiac function, the prognostic role of cardiopulmonary exercise testing (CPET) in predicting CTRCD remains underexplored. Methods: The prospective study enrolled 127 NHL patients, 72 men (56.7%) and 55 women (43.3%), with a median age of 62 years (range 34-83 years). The patients were assessed before initiating antitumor treatment and at six months follow-up using echocardiography and cardiopulmonary exercise testing. Results: Asymptomatic CTRCD occurred in 14.2% of NHL patients at six months of treatment. Patients with CTRCD exhibited significantly lower median work rates, volume of oxygen (VO2) at the anaerobic threshold, and O2 consumption efficiency, reflecting compromised metabolic and functional performance. Baseline peak oxygen consumption (VO2 peak) positively correlated with left ventricle ejection fraction (LVEF) at six months, while VO₂ peak < 14 mL/kg/min was negatively associated with LVEF. Conclusions: Asymptomatic CTRCD was identified in 14.2% of NHL patients at six months, with lower work rates, VO2 at the anaerobic threshold, and O2 consumption efficiency, indicating impaired performance. Baseline peak oxygen consumption correlated positively with LVEF, highlighting CPET's potential for early CTRCD risk assessment.

Review of the clinical status of cardiotoxicity of HER-2 positive breast cancer targeted therapeutic drugs

Breast cancer is a major health challenge for women worldwide, and human epidermal growth factor receptor 2 (HER-2)-positive breast cancers have a relatively high incidence and are highly aggressive. Targeted therapeutic agents, represented by trastuzumab, have been effective in improving the survival rate of HER-2-positive breast cancer patients. However, in clinical applications, this type of targeted drugs exhibits varying degrees of cardiotoxicity, and the mechanism of their cardiotoxicity is currently unclear. In this paper, we classify them into three categories: monoclonal antibodies (mAbs), small-molecule tyrosine kinase inhibitors (TKIs), and antibody-drug conjugate (ADCs). We list the evidence of cardiotoxicity for various drugs based on current clinical trials and summarize their corresponding epidemiological profiles. We also discuss the regulation of cardiotoxicity from three perspectives: clinical biomarkers of cardiotoxicity, permissive cardiotoxicity, and the current status of cardiotoxicity regulation.

Anticancer Chemotherapy-Induced Atherosclerotic Cardiovascular Disease: A Comprehensive Review

The introduction of anticancer agents has transformed oncology, significantly improving survival rates. However, these therapies have introduced unintended cardiovascular risks, with atherosclerovascular disease (ASCVD) emerging as a leading cause of morbidity and mortality among cancer survivors. The development of ASCVD in this population involves multifactorial mechanisms, including endothelial dysfunction, oxidative stress, systemic inflammation, and disrupted lipid metabolism. This review examines the various mechanisms through which anticancer chemotherapy contributes to ASCVD and highlights strategies for risk assessment and management. Each class of anticancer agents presents distinct cardiovascular challenges: anthracyclines induce oxidative stress and endothelial damage, promoting foam cell formation and plaque progression; taxanes and vascular endothelial growth factor (VEGF) inhibitors impair lipid metabolism and vascular stability; anti-metabolites exacerbate endothelial injury through reactive oxygen species; and mTOR inhibitors, hormonal therapies, tyrosine kinase inhibitors, and immune checkpoint inhibitors disrupt lipid profiles and inflammatory pathways, increasing the risk of plaque rupture and thrombosis. Mitigating chemotherapy-induced ASCVD necessitates a comprehensive, multidisciplinary approach. Detailed pre-treatment cardiovascular risk assessments must address traditional and cancer-specific risk factors, including demographics, pre-existing conditions, and modifiable behaviors such as smoking and inactivity. Pharmacological interventions like statins and angiotensin-converting enzyme (ACE) inhibitors, paired with lifestyle modifications, are essential to reducing ASCVD risk. In resource-limited settings, cost-effective strategies should be prioritized to enhance accessibility. Establishing cardio-oncology units facilitates care coordination, while long-term surveillance enables timely detection and intervention. These strategies collectively improve cardiovascular outcomes and survivorship in diverse patient populations.

