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)

Anthracycline-induced cardiovascular toxicity: validation of the Heart Failure Association and International Cardio-Oncology Society risk score

BACKGROUND AND AIMS

Baseline cardiovascular toxicity risk stratification is critical in cardio-oncology. The Heart Failure Association (HFA) and International Cardio-Oncology Society (ICOS) score aims to assess this risk but lacks real-life validation. This study validates the HFA-ICOS score for anthracycline-induced cardiovascular toxicity.

METHODS

Anthracycline-treated patients in the CARDIOTOX registry (NCT02039622) were stratified by the HFA-ICOS score. The primary endpoint was symptomatic or moderate to severe asymptomatic cancer therapy-related cardiac dysfunction (CTRCD), with all-cause mortality and cardiovascular mortality as secondary endpoints.

RESULTS

The analysis included 1066 patients (mean age 54 ± 14 years; 81.9% women; 24.5% ≥65 years). According to the HFA-ICOS criteria, 571 patients (53.6%) were classified as low risk, 333 (31.2%) as moderate risk, 152 (14.3%) as high risk, and 10 (0.9%) as very high risk. Median follow-up was 54.8 months (interquartile range 24.6-81.8). A total of 197 patients (18.4%) died, and 718 (67.3%) developed CTRCD (symptomatic: n = 45; moderate to severe asymptomatic: n = 24; and mild asymptomatic: n = 649). Incidence rates of symptomatic or moderate to severe symptomatic CTRCD and all-cause mortality significantly increased with HFA-ICOS score [hazard ratio 28.74, 95% confidence interval (CI) 9.33-88.5; P < .001, and hazard ratio 7.43, 95% CI 3.21-17.2; P < .001) for very high-risk patients. The predictive model demonstrated good calibration (Brier score 0.04, 95% CI 0.03-0.05) and discrimination (area under the curve 0.78, 95% CI 0.70-0.82; Uno's C-statistic 0.78, 95% CI 0.71-0.84) for predicting symptomatic or severe/moderate asymptomatic CTRCD at 12 months.

CONCLUSIONS

The HFA-ICOS score effectively categorizes patients by cardiovascular toxicity risk and demonstrates strong predictive ability for high-risk anthracycline-related cardiovascular toxicity and all-cause mortality.

Early detection of anthracycline-induced cardiotoxicity

Although anthracyclines are important anticancer agents, their use is limited due to various adverse effects, particularly cardiac toxicity. Mechanisms underlying anthracycline-induced cardiotoxicity (AIC) are complex. Given the irreplaceable role of anthracyclines in treatment of malignancies and other serious diseases, early monitoring of AIC is paramount. In recent years, multiple studies have investigated various biomarkers for early detection of AIC. Currently, the two most common are cardiac troponin and B-type natriuretic peptide. In addition, a range of other molecules, including RNAs, myeloperoxidase (MPO), C-reactive protein (CRP), various genes, and others, also play roles in AIC prediction. Unfortunately, current research indicates a need to validate their sensitivity and specificity of these biomarkers especially in large study populations. In this review, we summarize the mechanisms and potential biomarkers of AIC, although some remain preliminary.

Software Discrepancies in Radionuclide-Derived Left Ventricular Ejection Fraction

Gated equilibrium radionuclide angiography (ERNA), or multigated acquisition scanning, is a well-established technique to monitor left ventricular ejection fraction (LVEF) in patients treated with potentially cardiotoxic chemotherapy. To determine the results of a true change in LVEF, low inter- and intrareader variability is important. The aim of this study was to investigate inter- and intrareader variability in LVEF measurements using 2 different commercially available software packages with cardiac MR (CMR) as a reference standard. Methods: In 46 ERNA scans, LVEF was measured by 2 experienced nuclear medicine technologists, using the 2 software packages Xeleris and Corridor4DM. All patients had CMR performed within 1.5 h from ERNA. CMR-derived LVEF was measured by a cardiologist using cvi42 software. Eight patients were reanalyzed to investigate intrareader variability. Bland-Altman analysis was used to assess agreement between readers and software. Repeated-measures ANOVA was used to assess interactions between readers and software. Differences in mean LVEF were compared using a t test. The Lin concordance correlation coefficient (CCC) was used to test LVEF agreement between software packages and readers and the reference CMR results. Results: Corridor4DM had a significantly higher mean LVEF than did Xeleris. No significant interreader difference was observed within the same software. ANOVA found that readers did not influence LVEFs. The CCC between software packages was similar for both readers, at 0.409 for reader 1 and 0.418 for reader 2. Both software packages showed a significant LVEF bias compared with CMR (4% for Xeleris vs. 11% for Corridor4DM). For both readers, the CCC for correlation with MRI was higher for Xeleris (0.438/0.572) than for Corridor4DM (0.257/0.244). Conclusion: A high degree of variability was found between the 2 different software packages for the calculation of LVEF. No significant difference in LVEF was found between readers using the same software. Corridor4DM gave higher LVEF estimates than did Xeleris. Our findings suggest that different software programs for assessing LVEF in ERNA examinations are not interchangeable. The utmost caution is recommended if switching between different types of software.

