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)

Diagnostic and Prognostic Value of Cardiac Magnetic Resonance for Cardiotoxicity Caused by Immune Checkpoint Inhibitors: A Systematic Review and Meta-Analysis

Background

The complex process of cardiac magnetic resonance (CMR) and the uncertainty of each parameter in the diagnosis and prognosis of cardiotoxicity limit its promotion in the cardiac evaluation of patients treated with immune checkpoint inhibitors (ICI).

Methods

A comprehensive search was conducted across PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Cochrane databases for relevant articles published up until September 28, 2024.

Results

After screening, 8 articles were included in this study. The analysis revealed that following ICI treatment, the left ventricular global longitudinal strain (GLS) increased significantly [weighted mean difference (WMD) 2.33; 95% confidence interval (CI) 1.26, 3.41; p < 0.01], while the global radial strain (GRS) decreased [WMD -4.73; 95% CI -6.74, -2.71; p < 0.01]. Additionally, T1 and T2 values increased [standardized mean difference (SMD) 1.14; 95% CI 0.59, 1.68; p < 0.01] and [SMD 1.11; 95% CI 0.64, 1.58; p < 0.01], respectively. An elevated T2 was associated with a higher occurrence of major adverse cardiovascular events (MACE), with a hazard ratio of 1.36 (95% CI 1.12, 1.64).

Conclusions

Our findings demonstrate that T1, T2, and GLS increase, while GRS decreases following ICI administration. By consolidating these critical metrics, we propose a streamlined, abbreviated (non-contrast) CMR protocol that can be completed within 15 minutes, thereby facilitating the integration of CMR in cardio-oncology.

The PROSPERO registration

CRD42023437238, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437238.

Cardio-oncology: chances and challenges

Cardio-oncology is an emerging field that aims to ensure optimal cancer treatment while minimising cardiovascular toxicity. The management of cardiovascular toxicity is critical because it can lead to premature discontinuation of treatment, increasing the risk of cancer recurrence and mortality. The 2022 European Society of Cardiology guidelines were a milestone in advocating a patient-centred, multidisciplinary approach. Key components include risk stratification and a standardised criterion for adverse events, incorporating definitions from the International Cardio-Oncology Society. Effective risk stratification, supported by imaging and biomarkers, helps to anticipate cardiovascular problems and implement preventive measures. Future research should focus on understanding mechanisms, developing preventive strategies and implementing personalised medicine. Education and reducing disparities in care are essential to advance cardio-oncology and improve patient outcomes.

Molecular fingerprints of cardiovascular toxicities of immune checkpoint inhibitors

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy by unleashing the power of the immune system against malignant cells. However, their use is associated with a spectrum of adverse effects, including cardiovascular complications, which can pose significant clinical challenges. Several mechanisms contribute to cardiovascular toxicity associated with ICIs. First, the dysregulation of immune checkpoints, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein-1 (PD-1) and its ligand (PD-L1), and molecular mimicry with cardiac autoantigens, leads to immune-related adverse events, including myocarditis and vasculitis. These events result from the aberrant activation of T cells against self-antigens within the myocardium or vascular endothelium. Second, the disruption of immune homeostasis by ICIs can lead to autoimmune-mediated inflammation of cardiac tissues, manifesting as cardiac dysfunction and heart failure, arrhythmias, or pericarditis. Furthermore, the upregulation of inflammatory cytokines, particularly tumor necrosis factor-alpha, interferon-γ, interleukin-1β, interleukin-6, and interleukin-17 contributes to cardiac and endothelial dysfunction, plaque destabilization, and thrombosis, exacerbating cardiovascular risk on the long term. Understanding the intricate mechanisms of cardiovascular side effects induced by ICIs is crucial for optimizing patient care and to ensure the safe and effective integration of immunotherapy into a broader range of cancer treatment protocols. The clinical implications of these mechanisms underscore the importance of vigilant monitoring and early detection of cardiovascular toxicity in patients receiving ICIs. Future use of these key pathological mediators as biomarkers may aid in prompt diagnosis of cardiotoxicity and will allow timely interventions.

Short- and long-term outcomes of percutaneous left atrial appendage occlusion in cancer patients

Introduction and objectives

Percutaneous left atrial appendage occlusion (LAAO) is a viable option to mitigate bleeding and stroke risks in patients with atrial fibrillation (AF) who are not eligible for oral anticoagulation. Its safety and efficacy in cancer patients remain unclear due to their exclusion from trials. This study aimed to compare short- and long-term LAAO outcomes between cancer and non-cancer patients.

Methods

Retrospective single centre study of 361 consecutive patients who underwent LAAO between april-2010 and december-2023 were included. Short-term outcomes included periprocedural complications, 30-day hospital readmission and mortality. Long-term outcomes included the composite of stroke, bleeding, and mortality and each component assessed separately.

Results

The study included 93 cancer patients (54 % active, 46 % in remission) and 268 non-cancer patients. Baseline characteristics were similar, including ischemic and bleeding risk profiles (CHA2DS2-VASc: 4.5 ± 1.4 vs. 4.4 ± 1.5; HAS-BLED: 3.3 ± 0.9 vs. 3.2 ± 0.9), previous stroke and total bleeding events. Short-term outcomes showed no significant differences in periprocedural complications (7 % vs. 6 %), 30-day readmission (2 % vs. 3 %), or 30-day mortality (0 % vs. 1.5 %). Over 32 months, there was no significant difference regarding the composite endpoint (p = 0.067), stroke (SHR 0.54; p = 0.25) or bleeding events (SHR 1.36; p = 0.35). LAAO was effective in terms of stroke reduction in cancer and non-cancer patients (p = 0.027 and p = 0.006, respectively). All-cause mortality rates were higher in cancer patients (p = 0.002), mainly due to cancer progression and infections.

Conclusions

LAAO procedure was safe and effective in both populations. Cancer patients experienced higher rates of all-cause mortality, with no differences in stroke and bleeding outcomes between groups.

Targeted therapy for older patients with an oncogene driven non-small cell lung cancer: Recommendations from a SIOG expert group

Lung cancer is mostly a disease of aging with approximately half of newly diagnosed patients being 70 years or older. Treatment decisions in this population pose unique challenges because of their heterogeneity with regards to daily functioning, cognition, organ function, comorbidities and polypharmacy, their underrepresentation in clinical trials and the impact of treatment on patient-centered outcomes, particularly in frail patients. The advent of targeted therapies and immunotherapy has revolutionized the management of advanced non-small cell lung cancer (NSCLC). Molecular profiling has allowed for the identification of actionable genomic alterations and targeted therapies have become standard of care for oncogene-driven NSCLC, significantly improving prognosis and quality of life. However, the data on the efficacy and tolerability of these treatments in older patients remain sparse. This review, conducted by the International Society of Geriatric Oncology (SIOG) NSCLC task force, examines the available literature on the use of targeted therapies in patients aged 70 years or older with oncogene-driven NSCLC. The task force's expert recommendations aim to guide treatment decisions for older patients with oncogene driven NSCLC.

Successful treatment of immune checkpoint inhibitor-associated fulminant myocarditis with abatacept and ruxolitinib: a case report

Background

Immune checkpoint inhibitors (ICIs) are a class of cancer immunotherapy with growing indications for treatment of various malignancies. Immune checkpoint inhibitors are monoclonal antibodies that block inhibitory pathways in immune cells, including cytotoxic T lymphocyte antigen-4 (CTLA4), programmed death 1 receptor (PD1), and programmed cell death ligand-1 (PDL1), to activate the immune system. However, these agents can disrupt self-tolerance and lead to immune-related adverse events. Fulminant myocarditis, a feared complication of ICIs, can be highly fatal, and there is a need for effective treatment options.

Case summary

A 70-year-old patient with recurrent metastatic disease of urothelial carcinoma subsequently developed fulminant myocarditis after receiving eight cycles of pembrolizumab. He developed cardiogenic shock and required inotropes and a percutaneous microaxial flow pump placement for temporary mechanical circulatory support. He received methylprednisolone initially and then was started on second-line immunosuppression agents, ruxolitinib and abatacept, for steroid-refractory myocarditis. Abatacept is thought to inhibit activation of T-cell CTLA4 and PD1/PDL1 pathways and reverse ICI-activated pathways. Ruxolitinib is a Janus kinase inhibitor that impairs immune activation through suppressing cytokine sensing and production and T-cell activation. After these treatments, the patient subsequently clinically improved and his myocarditis resolved.