HER-SAFE study design: an open-label, randomised controlled trial to investigate the safety of withdrawal of pharmacological treatment for recovered HER2-targeted therapy-related cardiac dysfunction

INTRODUCTION

A quarter of breast cancers show human epidermal growth factor-2 (HER2) overexpression, where targeted therapy dramatically improves survival. However, cancer therapy-related cardiac dysfunction (CTRCD) occurs in up to 15% of patients. With the interruption of HER2 therapy, if necessary, and the initiation of heart failure therapy (HFT), HER2 CTRCD recovers in over 80% of cases. The need to continue HFT in 'recovered' HER2 CTRCD following completion of HER2 therapy is unclear and there are potential significant impacts on patient's quality of life (QoL). The Randomised Controlled Trial for the Safety of Withdrawal of Pharmacological Treatment for Recovered HER2 Targeted Therapy Related Cardiac Dysfunction (HER-SAFE) aims to evaluate whether HFT can be safely withdrawn in non-high cardiovascular (CV) risk patients with 'recovered' HER2 CTRCD.

METHODS AND ANALYSIS

This is a multicentre, open-label randomised controlled trial investigating whether withdrawal of HFT is non-inferior to continuation in non-high CV risk, breast cancer survivors with recovered HER2 CTRCD after cancer treatment completion. The primary endpoint is the incidence of guideline-defined cardiac dysfunction or clinical heart failure. Secondary endpoints include changes in cardiac blood biomarkers, cardiovascular magnetic resonance (CMR)-derived strain and tissue mapping and heart failure symptom questionnaires. The study will recruit 90 participants who will undergo serial clinical assessment over 12 months with advanced cardiovascular imaging (CMR scans with automated analysis at baseline, 6 and 12 months), cardiac biomarker measurement (six time points over 12 months), plus complete heart failure QoL and medication disutility questionnaires. This is the first multicentre study to address this significant clinical issue.

ETHICS AND DISSEMINATION

This study was approved by the research ethics committee (London-London Bridge, 23/LO/0152). The results will be disseminated in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05880160.

Solid Tumors, Liquid Challenges: The Impact of Coagulation Disorders

Coagulation disorders are increasingly recognized as significant complications in patients with solid tumors, affecting morbidity and mortality outcomes. Solid tumors can provoke a hypercoagulable state through the release of pro-coagulant factors, endothelial activation, and inflammation, leading to a heightened risk of coagulation disorders. These coagulation disorders may manifest as venous thromboembolism, arterial thromboembolism, thrombotic microangiopathy, or disseminated intravascular coagulation. These disorders can complicate surgical interventions and impact treatments, including chemotherapy and immunotherapy efficacy, leading to poor outcomes. Understanding the implications of coagulation disorders in solid tumors is essential for optimizing patient management, including identifying high-risk patients, implementing prophylactic measures, elucidating biomarkers for clinical outcomes, and exploring novel therapeutic agents. This review aims to provide insights into the current knowledge surrounding coagulation disorders in solid tumors and their clinical implications.

Acute and Chronic Cardiovascular Adverse Events in Patients with Acute Myeloid Leukemia: A Systematic Review

Background/Objectives: Patients with acute myeloid leukemia (AML) have a higher propensity for adverse cardiovascular outcomes, primarily due to the toxic effects of chemotherapeutic agents. The purpose of this systematic review is to explore the association of acute myeloid leukemia treatment with adverse cardiovascular events. Methods: We systematically screened the literature for studies providing comparative data on cardiovascular toxicities in patients treated for acute myeloid leukemia. After the initial search, 3649 papers were screened and a final total number of 46 were included for the review process. Results: Common chemotherapeutic agents used in AML may cause cardiovascular (CV) toxicities. A plethora of pathophysiological mechanisms are incriminated for these effects. Drug combinations may increase the risk in a synergistic way. In addition, common mutations of AML, personal history of previous cardiovascular disease and impaired heart function carry an increased complication risk. Biomarkers, as well as multimodality imaging, may be used for the early detection of cardiovascular toxicities. Conclusions: Increased risks of CV toxicity and comorbidities are observed among AML patients. With all the available diagnostic modalities, early detection and CV prevention strategies can improve the patient's prognosis and quality of life.

Early detection of myocarditis caused by immune checkpoint inhibitor therapy with nivolumab and ipilimumab for advanced recurrent renal cell carcinoma

Combination therapy with nivolumab and ipilimumab for advanced renal cell carcinoma (RCC) may cause immune-related myocarditis; however, its incidence in this cancer type and regimen remains unknown. At our institution, we measure biomarkers, such as high-sensitivity Troponin (hsTn), and perform electrocardiograms (ECGs) and echocardiography before and every month after the initiation of this therapy, and the findings obtained and patients' symptoms are continuously monitored by physicians and pharmacists. A retrospective survey was conducted on physiological and biochemical test findings and immune-related adverse events in patients with advanced RCC who received combination therapy with nivolumab and ipilimumab between October 1, 2018 and December 31, 2023. Patients suspected of having myocarditis consulted with cardiologists. Myocarditis due to this therapy was detected in 5 of the 86 patients (5.8%) assessed using the European Society of Cardiology 2022 guidelines. There were no fatal symptoms or death due to myocarditis. The median time to the onset of myocarditis was 25 days (21-86 days). The early detection of myocarditis caused by this therapy requires the monitoring of changes by periodically measuring hsTn and other cardiac markers and performing ECGs and echocardiography from the early stages of administration through to the end of treatment. In addition to checking symptoms, if these abnormalities are detected and myocarditis is suspected, prompt collaboration with cardiologists is recommended. Our management strategy of care by a onco-cardiology team may contribute to the early diagnosis and treatment of myocarditis.