Anticancer-Drug-Related Cardiotoxicity from Adjuvant Goserelin and Tamoxifen Therapy

Background: Breast cancer is a prevalent malignancy with rising incidence globally. Advances in endocrine therapy have improved outcomes for premenopausal women with hormone receptor-positive breast cancer. However, these treatments may induce menopause-like states, potentially elevating cardiovascular risks, including left ventricular (LV) dysfunction. This study aims to evaluate the impact of one year of adjuvant endocrine therapy with goserelin and tamoxifen on LV function in premenopausal breast cancer patients. Methods: The ISACS cardiovascular toxicity (NCT01218776) is a pilot multicenter registry of breast cancer patients referred to hospitals for routine surveillance, suspected, or confirmed anticancer-drug-related cardiotoxicity (ADRC). Patients may be enrolled retrospectively (1 year) and prospectively. The pilot phase focused on the available data on combined goserelin and tamoxifen therapy for breast cancer and its impact on LV disfunction at 1-year follow-up. Inverse probability of treatment weighting (IPTW) analysis of the ISACS registry was performed assigning 70 patients to combined endocrine therapy (goserelin and tamoxifen). Controls consisted of 120 patients with no adjuvant combined goserelin and tamoxifen therapy. None of the patients developed distant metastasis. Primary outcome measures were as follows: low LV function in women as defined by a left ventricular ejection fraction (LVEF) < 65% and subclinical LV dysfunction as defined by a 10-percentage point decrease in LVEF. Results: In the overall population, combined goserelin and tamoxifen therapy did not affect the mean LV function compared with controls at 3-, 6-, and 12-month follow-up (65.7 ± 2.7% versus 65.3 ± 2.1%, p value = 0.27; 65.5 ± 2.9% versus 65.1 ± 2.5%, p value = 0.34; 65.0 ± 3.2% versus 64.6 ± 3.1%, p value = 0.29, respectively). The mean LVEF reduction in patients who did or did not receive combination therapy for 12 months was small and approximately similar (1.03 ± 2.5% versus 1.16 ± 2.9%, p value = 0.73). Using IPTW analyses, there were no significant associations between combined therapy and low LV function (risk ratio [RR]: 1.75; 95% CI: 0.71-4.31) or subclinical LV dysfunction (RR: 1.50; 95% CI: 0.35-6.53) compared with controls. Conclusions: One year of endocrine therapy with goserelin and tamoxifen does not cause ADRC in patients with invasive breast cancer. Findings are independent of the severity of the disease. Results may not be definitive without replication in studies with larger sample size.

Anticoagulation for the prevention of arterial thromboembolism in cancer patients by primary tumour site: a systematic review and meta-analysis of randomized trials

AIMS

The incidence of arterial thromboembolism (ATE) among ambulatory cancer patients varies by primary tumour site. However, it is unclear whether this alters the benefit-to-harm profile of prophylactic anticoagulation for ATE prevention. Therefore, we systematically evaluated the efficacy and safety of anticoagulants for ATE prevention among ambulatory cancer patients according to the primary tumour site.

METHODS AND RESULTS

We conducted a systematic review using Medline, Embase, SCOPUS, and CENTRAL, and included randomized trials comparing prophylactic anticoagulation to no anticoagulation among ambulatory cancer patients who initiated tumour-directed systemic therapy. The incidence of symptomatic ATE (acute ischaemic stroke, acute myocardial infarction, or peripheral artery occlusion) and major bleeding, as well as risk differences (RDs) attributable to anticoagulation, were meta-analysed by primary tumour site using random-effects modelling. We included 10 randomized controlled trials with 9875 patients with follow-up ranging from 3.3 to 68 (median 6.6) months. While prophylactic anticoagulation did not reduce ATE risks overall (RD -0.49%; 95% CI -0.49% to 0.01%; I2 = 0%), it conferred a protective effect among pancreatic cancer patients (RD -3.2%; 95%CI -5.7% to -0.8%; I2 = 0%) without a detectable increase in major bleeding (RD -1.4%; 95% CI -4.6% to 1.8%; I2 = 0%). Prophylactic anticoagulation was not associated with ATE risk reduction in other tumour sites.