Discussion

This case highlights ICI myocarditis refractory to corticosteroids leading to treatment with second-line immunosuppression. As immunotherapies are increasingly applied to a broader range of cancers, further research is needed to evaluate the optimal treatment strategy for ICI-related myocarditis and other immune-related adverse events.

"There could be something going wrong and I wouldn't even know": a qualitative study of perceptions of people with cancer about cardiovascular disease (CVD) risk and its management

PURPOSE

Despite being at higher risk, many people with cancer do not receive adequate cardiovascular disease (CVD) risk assessment or management. The purpose of this research was to examine people with cancer's perceptions, experiences and needs regarding CVD risk factor awareness, assessment and management.

METHODS

We conducted 15 individual interviews to examine people with cancer's perspectives regarding CVD care in cancer. Reflexive thematic analysis was utilised to collect and organise data into themes and to synthesise findings.

RESULTS

Fifteen people (6 males) diagnosed with diverse cancer types participated. Majority participants were not or only somewhat aware of CVD risk in cancer, but all expressed it was an important issue. A diverse range of priorities and needs for CVD care was discussed, including some participants' prioritisation of dealing with cancer and preferred amount, type and manner of information provision and support. Websites and brochures were identified as potential solutions for optimising CVD care.

CONCLUSIONS

Codesign methodology should be used to engage patients in the development of flexible, tailored resources to increase awareness of CVD risk and strategies for its management.

IMPLICATIONS FOR CANCER SURVIVORS

Perceptions of people with cancer regarding CVD care can inform new interventions that reduce the impact of CVD in cancer.

Obesity Predisposes Anthracycline-Treated Survivors of Childhood and Adolescent Cancers to Subclinical Cardiac Dysfunction

Anthracyclines are effective chemotherapeutics used in approximately 60% of pediatric cancer cases but have a well-documented risk of cardiotoxicity. Existing cardiotoxicity risk calculators do not include cardiovascular risk factors present at the time of diagnosis. The goal of this study is to leverage the advanced sensitivity of strain echocardiography to identify pre-existing risk factors for early subclinical cardiac dysfunction among anthracycline-exposed pediatric patients. We identified 115 pediatric patients with cancer who were treated with an anthracycline between 2013 and 2019. Peak longitudinal left ventricular strain was retroactively calculated on 495 surveillance echocardiograms via the TOMTEC AutoSTRAIN software. Cox proportional hazards models were employed to identify risk factors for abnormal longitudinal strain (> - 16%) following anthracycline treatment. High anthracycline dose (≥ 250 mg/m2 doxorubicin equivalents) and obesity at the time of diagnosis (BMI > 95th percentile-for-age) were both significant predictors of abnormal strain with hazard ratios of 2.79, 95% CI (1.07-7.25), and 3.85, 95% CI (1.42-10.48), respectively. Among pediatric cancer survivors, patients who are obese at the time of diagnosis are at an increased risk of sub-clinical cardiac dysfunction following anthracycline exposure. Future studies should explore the incidence of symptomatic cardiomyopathy 10-15 years post-treatment among patients with early subclinical cardiac dysfunction.

Cardiac Complications of Radiation Therapy

Radiation therapy is a critical component in managing many malignancies by improving local control and survival. The benefits of radiation may come at the expense of unintended radiation injury to the surrounding normal tissues, with the heart being one of the most affected organs in thoracic radiation treatments. As cancer survivors live longer, radiation-induced cardiotoxicity (RICT) is now increasingly recognized. In this review, we highlight the spectrum and pathophysiology of RICT. We summarize contemporary recommendations for risk stratification, screening, prevention, and management of RICT. We briefly highlight novel applications for radiation to treat some cardiac conditions such as resistant arrhythmias.

Impact of adjuvant trastuzumab therapy and its discontinuation on cardiac function and mortality in patients with early-stage breast cancer: An analysis based on the Japanese Receipt Claim Database

Standard trastuzumab therapy can reduce the risk of early recurrence of HER2-positive breast cancer. However, trastuzumab-induced cardiac dysfunction may force the discontinuation of adjuvant trastuzumab therapy. Incidentally, there are still unclear whether or not trastuzumab treatment should be continued in the setting of reduced cardiac function. We aimed to investigate the association between trastuzumab discontinuation, the development of cardiac dysfunction during trastuzumab treatment, and all-cause mortality using the JMDC as the Japanese claims database. Between 2010 and 2019, 1779 women with early-stage breast cancer underwent surgery with adjuvant trastuzumab therapy (TZ). A 1:1 propensity score (PS) matching was conducted for patients who completed or discontinued TZ. The rates of cancer therapy-related-cardiovascular toxicity (CTR-CVT) and mortality in the TZ completion and discontinuation groups were compared. After PS matching, the TZ completion group (CMP_PSM: n = 83) and discontinuation group (INT_PSM: n = 83) were included in the study. TZ was administered for 12 and 5 months in CMP_PSM and INT_PSM, respectively. The cumulative incidence of CTR-CVT was significantly higher in CMP_PSM than INT_PSM (log-rank test, P = .0096). The mortality rate was significantly higher in INT_PSM than in CMP_PSM. The all-cause mortality in INT_PSM tended to increase at a constant rate after treatment, even after discontinuation. Our findings suggest that discontinuation of trastuzumab treatment worsens patient prognosis due to insufficient treatment of breast cancer rather than due to the cardiovascular toxicity of the drug.

Atorvastatin and Myocardial Extracellular Volume Expansion During Anthracycline-Based Chemotherapy

BACKGROUND

In the STOP-CA (Statins to Prevent the Cardiotoxicity From Anthracyclines) trial, atorvastatin preserved the left ventricular ejection fraction among patients with lymphoma treated with anthracyclines. The protective mechanisms are currently unclear.

OBJECTIVES

The aim of this study was to test the effect of atorvastatin on the anthracycline-associated increase in myocardial extracellular volume (ECV) using cardiac magnetic resonance imaging (MRI).

METHODS

Cardiac MRI with mapping was performed at baseline and at 12-month follow-up. ECV was calculated, and the primary endpoint was a ≥3% increase. Increases of ≥1 SD in native T1 and T2 times and ECV were secondary endpoints.

RESULTS

The subgroup included 171 participants with paired cardiac MRI scans, and 127 had contrast scans of appropriate quality (median age 52 years, 47% women). The proportion of participants with ≥3% increases in ECV was lower in the atorvastatin compared with the placebo group (8% vs 29%; P = 0.002; OR: 0.20; 95% CI: 0.06 to 0.59). A ≥3% increase in ECV was associated with an 8.4% decrease in left ventricular ejection fraction at follow-up (95% CI: -6.31 to -10.38; P < 0.001). The proportion of participants with ≥1-SD increases in T1 and T2 times was statistically similar between groups at 12 months. At 24 months, there were fewer heart failure events among those without ≥3% increases in ECV (8% vs 24%; P = 0.054), though not statistically significantly.

CONCLUSIONS

Compared with placebo, atorvastatin limited ECV expansion among participants with lymphoma undergoing anthracycline chemotherapy. This study is the first to provide mechanistic insight into statins' cardioprotective effects with anthracyclines. (Statins to Prevent the Cardiotoxicity From Anthracyclines [STOP-CA]; NCT02943590).

Cardio-Oncology Program Building: A Practical Guide

The organization of a cardio-oncology clinic and overall program is designed to provide comprehensive cardiovascular care to patients who are at risk of or have developed cardiovascular sequelae during or following cancer treatments. In this article, we summarize the core components of a contemporary cardio-oncology program, including its core members (cardiologists, oncologists, clinical pharmacists, advanced practice providers, nurses, and coordinators), key services (risk assessment, treatment planning, cardiac imaging, intervention, and management), and practical integration within the health care system.