Arrhythmia Challenges in Cardio-Oncology: High-Risk Therapies, Management, and Anticoagulation

Cardiovascular disease and cancer are the leading cause of mortality in the United States. In 2021, there were 695,547 and 605,213 deaths due to heart disease and cancer, respectively. With novel oncologic and cardiac therapies, survival has improved leading to increased life-expectancy albeit with chronic illness burden. Arrhythmia management in patients with cancer, whether active or in remission, can be quite challenging. In this review, we will discuss high-risk oncological therapies, prevention, and management of Atrial fibrillation, Ventricular Arrhythmias, and Bradyarrhythmias.

Gender-specific risks for incident cancer in patients with different heart failure phenotypes

BACKGROUND

There is conflicting evidence regarding whether heart failure (HF) increases the risk of developing cancer.

OBJECTIVE

This study aimed to assess the association between HF and incident cancer, considering gender differences and HF phenotypes.

METHODS

This retrospective study was conducted on data of adult individuals, free of cancer at baseline, from the First Affiliated Hospital of Wenzhou Medical University between January 2009 and February 2023. The patients with HF were categorized as HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). The primary outcome was incident cancer, including obesity-related, tobacco-related, lung, colorectal and breast cancers.

RESULTS

Of 33 033 individuals enrolled, 16 722 were diagnosed with HF, including 10 086 (60.3%) with HFpEF and 6636 (39.7%) with HFrEF. During a median follow-up period of 4.6 years (inter-quartile range: 2.6-7.3), incident cancer was diagnosed in 10.5% (1707 patients) of the non-HF group and 15.1% (2533 individuals) of the HF group. After adjusting for potential confounding factors, patients with HF had a 58% increased risk of cancer than those without HF [adjusted hazard ratio (HR) 1.58, 95% confidence interval (CI) 1.48-1.69, P < 0.001]. This risk was consistent across genders (female: adjusted HR 1.95, 95% CI 1.74-2.18, P < 0.001; male: adjusted HR 1.41, 95% CI 1.30-1.54, P < 0.001) and HF phenotypes (HFpEF: adjusted HR 1.69, 95% CI 1.57-1.81, P < 0.001; HFrEF: adjusted HR 1.32, 95% CI 1.20-1.46, P < 0.001).

CONCLUSIONS

Both HFpEF and HFrEF are associated with an increased risk of incident cancer. This correlation maintains its validity across genders.

Cardiotoxicity of Anthracyclines

Anthracycline chemotherapy is associated with cardiotoxicity, predominantly manifesting as left ventricular systolic dysfunction within the first year of treatment. Early detection is possible through biomarkers and cardiovascular imaging before clinical symptoms develop. Comprehensive cardiovascular risk assessment is essential for all patients prior to anthracycline therapy to stratify their risk of cardiotoxicity. Preventive measures, including cardiovascular risk optimization, as well as anthracycline dose adjustments, the use of liposomal anthracyclines, and dexrazoxane in high-risk patients, are crucial to mitigate the risk of cardiotoxicity. Long-term follow-up and cardiovascular risk optimization are critical for cancer survivors to optimize cardiovascular outcomes.

Cardiovascular disease risk after breast cancer treatment in patients with a BRCA1/2 pathogenic variant

PURPOSE

Breast cancer (BC) treatment can induce adverse events, such as cardiovascular disease (CVD). Defective DNA repair, as in carriers of BRCA1/2 pathogenic variants (BRCA1/2pv), may contribute to CVD risk. We aimed to study if female BRCA1/2pv carriers are more sensitive to develop CVD after BC treatment than BC patients without a known BRCA1/2pv.

METHODS

In a hospital-based cohort of 17,300 female BC patients, we identified 509 BRCA1/2pv carriers. Cardiovascular morbidity and mortality were assessed through hospital charts and general practitioner questionnaires. We performed Cox regression analyses comparing BRCA1/2pv carriers with all other BC patients, adjusting for age, radiotherapy regimen, chemotherapy regimen, and smoking status.