CONCLUSION

Based on available evidence, prophylactic anticoagulation did not reduce ATE risk among ambulatory cancer patients overall. However, we observed a lower incidence of ATE among pancreatic cancer patients randomized to receive anticoagulation. Prophylactic anticoagulant use to reduce ATEs in pancreatic cancer should be evaluated in future research.

Matters of the Heart: Cardiotoxicity Related to Target Therapy in Oncogene-Addicted Non-Small Cell Lung Cancer

The treatment of Non Small Cell Lung Cancer (NSCLC) has been revolutionised by the introduction of targeted therapies. With the improvement of response and frequently of overall survival, however, a whole new set of adverse events emerged. In fact, due to the peculiar mechanism of action of each one of the tyrosine kinase inhibitors and other targeted therapies, every drug has its own specific safety profile. In addition, this safety profile could not fully emerge from clinical trials data, as patients in clinical practice usually have more comorbidities and frailties. Cardiotoxicity is a well-known and established adverse event of anti-cancer therapies. However, only recently it has become a central topic for targeted therapies in NSCLC, due to the unknown real range and frequency. Management of this toxicity begins with prevention, and must balance the need of continuing an effective anticancer treatment versus low risk of even fatal events and the preservation of long-term quality of life. The aim of this review is to summarise the current knowledge focusing on currently used targeted therapies in NSCLC.

Strategies to enhance management of HER2-positive breast cancer in the elderly: an expert consensus perspective

Therapeutic decision-making for older patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer highlights the importance of a comprehensive geriatric assessment (CGA). This assessment considers the functional status, comorbidities, and relevant conditions of the patient, and allows for an estimation of life expectancy, but it does not facilitate individualized treatment plans. There are also other challenges to consider related to the cardiac toxicity of the treatments and the under-representation of older patients in clinical trials. The Oncogeriatrics Section of the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica, SEOM), the Spanish Group for Breast Cancer Research (Grupo Español de Investigación en Cáncer de Mama, GEICAM) and the Spanish Group of Study, Treatment and other Experimental Strategies in Solid Tumours (Grupo Español de Estudio, Tratamiento y otras Estrategias Experimentales en Tumores Sólidos, SOLTI) have gathered an expert committee to evaluate the scientific evidence on the management of older patients with HER2-positive breast cancer and to establish recommendations based on a comprehensive review of the existing literature. These recommendations underscore the importance of individualizing treatment plans based on the patient's physical status and tolerability to maximize efficacy while minimizing toxicity. Emphasis is placed on adapting neoadjuvant and adjuvant therapies according to geriatric assessment and specific patient needs. A careful selection of treatment schedules for advanced stages is needed to improve survival and quality of life, assuming that scientific evidence in this age group is limited.

Global longitudinal strain as an early marker of cardiac damage after cardiotoxic medications, a state of the art review

Ejection fraction (EF) is the principal parameter used clinically to assess cardiac function and provides prognostic information. However, significant myocardial damage can be present despite preserved EF. Recently, the measurement of left ventricle (LV) deformation by global longitudinal strain (GLS) has been introduced as a novel early marker of cardiac dysfunction. Cardiotoxicity is a frequent side effect of several drugs most notably those used in the treatment of cancer. Although oncology drugs remain the best known cardiotoxic medications, many other drugs can potentially affect LV function. The early recognition of LV dysfunction due to cardiotoxicity is important and of increasing clinical relevance particularly with the rapid pace of development of new drugs. The aim of our review is to provide an overview of the current literature regarding utility of GLS to assess drug-induced myocardial damage. We propose that GLS is a sensitive early marker of myocardial dysfunction associated with the use of certain medications with high risk of cardiotoxicity. Thus, the use of this technique can potentially alert the clinician to myocardial toxicity before reductions in EF are seen.

Safety and efficacy of immune checkpoint inhibitors in patients with pre-treatment reduced left ventricular function

AIMS

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment outcomes. However, the response varies across different populations, and their use may lead to life-threatening cardiovascular (CV) events. While pre-treatment reduced left ventricular ejection fraction (LVEF) is considered a marker for high-risk cardiotoxicity and a contraindication for anthracycline and HER2-targeted therapies, there is limited evidence on the safety and efficacy of ICIs therapy in patients presenting with pre-treatment reduced LVEF. The study aims to evaluate the safety and efficacy of ICIs therapy in patients with pre-treatment reduced LVEF.