Cardio-oncology Drug Interactions: A Primer for Clinicians on Select Cardiotoxic Oncologic Therapies

Cardio-oncology is an emerging multidisciplinary field intended to mitigate and manage cardiovascular side effects and risks associated with cancer therapies. Clinician awareness of drug interaction management among cancer treatments, cardiovascular medications, and supportive care agents is important for optimizing efficacy and safety. Historically, chemotherapies have been associated with pharmacodynamic interactions with few, but important, pharmacokinetic interactions. The advent of oral targeted inhibitors has introduced more complex pharmacokinetic interactions, especially via cytochrome P450 pathways. Given the accelerated development of oncology therapies, clinicians need to be familiar with reviewing multiple sources for interaction information as well as adjusting and monitoring regimens when contending with drug interaction challenges.

The Association of Malignancy With Stroke and Bleeding in Atrial Fibrillation: A Population-Based Cohort Study

BACKGROUND

It is undetermined if malignancy independently increases stroke risk in atrial fibrillation (AF).

OBJECTIVES

This study sought to determine the association of malignancy with stroke and bleeding in AF.

METHODS

Population-based cohort study using administrative datasets of people aged ≥66 years with newly diagnosed AF. People diagnosed with malignancy within 5 years before AF diagnosis were matched to cancer-free control subjects on age, sex, AF diagnosis details, CHA2DS2-VASc score, and ATRIA bleeding score. Outcomes included hospitalizations for stroke and hospitalization/emergency visits for bleeding. Cause-specific regression was used to determine the HR for malignancy after adjusting for time-varying anticoagulation status. Analyses were repeated for specific subgroups of cancer patients (with matched control subjects).

RESULTS

Among 199,710 AF patients, 24,991 (12.5%) people had prior malignancy. Malignancy was associated with more inpatient diagnoses of AF (vs outpatient) and less anticoagulation. We matched 43,802 people with AF (21,901 with malignancy, mean age 78.1 years; 59.5% male). After adjusting for anticoagulation status, malignancy had a similar hazard of stroke (HR: 1.01; 95% CI: 0.88-1.15) but higher hazard of bleeding (HR: 1.45; 95% CI: 1.37-1.53) compared with cancer-free control subjects in the matched sample. Analyses of cancer subgroups with comparison to matched control subjects mostly showed consistent results, except for: 1) increased hazard of stroke in lung cancer; and 2) lack of increased bleeding hazard in breast cancer and lymphoma.

CONCLUSIONS

People with AF and malignancy generally had similar hazards of stroke but higher hazards of bleeding compared with cancer-free control subjects, suggesting that malignancy should not lower the threshold for anticoagulation in AF.

Chemotherapy-Associated Cardiotoxicity: A Silent Threat Evidenced in a Retrospective Cohort Study

INTRODUCTION

At present, cancer represents one of the main causes of mortality both globally and in Colombia, with a growing trend that could position it as the leading cause of death shortly, surpassing other diseases of great health impact. Cardiotoxicity associated with antineoplastic treatments can manifest itself at different times, either during the administration of chemotherapy or sometime after its completion, becoming evident only when clinical complications such as heart failure have developed. Therefore, it is essential to use diagnostic tools to identify patients at greater risk of developing cardiotoxicity associated with administering chemotherapeutic agents.

METHODS

We conducted a descriptive observational cohort study, which included patients over 18 years of age with an active diagnosis of cancer, both of hematological or nonhematological origin, who were treated in a university hospital in Colombia between 2016 and 2019.

RESULTS

One hundred ninety-seven patients were included, with a mean age of 53. During follow-up, 20 patients (10%) developed cardiotoxicity, with an incidence density of 3.64% person-months. Dyslipidemia was the most prevalent comorbidity (45%), followed by arterial hypertension (28.7%). Non-Hodgkin's lymphoma was the most frequent oncologic diagnosis (40.3%), with an incidence of cardiotoxicity of 13%. Patients exposed to anthracyclines had a higher incidence of cardiotoxicity (11.8%) compared to those not exposed (5.7%), with a relative risk of 2.074 (95% confidence interval = 1.91-2.24). The left ventricular ejection fraction was significantly lower in patients with cardiotoxicity (55.3%) compared to those without cardiotoxicity (62.1%) (p = 0.029).

CONCLUSIONS

Taking into account the usefulness of echocardiography and the use of biomarkers found in this study and referred to in the literature, we can determine that these studies, far from being routine, are one of the main strategies that the clinician has to favor the early and timely identification of those patients who are developing a cardiotoxic effect; therefore, it is essential to include these tools in the algorithms of care as a model of serial monitoring. This is not only to reduce the incidence of cardiotoxicity but also as part of an integral management of the oncologic patient to increase the efficiency of pharmacological treatment and improve the quality of life of the patients treated in the short, medium, and long term.

Management of Patients with Advanced Prostate Cancer. Report from the 2024 Advanced Prostate Cancer Consensus Conference (APCCC)

BACKGROUND AND OBJECTIVE

Innovations have improved outcomes in advanced prostate cancer (PC). Nonetheless, we continue to lack high-level evidence on a variety of topics that greatly impact daily practice. The 2024 Advanced Prostate Cancer Consensus Conference (APCCC) surveyed experts on key questions in clinical management in order to supplement evidence-based guidelines. Here we present voting results for questions from APCCC 2024.

METHODS

Before the conference, a panel of 120 international PC experts used a modified Delphi process to develop 183 multiple-choice consensus questions on eight different topics. Before the conference, these questions were administered via a web-based survey to the voting panel members ("panellists").

KEY FINDINGS AND LIMITATIONS

Consensus was a priori defined as ≥75% agreement, with strong consensus defined as ≥90% agreement. The voting results show varying degrees of consensus, as discussed in this article and detailed in the Supplementary material. These findings do not include a formal literature review or meta-analysis.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The voting results can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers in prioritising areas for future research. Diagnostic and treatment decisions should always be individualised on the basis of patient and cancer characteristics, and should incorporate current and emerging clinical evidence, guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2024 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials.

Effects of lenvatinib on glucose, cholesterol, triglycerides and estimated cardiovascular risk in patients with advanced thyroid cancer

PURPOSE

Multitarget kinase inhibitors (MKIs) are effective options in the treatment of cancer, significantly increasing the progression-free survival (PFS) of many tumors. Data about severity and prevalence of metabolic adverse events is scarce and may be significant in patients with a better survival. The aim of this study was to investigate glucose and lipids values of patients treated with lenvatinib. Secondary aims included evaluating changes in the estimated risk of cardiovascular disease and the relationship between metabolic alterations and tumor response to therapy.

METHODS

A retrospective pilot study on 29 patients with advanced differentiated thyroid cancer was conducted. Clinical and biochemical characteristics were collected at the day of therapy initiation and follow up. The 10-year risk of cardiovascular disease was estimated with the SCORE2 and SCORE2-OP algorithms. Tumor burden change was assessed according to the Response Evaluation Criteria in Solid Tumors (RECIST).

RESULTS

No differences in glucose values were observed. A significant increase in total cholesterol (208 ± 41 versus 245 ± 67 mg/dl), triglycerides (112 [interquartile range, 58-326] versus 157 [78-296] mg/dl), calculated LDL cholesterol (128 [66-204] versus 140 [81-308] mg/dl) and cardiovascular risk was observed from baseline to follow up. Furthermore, these parameters increase progressively with increasing tumor response to therapy.

CONCLUSIONS

Despite limitations, this study shows an association between the use of lenvatinib and the development of lipid alterations in patients with advanced thyroid cancer. However, further investigation is necessary for a more comprehensive understanding of the adverse metabolic profile of MKIs.

Classes of Antineoplastic Agents Associated with Increased Risk of Cancer Therapy-associated Hypertension and Management Strategies

Hypertension (HTN) has been found to be the most common comorbidity in patients with cancer. In addition to increased prevalence of baseline HTN, patients with cancer may be at increased risk of HTN as a short-term or long-term adverse event from cancer therapy. Different classes of cancer therapies have been implicated in the development of HTN, including inhibitors of vascular endothelial growth factor (VEGF), Bruton tyrosine kinase inhibitors, proteasome inhibitors, androgen deprivation therapy, and others. While some of these drugs may lead to increases in blood pressure through on-target effects (eg, with VEGF inhibition), others may be associated with HTN from off-target mechanisms that are not always well understood.