RESULTS

Median follow-up time since BC treatment was 14 years. In total, 1108 women experienced ischemic heart disease (IHD), of whom 20 (1.8%) were BRCA1/2pv carriers. Heart failure (HF) was diagnosed in 638 women, of whom 10 (1.6%) were BRCA1/2pv carriers. BRCA1/2pv carriership was associated with a slight not statistically significant increase of IHD (adjHR 1.51, 95%CI 0.93; 2.42), but not with risk of HF (adjHR 0.86, 95%CI 0.44; 1.69). The association between radiotherapy and IHD risk was not significantly different between BRCA1/2pv carriers [HR 2.30 (95%CI 0.79; 6.66)] and other BC patients (HR 1.50, 95%CI 1.30; 1.73). Associations between anthracycline-based chemotherapy and HF risk also did not differ between carriers and other BC patients (HRs of 4.02 (95%CI 1.02; 15.77) and 2.31 (95%CI 1.77; 3.01), respectively).

CONCLUSIONS

In BRCA1/2pv BC patients, we found no evidence for a higher risk of BC treatment-related CVD than in other BC patients.

The cardio-oncologic burden of breast cancer: molecular mechanisms and importance of preclinical models

Breast cancer, the most prevalent cancer affecting women worldwide, poses a significant cardio-oncological burden. Despite advancements in novel therapeutic strategies, anthracyclines, HER2 antagonists, and radiation remain the cornerstones of oncological treatment. However, each carries a risk of cardiotoxicity, though the molecular mechanisms underlying these adverse effects differ. Common mechanisms include DNA damage response, increased reactive oxygen species, and mitochondrial dysfunction, which are key areas of ongoing research for potential cardioprotective strategies. Since these mechanisms are also essential for effective tumor cytotoxicity, we explore tumor-specific effects, particularly in hereditary breast cancer linked to BRCA1 and BRCA2 mutations. These genetic variants impair DNA repair mechanisms, increase the risk of tumorigenesis and possibly for cardiotoxicity from treatments such as anthracyclines and HER2 antagonists. Novel therapies, including immune checkpoint inhibitors, are used in the clinic for triple-negative breast cancer and improve the oncological outcomes of breast cancer patients. This review discusses the molecular mechanisms underlying BRCA dysfunction and the associated pathological pathways. It gives an overview of preclinical models of breast cancer, such as genetically engineered mouse models, syngeneic murine models, humanized mouse models, and various in vitro and ex vivo systems and models to study cardiovascular side effects of breast cancer therapies. Understanding the underlying mechanism of cardiotoxicity and developing cardioprotective strategies in preclinical models are essential for improving treatment outcomes and reducing long-term cardiovascular risks in breast cancer patients.

Coronary artery calcification severity in long term breast cancer survivors treated with isolated contemporary radiotherapy: Relation to dose and CV risk factors

BACKGROUND

Ancillary breast cancer (BC) radiation therapy (RT), particularly associated with chemotherapy, increases the risk of coronary artery disease (CAD). However, it remains unclear whether this risk also applies to isolated contemporary radiotherapy without chemotherapy.

METHODS

Seventy-five BC patients (35 left-sided and 40 right-sided) treated with RT and available dosimetry, prospectively underwent Agatston calcium score (CAC) and coronary CT angiography (CTCA) a median of 11 ± 1 years later and were compared to 75 age- and cardiovascular (CV) risk factor-matched female controls without a history of cancer.

RESULTS

BC patients and controls had similar ages (62 ± 7 vs. 61 ± 7 years, p = 0.63), CV risk factors and estimated Score2/OP risk (3.8 % IQR 2.6-6 vs. 3.3 % IQR 2.3-5.4, p = 0.52). CAC scores (0 IQR 0-79 vs. 0 IQR 0-34, p = 0.62) and age-predicted percentile CAC scores (p = 0.61) were similar between BC patients and controls, with no significant difference between left- and right-sided RT. Multivariable analysis revealed that CAC scores in BC patients were predicted only by a family history of CAD and by Score-2/OP risk, but not by cardiac radiation exposure. By CTCA 68 % of BC patients had no or very mild coronary disease, and only 14 % had more than moderate stenosis (>50 %), which was predicted by CAC scores > 79 (AUC = 0.97).

CONCLUSION

Eleven years post-treatment with isolated contemporary RT for BC, patients exhibited similar CAC severity as age- and risk factor-matched controls. CAC was associated only with CV risk factors, but not radiation dose, suggesting contemporary RT for BC is not linked to higher subclinical CAD prevalence.