METHODS

Retrospective single center cohort of patients treated with ICIs therapy, who performed pre-treatment LVEF assessment. The primary endpoint was to evaluate the safety of ICIs among this population, assessed by CV events (composite of myocarditis, acute coronary syndrome, heart failure, and arrhythmias). The secondary endpoint was to evaluate the efficacy of ICIs, assessed by all-cause mortality and progression-free survival (PFS).

RESULTS

The cohort included 307 patients, with 30 (10%) presenting with pre-treatment reduced LVEF, with a mean LVEF of 39 ± 7%. While a significantly higher incidence of CV events was observed in the reduced LVEF group (37% vs. 14%, p = 0.004), following a multivariate Cox regression analysis including baseline CV diseases and risk factors, pre-treatment reduced LVEF did not remain a significant independent predictor (p = 0.358). No significant differences were observed between the groups regarding all-cause mortality and PFS.

CONCLUSIONS

Pre-treatment reduced LVEF was not identified as an independent marker for clinical outcomes in patients treated with ICIs therapy.

Variance in development of early and late cardiotoxicities in patients with lymphoma and myeloma receiving CAR T-cell therapies

Cardiovascular adverse events (CVAEs) are recognized complications of chimeric antigen receptor (CAR) T-cell therapies. However, data are lacking regarding subtypes of adverse events that develop in patients with different malignancies, and little is known about the timeframe in which different cardiotoxicities are most likely to occur post-CAR T-cell therapies. In this study, 211 patients, including 138 lymphoma patients and 66 myeloma patients who received CAR T-cell therapies were retrospectively identified. Of these, 42 patients (19.9%) developed CVAEs post-treatment. Myeloma patients predominantly experienced heart failure while lymphoma patients predominantly experienced arrhythmia. Severe CVAEs were observed even at >12 months post-treatment. Lower baseline global longitudinal strain was significantly associated with development of post-CAR T-cell therapy CVAEs in both lymphoma and myeloma patients. These findings highlight the spectra of post-CAR T-cell cardiotoxicities in lymphoma and myeloma patients and the importance of echocardiography for pretreatment risk stratification and long-term surveillance.

Myocarditis in Patients Starting Combination Checkpoint Inhibitor Therapy: Analysis of a Commercial Claims Database

BACKGROUND

Immune checkpoint inhibitors have improved the clinical outcomes of several cancers but have also been associated with a greater risk of immune-related adverse effects, especially when combined. The objective of this study was to investigate the incidence of myocarditis in relation to the use of dual concurrent versus single immune checkpoint inhibitors therapies.

METHODS AND RESULTS

A cohort study was conducted using medical and pharmacy claims data (2011-2022) from a large US commercial insurer. Cox regression quantified the comparative risks of myocarditis or heart failure in patients with cancer receiving treatment with combination therapy (nivolumab and ipilimumab) in comparison to taking a single immune checkpoint inhibitor only. Mean follow-up time in 53 018 patients was 226 days (interquartile range, 93-495 days). There were 148 cases of myocarditis (0.3%), 33 (0.7%) in patients on combination therapy, and 115 (0.2%) in patients on monotherapy. The risk of myocarditis per 1000 patients was 7.40 in the combination therapy group and 2.37 in the monotherapy group (risk ratio, 3.12 [95% CI, 2.12-4.60]). Using multivariable regression analysis, the hazard ratio for myocarditis in the combination therapy group was 2.38 (1.57-3.63). No difference in the risk of heart failure was found between combination and single therapy.

CONCLUSIONS

Therapy with 2 immune checkpoint inhibitors was associated with an increased risk of myocarditis compared with monotherapy, with most cases occurring in the first 6 months of therapy.

Association of genetically proxied cancer-targeted drugs with cardiovascular diseases through Mendelian randomization analysis

BACKGROUND

Cancer-targeted therapies are progressively pivotal in oncological care. Observational studies underscore the emergence of cancer therapy-related cardiovascular toxicity (CTR-CVT), impacting patient outcomes. We aimed to investigate the causal relationship between different types of cancer-targeted therapies and cardiovascular disease (CVD) outcomes through a two-sample Mendelian randomization (MR) study.

METHODS

This genome-wide association study was conducted using a two-sample Mendelian randomization framework. Genetic instruments for drug target gene expression were extracted from the eQTLGen consortium (31684 individuals, 37 cohorts). Genome-wide association study (GWAS) summary statistics for 19 cardiovascular diseases were derived from the FinnGen database. Primary analysis was carried out using the summary-data-based MR (SMR) method, with sensitivity analysis for validation. Colocalization analysis identifies shared causal variants between exposure eQTLs and CVD-associated single-nucleotide polymorphisms (SNPs).