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Early microvascular coronary endothelial dysfunction precedes pembrolizumab-induced cardiotoxicity. Preventive role of high dose of atorvastatin

Immune checkpoint inhibitors (ICIs) exhibit remarkable antitumor activity and immune-related cardiotoxicity of unknown pathomechanism. The aim of the study was to investigate the ICI class-dependent cardiotoxicity in vitro and pembrolizumab's (Pem's) cardiotoxicity in vivo, seeking for translational prevention means. Cytotoxicity was investigated in primary cardiomyocytes and splenocytes, incubated with ipilimumab, Pem and avelumab. Pem's cross-reactivity was assessed by circular dichroism (CD) on biotechnologically produced human and murine PD-1 and in silico. C57BL6/J male mice received IgG4 or Pem for 2 and 5 weeks. Echocardiography, histology, and molecular analyses were performed. Coronary blood flow velocity mapping and cardiac magnetic resonance imaging were conducted at 2 weeks. Human EA.hy926 endothelial cells were incubated with Pem-conditioned media from human mononuclear cells, in presence and absence of statins and viability and molecular signaling were assessed. Atorvastatin (20 mg/kg, daily) was administered in vivo, as prophylaxis. Only Pem exerted immune-related cytotoxicity in vitro. Pem's cross-reactivity with the murine PD-1 was confirmed by CD and docking. In vivo, Pem initiated coronary endothelial and diastolic dysfunction at 2 weeks and systolic dysfunction at 5 weeks. At 2 weeks, Pem induced ICAM-1 and iNOS expression and intracardiac leukocyte infiltration. At 5 weeks, Pem exacerbated endothelial activation and triggered cardiac inflammation. Pem led to immune-related cytotoxicity in EA.hy926 cells, which was prevented by atorvastatin. Atorvastatin mitigated functional deficits, by inhibiting endothelial dysfunction in vivo. We established for the first time an in vivo model of Pem-induced cardiotoxicity. Coronary endothelial dysfunction precedes Pem-induced cardiotoxicity, whereas atorvastatin emerges as a novel prophylactic therapy.

Characterization of anthracycline-induced cardiotoxicity by diffusion tensor magnetic resonance imaging

Anthracyclines are highly potent anti-cancer drugs, but their clinical use is limited by severe cardiotoxic side effects. The impact of anthracycline-induced cardiotoxicity (AIC) on left ventricular (LV) microarchitecture and diffusion properties remains unknown. This study sought to characterize AIC by cardiovascular magnetic resonance diffusion tensor imaging (DTI). Mice were treated with Doxorubicin (DOX; n = 16) for induction of AIC or saline as corresponding control (n = 15). Cardiac function was assessed via echocardiography at the end of the study period. Whole hearts (n = 8 per group) were scanned ex vivo by high-resolution DTI at 7 T. Results were correlated with histopathology and mass spectrometry imaging. Mice with AIC demonstrated systolic dysfunction (LVEF 52 ± 3% vs. 43 ± 6%, P < 0.001), impaired global longitudinal strain (-19.6 ± 2.0% vs. -16.6 ± 3.0%, P < 0.01), and cardiac atrophy (LV mass index [mg/mm], 4.3 ± 0.1 vs. 3.6 ± 0.2, P < 0.01). Regional sheetlet angles were significantly lower in AIC, whereas helix angle and relative helicity remained unchanged. In AIC, fractional anisotropy was increased (0.12 ± 0.01 vs. 0.14 ± 0.02, P < 0.05). DOX-treated mice displayed higher planar and less spherical anisotropy (CPlanar 0.07 ± 0.01 vs. 0.09 ± 0.01, P < 0.01; CSpherical 0.89 ± 0.01 vs. 0.87 ± 0.02, P < 0.05). CPlanar and CSpherical yielded good discriminatory power to distinguish between mice with and without AIC (c-index 0.91 and 0.84, respectively, P for both < 0.05). AIC is associated with regional changes in sheetlet angle but no major abnormalities of global LV microarchitecture. The geometric shape of the diffusion tensor is altered in AIC. DTI may provide a new tool for myocardial characterization in patients with AIC, which warrants future clinical studies to evaluate its diagnostic utility.

A Primer on the Evolving Subspecialty of Onco-Electrophysiology

Cardio-oncology has become a well-established subspecialty because of the growing burden of cardiovascular diseases in oncology patients, resulting from the cardiac toxicities of cancer therapies and the coexistence of both conditions in the same population. As with other cardiovascular conditions, cardiac arrhythmias have emerged as an important concern in patients with cancer. However, the management of arrhythmias is more complicated in these patients because of complex interactions between oncotherapeutics and arrhythmia-treatment strategies. Similarly, patients with cardiac implantable electronic devices (CIEDs) require cancer treatment strategies that involve radiation therapy require specific management strategies. Thus, there is a need for a specific mechanistic understanding of electrophysiological abnormalities, arrhythmia, and device management in oncology patients, especially given the expanding range of oncologic therapies and radiation strategies. This increasingly prevalent clinical challenge requires new expertise that expands on a yearly basis. This narrative review deals with this recent expansion and addresses key areas of onco-electrophysiology, including the mechanistic basis of common electrocardiographic changes, diagnosis, and management of arrhythmias attributable to oncotherapeutics and the care of patients with arrhythmias who require oncologic therapies, especially patients with devices and drug interactions leading to arrhythmias as seen by cardiac physicians dealing with oncology patients. In addition, it reviews evolving management strategies and protocols for patients with implantable devices, especially if urgent radiation is needed. This review aims to bridge the recent knowledge growth in arrhythmia care for patients with cancer and highlight the evolution of onco-electrophysiology as a subspeciality.

Cardiovascular Health in Breast Cancer: Survivorship Care

Improved screening and treatment have increased breast cancer survival rates, with over 7.8 million women surviving 5 years post-diagnosis globally. However, survivors face heightened cardiovascular morbidity and mortality due to cancer treatment and patient related risk factors. Cardio-oncology has emerged as a discipline to manage cardiovascular health in patients throughout and following cancer treatment. This review focuses on strategies to optimize cardiovascular health in breast cancer survivors, aligning with ASCO's survivorship principles. Key strategies include risk stratification, primary prevention, lifestyle interventions, pharmacologic management, appropriate cardiovascular monitoring, and tailored exercise programs. Effective cardio-oncology care hinges on collaboration between specialists and patients, underscoring the significance of shared-care models and telemedicine options in survivorship management.

Exercise, cancer, and the cardiovascular system: clinical effects and mechanistic insights

Cardiovascular diseases and cancer are the leading causes of death in the Western world and share common risk factors. Reduced cardiorespiratory fitness (CRF) is a major determinant of cardiovascular morbidity and cancer survival. In this review we discuss cancer- induced disturbances of parenchymal, cellular, and mitochondrial function, which limit CRF and may be antagonized and attenuated through exercise training. We show the impact of CRF on cancer survival and its attenuating effects on cardiotoxicity of cancer-related treatment. Tailored exercise programs are not yet available for each tumor entity as several trials were performed in heterogeneous populations without adequate cardiopulmonary exercise testing (CPET) prior to exercise prescription and with a wide variation of exercise modalities. There is emerging evidence that exercise may be a crucial pillar in cancer treatment and a tool to mitigate cardiotoxic treatment effects. We discuss modalities of aerobic exercise and resistance training and their potential to improve CRF in cancer patients and provide an example of a periodization model for exercise training in cancer.

Immuno-related cardio-vascular adverse events associated with immuno-oncological treatments: an under-estimated threat for cancer patients

Immunotherapy represents an emergent and heterogeneous group of anticancer treatments harnessing the human immune-surveillance system, including immune-checkpoint inhibitor monoclonal antibodies (mAbs), Chimeric Antigen Receptor T Cells (CAR-T) therapy, cancer vaccines and lymphocyte activation gene-3 (LAG-3) therapy. While remarkably effective against several malignancies, these therapies, often in combination with other cancer treatments, have showed unforeseen toxicity, including cardiovascular complications. The occurrence of immuno-mediated adverse (irAEs) events has been progressively reported in the last 10 years. These irAEs present an extended range of severity, from self-limiting to life-threatening conditions. Although recent guidelines in CardioOncology have provided important evidence in managing cancer treatments, they often encompass general approaches. However, a specific focus is required due to the particular etiology, unique risk factors, and associated side effects of immunotherapy. This review aims to deepen the understanding of the prevalence and nature of cardiovascular issues in patients undergoing immunotherapy, offering insights into strategies for risk stratification and management.

Cardiovascular Safety in Oncology Clinical Trials: JACC: CardioOncology Primer

The development of novel treatments has improved cancer outcomes but may result in cardiovascular toxicities. Traditional approaches to clinical trial safety evaluation have limitations in their ability to detect signals of cardiovascular risk. Mechanisms to increase power and specificity to clarify cardiovascular safety are required. However, implications include increased costs and slower development. The Cardiovascular Safety Research Consortium facilitated stakeholder discussions with representation from academia, industry, and regulators. A think tank was assembled with the aim of providing recommendations for improved collection and reporting of cardiovascular safety signals in oncology trials. Two working groups were formed. The first focuses on incorporation of consensus definitions of cardiovascular disease into the Common Terminology Criteria for Adverse Events used in oncology trial reporting. The second group considers methods for ascertainment and adjudication of cardiovascular events in cancer trials. The overarching aim of this primer is to improve understanding of the potential cardiovascular toxicities of cancer therapies.

Ischemic Heart Disease in the Cancer Population: Trends, Outcomes, Epidemiology, and Challenges in Diagnosis and Treatment

Patients with cancer are at increased risk of ischemic heart disease (IHD). The increased risk of IHD in these patients is due to the interaction of shared risk factors, cancer type and stage, and immuno/chemotherapy and radiotherapy regimens. Management of IHD in cancer patients is challenging, due to atypical presentation, increased thrombotic and bleeding risk, and worse outcomes compared to patients without cancer. In this review, we will discuss the trends, outcomes, epidemiology and challenges in the diagnosis and treatment of IHD among cancer patients.

Doxorubicin or Epirubicin Versus Liposomal Doxorubicin Therapy-Differences in Cardiotoxicity

Doxorubicin (DOX) is an important drug used in the treatment of many malignancies. Unfortunately DOX causes various side effects, with cardiotoxicity being the most characteristic. Risk factors for DOX induced cardiotoxicity (DIC) include cumulative dose of DOX, preexisting cardiovascular diseases, dyslipidemia, diabetes, smoking, along with the use of other cardiotoxic agents. Development of DIC is associated with many pathological phenomena - increased oxidative stress, as well as upregulation of ferroptosis, apoptosis, necrosis, and autophagy. In DIC expression of many microRNAs is also deregulated. In order to avoid cardiotoxicity and still use DOX effectively DOX derivatives such as epirubicin were synthesized. Nowadays a new liposomal form of DOX (L-DOX) appeared as an alternative to conventional treatment with greatly reduced cardiotoxicity. L-DOX can be divided into two groups of substances - pegylated (PLD) with increased solubility and stability, and non-pegylated (NLPD). Many metaanalyses, clinical along with preclinical studies have shown L-DOX treatment is associated with a smaller decrease of left ventricular ejection fraction (LVEF) and other heart functions, but efficacy of this treatment is comparable to the use of convenctional DOX.

Incidence and Risk of Thromboembolic and Cardiovascular Adverse Events with PARP Inhibitor Treatment in Patients with Metastatic Castration-resistant Prostate Cancer: A Systematic Review and Safety Meta-analysis

Background and objective

PARP inhibitor (PARPi) treatment is an effective option for patients with metastatic castration-resistant prostate cancer (mCRPC). There are few data on the cardiovascular and thromboembolic safety of these agents in mCRPC, as cardiovascular and thromboembolic adverse events (AEs) are uncommon. Our aim was to analyze the incidence and risk of major adverse cardiovascular events (MACEs), thromboembolic events, and hypertension with PARPi therapy in mCRPC.

Methods

We conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We systematically searched the PubMed, EMBASE, and Cochrane databases and the American Society of Clinical Oncology and European Society of Medical Oncology meeting abstracts for clinical trials on PARPi use in mCRPC up to March 31, 2024. We analyzed the pooled incidence of all-grade and high-grade MACEs, thromboembolic events, and hypertension, and calculated risk ratios (RRs) for PARPi versus non-PARPi treatment.

Key findings and limitations

We included 11 phase 2 or 3 trials in our meta-analysis. Hypertension was the most common AE for both any-grade (17.2%) and high-grade (9.3%) events. In comparison to other treatments, PARPi was associated with significantly higher risk of high-grade MACEs (RR 2.03; p = 0.03) and thromboembolic events (RR 2.15; p = 0.002), especially venous thromboembolism (VTE; RR 2.13; p = 0.004) and pulmonary embolism (RR 3.60; p = 0.001). The risk of hypertension, any-grade MACEs, and thromboembolic AEs was not significantly higher, apart from VTE (RR 2.17; p = 0.01).

Conclusions and clinical implications

There is higher risk of high-grade cardiovascular and thromboembolic toxicity with PARPi use in comparison to other treatments in mCRPC, although these toxicities are rare. Clinicians should be aware of this risk, especially in a population that often has comorbidities and concomitant treatments, for correct monitoring and management of these AEs.

Patient summary

Drugs called PARP inhibitors are very effective in the treatment of metastatic prostate cancer that does not respond to hormone treatment. However, their use is associated with some cardiovascular adverse events, although these are rare. Our study shows that these events seem to be more frequent with PARP inhibitors than with other treatments, especially for severe grades. Doctors and patients should be aware of this risk to help in preventing, recognizing, and managing the occurrence of these rare complications.

Comparing Renin-Angiotensin-Aldosterone Blockade Regimens for Long-Term Chemotherapy-Related Cardiac Dysfunction: A Network Meta-Analysis

PURPOSE

Cancer therapies including trastuzumab and anthracyclines are cardiotoxic and cause cardiac dysfunction. To prevent cardiotoxicity, pharmacological agents used in heart failure have been administered concomitantly with cardiotoxic cancer therapy, but few studies to date have performed a head-to-head comparison of these different agents. This systematic review and network meta-analysis of randomized-controlled trials aims to evaluate the efficacy of renin-angiotensin-aldosterone system (RAAS) blockers, namely angiotensin-converting enzyme inhibitors (ACE-Is), aldosterone receptor blockers (ARBs), and mineralocorticoid receptor antagonists (MRAs), in primary prevention against chemotherapy-related cardiac dysfunction in patients receiving anthracyclines and/or trastuzumab.

METHODS

A systematic search was performed in major web databases for studies from inception to 15 September 2022. A Bayesian network meta-analysis model was used to assess the relative effects of competing treatments on the primary outcomes of risk of significant decline in left ventricular ejection fraction (LVEF) and mean LVEF decline. Secondary outcomes included left ventricular diastolic function, global longitudinal strain, and cardiac biomarkers. This study is registered with PROSPERO, CRD42022357980.

RESULTS AND CONCLUSION

Nineteen studies reported the effects of 13 interventions (N = 1905 patients). Only enalapril (RR 0.05, 95% CI 0.00-0.20) was associated with reduced risk of patients developing significant decline in LVEF relative to placebo. Subgroup analysis showed that the beneficial effect of enalapril was driven by protection against anthracycline-associated toxicity. In addition, no RAAS-inhibiting agents showed efficacy in protection against treatment with both anthracycline and trastuzumab. The use of RAAS inhibition therapy did not conclusively impact on other markers of cardiac function, including left ventricular diastolic function and cardiac biomarkers.

SGLT2i Therapy Prevents Anthracycline-Induced Cardiotoxicity in a Large Animal Model by Preserving Myocardial Energetics

BACKGROUND

Anthracycline-induced cardiotoxicity (AIC) is characterized by a disruption in myocardial metabolism.

OBJECTIVES

The authors used a large animal model to test sodium-glucose cotransporter inhibitor therapy to prevent AIC.

METHODS

Female large white pigs (n = 36) were used to identify the most translational AIC regimen: 6 triweekly intravenous doxorubicin injections (1.8 mg/kg each). Another group of 32 pigs were randomized (1:1:2) to doxorubicin plus empagliflozin 20 mg, doxorubicin plus empagliflozin 10 mg, or doxorubicin control. Pigs were serially examined using multiparametric cardiac magnetic resonance and magnetic resonance spectroscopy. At the end of the 21-week follow-up period, blood samples were obtained to measure myocardial metabolic substrate extraction, and the left ventricle was harvested and processed for analysis using metabolomics, transmission electron microscopy, mitochondrial respirometry, and histopathology.

RESULTS

Final left ventricular ejection fraction (LVEF), the prespecified primary outcome, was significantly higher in pigs receiving 20 mg empagliflozin than in the doxorubicin control group (median 57.5% [Q1-Q3: 55.5%-60.3%] vs 47.0% [Q1-Q3: 40.8%-47.8%]; P = 0.027). Final LVEF in pigs receiving 10 mg empagliflozin was 51% (Q1-Q3: 46.5%-55.5%; P = 0.020 vs 20 mg empagliflozin). The incidence of AIC events was 0%, 50%, and 72% in the empagliflozin 20 mg, empagliflozin 10 mg, and doxorubicin control groups, respectively. Empagliflozin 20 mg treatment resulted in enhanced ketone body consumption by the myocardium, preserved magnetic resonance spectroscopy-measured cardiac energetics, and improved mitochondrial structure and function on transmission electron microscopy and respirometry. These changes were more modest with the 10-mg empagliflozin dose.

CONCLUSIONS

Sodium-glucose cotransporter-2 inhibitor therapy with empagliflozin exerts a dose-dependent cardioprotective effect against AIC. The improved LVEF was accompanied by enhanced ketone body consumption, improved cardiac energetics, and preserved mitochondrial structure and function.

Acute Myocarditis and Inflammatory Cardiomyopathies: Insights From Cardiac Magnetic Resonance Findings

Myocardial inflammation encompasses a broad spectrum of conditions, including acute myocarditis, chronic inflammatory cardiomyopathy, and several overlapping entities that differ in clinical presentation, pathophysiology, and progression. These conditions range from self-limiting acute inflammation to chronic myocardial injury and dysfunction. The etiologic classification of myocardial inflammation highlights the complexity of its pathogenesis, involving direct tissue damage, immune-mediated mechanisms, and environmental triggers. Cardiac magnetic resonance (CMR) imaging has become a central diagnostic tool in the assessment of myocardial inflammation, providing precise characterization of myocardial tissue, assessing cardiac function, and stratifying prognosis. Advanced techniques such as T1 and T2 mapping and extracellular volume quantification have further expanded its diagnostic capabilities. This review highlights the essential role of CMR in diagnosing myocardial inflammation, recognizing various imaging findings associated with different underlying causes, and informing clinical management. The standardization of CMR protocols, along with advancements in imaging techniques and strengthened interdisciplinary collaboration, represents a fundamental step toward improving diagnostic accuracy, patient outcomes, and the understanding of the broad spectrum of myocardial inflammatory diseases.

Cardioprotection strategies for anthracycline cardiotoxicity

Thanks to the fantastic progress in cancer therapy options, there is a growing population of cancer survivors. This success has resulted in a need to focus much effort into improving the quality of life of this population. Cancer and cardiovascular disease share many common risk factors and have an interplay between them, with one condition mechanistically affecting the other and vice versa. Furthermore, widely prescribed cancer therapies have known toxic effects in the cardiovascular system. Anthracyclines are the paradigm of efficacious cancer therapy widely prescribed with a strong cardiotoxic potential. While some cancer therapies cardiovascular toxicities are transient, others are irreversible. There is a growing need to develop cardioprotective therapies that, when used in conjunction with cancer therapies, can prevent cardiovascular toxicity and thus improve long-term quality of life in survivors. The field has three main challenges: (i) identification of the ultimate mechanisms leading to cardiotoxicity to (ii) identify specific therapeutic targets, and (iii) more sensible diagnostic tools to early identify these conditions. In this review we will focus on the cardioprotective strategies tested and under investigation. We will focus this article into anthracycline cardiotoxicity since it is still the agent most widely prescribed, the one with higher toxic effects on the heart, and the most widely studied.

Longitudinal Displacement for Left Ventricular Function Assessment

BACKGROUND

Quantitative evaluation of myocardial function traditionally relies on parameters such as ejection fraction and strain. Strain, reflecting the relative change in the length of a myocardial segment over the cardiac cycle, has been extensively studied in various cardiac pathologies over the past two decades. However, the absolute length change, or longitudinal displacement, of myocardial segments during the cardiac cycle has received limited attention. This study aims to evaluate longitudinal displacement in two separate groups: healthy athletes and patients with left ventricular dysfunction, providing new insights into myocardial function assessment.

METHODS

Echocardiographic examinations were performed on 30 healthy football players and 30 patients with left ventricular dysfunction using speckle-tracking imaging analysis. Global and regional peak longitudinal displacement values were calculated and compared with corresponding global and regional peak longitudinal strain measurements. A manual alternative for calculating global longitudinal strain was also proposed.

RESULTS

An inverse correlation was found between regional longitudinal displacement and regional longitudinal strain. Longitudinal displacement was maximal in the basal segments and lowest in the apex of the left ventricle, exhibiting a reversed basal-to-apical gradient (17.6 ± 3.5 mm vs. 11.5 ± 2.9 mm vs. 4.22 ± 1.7 mm in basal, mid, and apical segments, respectively; p < 0.000001). Maximal longitudinal displacement was observed in the inferior and posterior walls of the left ventricle. In the 30 patients with left ventricular dysfunction, global longitudinal displacement was significantly lower than in healthy individuals (4.4 ± 1.7 mm vs. 11.7 ± 1.5 mm, p < 0.000001). Global longitudinal displacement and global longitudinal strain showed a strong negative correlation (r = -0.72, p < 0.000001). Manually calculated global longitudinal strain demonstrated good agreement with speckle-tracking-based global longitudinal strain.

CONCLUSIONS

Peak longitudinal displacement can be used to evaluate both regional and global myocardial function, similarly to peak longitudinal strain. Unlike strain, longitudinal displacement exhibits a reversed basal-to-apical gradient, with the highest values at the base of the left ventricle and the lowest at the apex. Global and regional longitudinal displacement is significantly reduced in patients with left ventricular dysfunction. Global longitudinal strain can be manually calculated using displacement measurements. Further studies are needed to evaluate peak longitudinal displacement in various cardiac pathologies.

Atrioventricular block and conduction disorders induced by ICIs: Individual patient data systematic review: "Conduction disorders induced by ICIs"

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that enhance T cell-mediated anti-tumor responses but may induce cardiotoxicity, including conduction disorders and atrioventricular blocks (AVB). A systematic review of 30 case reports involving cancer patients treated with ICIs was conducted. The majority of affected patients were in advanced stages of lung and kidney/urothelial cancers, predominantly male, and typically developed AVB within three weeks of therapy, often accompanied by myocarditis. Complete AVB was the most frequently observed disorder, necessitating interruption of therapy and temporary pacing. Less than half of the cases were reversible, and in-hospital mortality was significant. Further research is needed.

The ImageGuideEcho Registry: Using Data Science to Understand and Improve Echocardiography

PURPOSE OF REVIEW

To provide a contemporary update on the American Society of Echocardiography's ImageGuideEcho Registry and present a case study of an individual institution's experience with enrollment.

RECENT FINDINGS

Technical innovation in clinical echocardiography has expanded the impact of echocardiography in cardiovascular care and provides new opportunities to leverage clinical data to inform quality improvement initiatives and research. The ImageGuideEcho Registry is the first echocardiography-specific imaging registry in the United States and provides a data infrastructure for quality improvement and multicenter research. The ImageGuideEcho Registry continues to grow, offering a window into echocardiography care across the United States in a variety of practice settings. This early experience highlights its value, opportunities, and ongoing challenges. Continued innovation, such as the addition of primary images, will further add to the substantial value of the registry.

Rationale and design of the HOVON 170 DLBCL-ANTICIPATE trial: preventing anthracycline-induced cardiac dysfunction with dexrazoxane

BACKGROUND

Dexrazoxane has been studied for its ability to prevent anthracycline-induced cardiac dysfunction (AICD) in several trials but its use in clinical practice remains limited. This is related to the low to moderate quality of the generated evidence, safety concerns and restricted prescribing indications. Additional randomized trials are needed before this drug can be routinely integrated into cardio-oncology clinical practice.

OBJECTIVES

To describe the rationale and design of the HOVON 170 DLBCL - ANTICIPATE trial. This trial aims to establish the efficacy and safety of dexrazoxane for the primary prevention of AICD in patients diagnosed with Diffuse Large B-Cell Lymphoma (DLBCL) treated with six cycles R-CHOP21 chemo-immunotherapy.

METHODS

This is a multicenter, parallel-group, open-label, phase III trial, randomizing 324 patients between either no cardioprotective treatment or dexrazoxane from the first R-CHOP cycle. The primary and co-primary endpoints are the incidence of AICD within 12 months of registration and the percentage of patients with complete metabolic remission at the end-of-treatment PET-CT respectively. The trial is registered at the EU Clinical Trials Register (EU-CT number 2023-505377-32) and ClinicalTrials.gov (NCT06220032).

RESULTS

The medical research ethics committee approved the trial in May 2024. Recruitment has started in September 2024 and is expected to last for three years.

CONCLUSIONS

This trial is poised to contribute crucial evidence concerning the efficacy and safety on the use of dexrazoxane in the primary prevention of AICD. The trial is anticipated to address critical knowledge gaps and offer important insights into the value of dexrazoxane in cardio-oncology practice.

Anthracycline-induced cardiomyopathy: risk prediction, prevention and treatment

Anthracyclines are the cornerstone of treatment for many malignancies. However, anthracycline cardiotoxicity is a considerable concern given that it can compromise the clinical effectiveness of the treatment and patient survival despite early discontinuation of therapy or dose reduction. Patients with cancer receiving anthracycline treatment can have a reduction in their quality of life and likelihood of survival due to cardiotoxicity, irrespective of their oncological prognosis. Increasing knowledge about anthracycline cardiotoxicity has enabled the identification of patients who are candidates for anthracycline regimens and those who might develop anthracycline-induced cardiomyopathy. Anthracycline cardiotoxicity is a unique and evolving phenomenon that begins with myocardial cell damage, progresses to reduced left ventricular ejection fraction, and culminates in symptomatic heart failure if it is not promptly detected and treated. Early risk stratification can be guided by imaging or biomarkers. In this Review, we present a comprehensive and clinically useful approach to cardiomyopathy related to anthracycline therapy, encompassing its epidemiology, definition, mechanisms, novel classifications, risk factors and patient risk stratification, diagnostic approaches (including imaging and biomarkers), treatment guidelines algorithms, and the role of new cardioprotective drugs that are used for the treatment of heart failure.

Preventing Allogeneic Stem Cell Transplant-Related Cardiovascular Dysfunction: ALLO-Active Trial

BACKGROUND

Allogeneic stem cell transplantation (allo-SCT) is an efficacious treatment for hematologic malignancies but can be complicated by cardiac dysfunction and exercise intolerance impacting quality of life and longevity. We conducted a randomized controlled trial testing whether a multicomponent activity intervention could attenuate reductions in cardiorespiratory fitness and exercise cardiac function (co-primary end points) in adults undergoing allo-SCT.

METHODS

Sixty-two adults scheduled for allo-SCT were randomized to a 4-month activity program (activity; n=30) or usual care (UC; n=32). Activity comprised a multicomponent exercise training (3 days.week-1) and sedentary time reduction (≥30 minutes.day-1) program and was delivered throughout hospitalization (≈4 weeks) and for 12 weeks after discharge. Physiological assessments conducted before admission and at 12 weeks after discharge included cardiopulmonary exercise testing to quantify peak oxygen uptake ([Formula: see text]), exercise cardiac magnetic resonance imaging for peak cardiac (CIpeak) and stroke volume (SVIpeak) index, echocardiography-derived left ventricular ejection fraction and global longitudinal strain, and cardiac biomarkers (cTn-I [troponin-I] and BNP [B-type natriuretic peptide]).

RESULTS

Fifty-two participants (84%) completed follow-up (25 activity and 27 UC); median (interquartile range [IQR]) adherence to the activity program was 74% (41%-96%). There was a marked decline in [Formula: see text] in the UC program (-3.4 mL‧kg-1‧min-1 [95% CI, -4.9 to -1.8]) that was attenuated with activity (-0.9 mL‧kg-1‧min-1 [95% CI, -2.5 to 0.8]; interaction P=0.029). Activity preserved exercise cardiac function, with preservation of CIpeak (0.30 L‧min-1‧m-2 [95% CI, -0.34 to 0.41]) and SVIpeak (0.6 mL.m-2 [95% CI, -1.3 to 2.5]), both of which declined with UC (CIpeak, -0.68 L‧min-1‧m-2 [95% CI, -1.3 to -0.32]; interaction P=0.008; SVIpeak, -2.7 mL.m-2 [95% CI, -4.6 to -0.9]; interaction P=0.014). There were no treatment effects of activity on cardiac biomarkers or echocardiographic indices.

CONCLUSIONS

Intervening during and after allo-SCT with a multicomponent activity program during and after allo-SCT is beneficial for preserving a patient's cardiorespiratory fitness and exercise cardiac function. These results may have important implications for cardiovascular morbidity and mortality after allo-SCT.

REGISTRATION

URL: https://anzctr.org.au/; Unique identifier: ACTRN12619000741189.

Indolent lymphoma: addressing the needs of survivors

Over the past two decades, there has been a continuous improvement in outcome for patients with indolent lymphoma (iNHL) resulting in a gradual accumulation of survivors. While life expectancy in the current era approaches that of the lymphoma-free population, patients continue to experience lifelong complications of the disease and its treatment affecting general health, emotional, psychological and social wellbeing, relationships, employment, finances, and fitness. Contemporary care models while suited to the management of lymphoma are often lacking when it comes to identification and management of these additional needs. Given improvements in physical survival achieved over the past decades, it is timely for us to focus on other issues affecting patient wellbeing including immunodeficiency and infection, second cancers, cardiovascular disease, bone health, psychological wellbeing, and sexual health. Many of these aspects are in the domain of the primary care physician; however, there is limited guidance on how these issues should be addressed. It is now time for us to engage our patients, their caregivers, and other healthcare providers in care aspects beyond the lymphoma diagnosis, so they can anticipate a rich and full life, free from both direct and indirect consequences of the lymphoma diagnosis.

Risk Assessment Prior to Cardiotoxic Anticancer Therapies in 7 Steps

The burdens of cardiovascular (CV) diseases and cardiotoxic side effects of cancer treatment in oncology patients are increasing in parallel. The European Society of Cardiology (ESC) 2022 Cardio-Oncology guidelines recommend the use of standardized risk stratification tools to determine the risk of cardiotoxicity associated with different anticancer treatment modalities and the severity of their complications. The use of the Heart Failure Association-International Cardio-Oncology Society (HFA-ICOS) is essential for assessing risk prior to starting cancer treatment, and validation of these methods has been performed in patients receiving anthracyclines, human epidermal receptor 2 (HER2)-targeted therapies and breakpoint cluster region-abelson oncogene locus (BCR-ABL) inhibitors. The benefits of performing baseline CV risk assessment and stratification include early recognition of cardiotoxicities, personalisation of cancer treatment and monitoring strategies, and allocation of cardioprotection to those at the highest risk. This review summarizes the key points of risk stratification in these patients. The steps include identifying the target population, assessing nonmodifiable and modifiable CV risk factors, reviewing previous oncologic therapies and CV histories, and performing baseline investigations. In summary, this review aims to provide general physicians with a simple 7-step guide that will help steer and navigate them through cardiac risk evaluation of potentially cardiotoxic oncologic treatment strategies.

Cardiovascular health in breast cancer patients: insight on BRCA1/2 mutations impact

BACKGROUND

Breast cancer (BC) and cardiovascular disease (CVD) are prevalent comorbidities in aging populations. Advances in BC treatment have improved survival rates but increased the risk of CVD, particularly among younger patients with BRCA1/2 mutations. BRCA1/2 gene mutations, prevalent in younger BC patients, impair cardioprotective effects, elevating CVD risk alongside cancer treatments. This study examined the prevalence and incidence of CVD and cardiovascular risk factors (CVRFs) before and after BC diagnosis in BRCA1/2 mutation carriers (BRCA-BC) and those with sporadic BC (Sporadic-BC).

METHODS

This descriptive retrospective cohort study analyzed BC patients from 1995 to 2020 in Stockholm-Gotland, Sweden. Data from regional and national registries provided insights into CVRFs, pre-existing CVDs, demographics, and cancer treatments. Analyses focused on single and multiple CVD events, comparing inpatient and outpatient settings across subgroups.

RESULTS

The cohort included 438 BRCA-BC and 32,626 Sporadic-BC patients. BRCA-BC patients were younger at BC diagnosis (median: 45 years, IQR 37-53) and first CVD event (median: 62 years, IQR 53-68) compared to Sporadic-BC patients (median: 61 years, IQR 51-71; and 74 years, IQR 65-81, respectively). Before BC diagnosis, CVD prevalence was lower in BRCA-BC patients (4.2%) than in Sporadic-BC patients (11.1%). Post-diagnosis, CVD prevalence increased in both groups, reaching 19.7% in BRCA-BC and 24.6% in Sporadic-BC patients. Heart failure (HF) was the most common major adverse cardiovascular event (MACE), affecting 4.6% of BRCA-BC and 9.5% of Sporadic-BC patients. Sporadic-BC patients exhibited a higher overall cardiovascular burden, including arrhythmias, coronary artery disease, and stroke.

CONCLUSIONS

Distinct cardiovascular profiles between BRCA-BC and Sporadic-BC patients underscore the need for tailored survivorship care. Early cardiovascular screening benefits BRCA-BC patients, while Sporadic-BC patients require comprehensive management of pre-existing CVRFs. These findings align with international cardio-oncology guidelines advocating integrated cardiovascular care for BC survivors.

Serial assessment of coronary artery inflammation using cardiac CT in anthracycline chemotherapy for breast cancer

OBJECTIVES

There is limited evidence of the pericoronary fat attenuation index (FAI) as an imaging marker to assess cancer therapy-related cardiovascular toxicity. We aimed to measure FAI in four consecutive coronary CT angiography (CTA) scans before and 3, 6, and 12 months after anthracycline treatment in patients with breast cancer to determine trends in dynamic changes in FAI after treatment.

METHODS

We performed a post hoc analysis of a prospective study (between August 2019 and July 2020) in which anthracycline-induced myocardial injury was evaluated using cardiac CT. FAI was quantified using coronary CTA images before and 3, 6, and 12 months after anthracycline treatment. The FAIs of the three coronary arteries were averaged to calculate the FAI (Total).

RESULTS

FAI was analyzed on 14 patients with breast cancer who had adequate CT image quality (mean age, 62 years ± 11 (SD); 14 women). During the observation period, all 14 patients treated with anthracycline developed mild asymptomatic cardiac dysfunction related to cancer treatment (CTRCD). FAI (Total) showed a gradual increase during the observation period compared to baseline (baseline: -77.3 ± 5.6 HU, 3 months: -77.1 ± 4.8 HU, 6 months: -76.5 ± 5.4 HU, 12 months: -73.8 ± 5.8 HU). FAI (Total) was significantly elevated at 12 months compared to baseline (p < 0.001).

CONCLUSION

In patients with breast cancer, FAI showed a gradual increase at 3, 6, and 12 months after treatment with anthracyclines compared to before treatment. FAI may be used as an imaging biomarker of coronary artery inflammation in the follow-up of anthracycline therapy and may contribute to the personalization of therapy through early detection of coronary toxicity.

KEY POINTS

Question Is pericoronary fat attenuation index (FAI) a potential imaging biomarker for assessing changes in pericoronary adipose tissue related to cancer therapy-related cardiovascular toxicity? Findings In 14 patients with breast cancer, FAI showed a gradual increase at 3, 6, and 12 months after treatment with anthracyclines compared to before treatment. Clinical relevance FAI may be an imaging biomarker for the detection and treatment of cancer therapy-related cardiovascular toxicity.

Recovery of Left Ventricular Ejection Fraction in Patients With Anthracycline-Induced Cardiomyopathy: A Contemporary Cohort Study

BACKGROUND

Data on left ventricular ejection fraction (LVEF) recovery in patients with anthracycline-induced cardiomyopathy (AIC) are limited.

OBJECTIVES

To evaluate LVEF recovery rate, its predictors and its association with cardiovascular outcomes in a contemporary and diverse cohort with AIC.

METHODS

This retrospective study analyzed patients diagnosed with AIC from 2010-2023 at 2 U.S. university hospitals and an affiliated cancer center. LVEF recovery, defined as ≥ 10% improvement in LVEF to a value ≥ 50% within 3 years of AIC detection, was assessed by using Cox proportional-hazards accounting for competing risks. The association between LVEF recovery and the composite of heart failure (HF) hospitalizations, mechanical circulatory support, heart transplantation, or cardiovascular death was assessed by using Cox regression analysis with LVEF recovery as a time-dependent factor.

RESULTS

Among 167 patients with anthracycline-induced cardiomyopathy (AIC) (median age 67 [Q1, Q3: 53, 74] years, 53% female), the majority had lymphoma (55%) or breast cancer (23%). The median time from first anthracycline exposure to AIC detection was 631 (219, 3569) days, and the median LVEF was 38% (29%, 45%). At the detection of AIC, 69% had symptomatic HF. LVEF recovered in 38% (n = 63) at a median of 349 (137, 691) days from AIC detection. Age ≥ 60 years at anthracycline exposure, non-white race, diabetes mellitus, longer interval between anthracycline exposure and AIC detection, and LV dilation were associated with a lower likelihood of recovery, while statin use and AIC detection after 2022 were associated with a higher likelihood of recovery. LVEF recovery was not associated with cardiovascular outcomes.

CONCLUSION

In this contemporary and diverse AIC cohort, 38% achieved LVEF recovery. Routine screening for AIC and statin therapy may improve recovery rates.

Vericiguat improves cardiac remodelling and function in rats with doxorubicin-induced cardiomyopathy

PURPOSE

Vericiguat, a soluble guanylate cyclase (sGC) stimulator, has been demonstrated effective in improving prognosis of patients with heart failure with reduced ejection fraction. However, there are limited data concerning the effect of vericiguat in patients with doxorubicin (DOX)-induced cardiomyopathy (DIC). In this study, we investigated the effects of vericiguat on cardiac structure and function in rats with DIC as well as their potential mechanisms of action.

METHODS

DIC rats were established by intraperitoneal injection of DOX (1 mg/kg) twice a week for 6 weeks, followed by intragastric administration of vericiguat 1 mg/kg/day or an equal volume of normal saline for 8 weeks. Cardiac histology and function, circulating levels of amino-terminal pro-B-type natriuretic peptide (NT-proBNP), nitric oxide (NO), and oxidative indices, as well as myocardial cyclic guanosine monophosphate (cGMP)-protein kinase G (PKG) signalling, oxidative and apoptosis-associated protein were measured.

RESULTS

Compared with the control group, rats treated with DOX exhibited significantly increased heart size, reduced systolic function and elevated plasma levels of NT-proBNP. Histological findings revealed myocardial cell atrophy, fibrosis and apoptosis. Vericiguat treatment effectively reversed DOX-induced cardiac remodelling and improved systolic function. Mechanistically, Vericiguat attenuated the inhibitory effects of DOX on the myocardial cGMP-PKG axis and nuclear factor erythroid 2-related factor 2 (Nrf2) protein, thereby alleviating oxidative stress and apoptosis.

CONCLUSIONS

Vericiguat improved cardiac remodelling and contractile function in rats with DIC through upregulation of cGMP-PKG signalling and inhibition of oxidative stress and myocardial apoptosis.