RESULTS

Among the 39 drug target genes, 8 were identified with detectable cis-eQTLs and were subsequently validated through positive control analysis for further investigation. In the SMR and sensitivity analyses, genetically proxied VEGFA inhibition showed significantly strong association with stroke (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.09-1.26, p = 1.33 × 10- 5). Additionally, the inhibition of FGFR1, FLT1, and MAP2K2 exhibited suggestive association with corresponding cardiovascular disease outcomes. Nevertheless, only VEGFA expression and stroke shared a causal variant (93.6%), whereas FGFR1, MAP2K2, and FLT1 did not share causal variants with corresponding cardiovascular diseases in the colocalization analysis.

CONCLUSIONS

This genetic association study revealed evidence supporting the genetic association between the use of VEGFA inhibitors and increased stroke risk, highlighting the need for enhanced pharmacovigilance. These findings underscore the delicate balance between cardiovascular toxicity risk and the benefits of cancer-targeted therapy.

Cardiorespiratory fitness, cardiac morphology and function, and cardiovascular risk factors in long-term breast cancer survivors compared with non-cancer controls

BACKGROUND

Although anthracycline-related cardiotoxicity is widely studied, only a limited number of echocardiographic studies have assessed cardiac function in breast cancer survivors (BCSs) beyond ten years from anthracycline treatment, and the knowledge of long-term cardiorespiratory fitness (CRF) in this population is scarce. This study aimed to compare CRF assessed as peak oxygen uptake (V̇O2), cardiac morphology and function, and cardiovascular (CV) risk factors between long-term BCSs treated with anthracyclines and controls with no history of cancer.

METHODS

The CAUSE (Cardiovascular Survivors Exercise) trial included 140 BCSs recruited through the Cancer Registry of Norway, who were diagnosed with breast cancer stage II to III between 2008 and 2012 and had received treatment with epirubicin, and 69 similarly aged activity level-matched controls. All the participants underwent blood sampling, blood pressure measurements, echocardiography and cardiopulmonary exercise testing from October 2020 to August 2022.

RESULTS

BCSs were aged 59 ± 6 years and had received a cumulative dose of 357 (243 to 366) mg/m2 of epirubicin on average 11 ± 1 years before inclusion. There was no difference between BCSs and controls with respect to peak V̇O2 (27.6 ± 5.4 mL/kg/min vs. 27.1 ± 5.4 mL/kg/min, P = 0.25), 2D left ventricular ejection fraction (57 ± 3% vs. 57 ± 3%, P = 0.43), left ventricular global longitudinal strain (-20.5 ± 1.0% vs. -20.6 ± 1.0%, P = 0.46) or the proportion with N-terminal pro-brain natriuretic peptide ≥ 125 (22% vs. 20%, P = 0.93). The proportions with hypertension, dyslipidemia or diabetes did not differ between the groups.

CONCLUSION

We found that CRF, cardiac function, and CV risk profile in BCSs examined a decade after treatment with anthracyclines were similar to that in women with no history of cancer.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04307407) https://clinicaltrials.gov/ct2/show/NCT04307407 .

Apelinergic System Affects Electrocardiographic Abnormalities Induced by Doxorubicin

Background/Objectives: Anthracyclines remain a pivotal element of numerous tumor management regimens; however, their utilization is associated with a range of adverse effects, the most significant of which is cardiotoxicity. Research is constantly being conducted to identify substances that could be incorporated into ongoing cancer chemotherapy to mitigate anthracycline-induced cardiotoxicity. Recently, the apelinergic system has received a lot of attention in this field due to its involvement in cardiovascular regulation. Therefore, the aim of our study was to investigate the ability of the apelinergic system to inhibit the cardiotoxic effects of anthracycline-doxorubicin (DOX). Methods: In this study, 54 Sprague-Dawley rats were divided into seven groups and received intraperitoneal injections with DOX once a week for 4 consecutive weeks. The osmotic pumps provided a continuous release of NaCl (control groups), apelin-13 and elabela at two different doses, and the apelin receptor (APJ) antagonist ML221. Electrocardiography (ECG) and transthoracic echocardiography (TTE) with assessment of left ventricular (LV) systolic parameters were conducted on the first and last days of the experiment. Results: Lower doses of APJ agonists prevented the prolongation of QT and QTc intervals induced by DOX, while higher doses of these drugs exerted no such effect. The TTE examination confirmed DOX-induced LV systolic dysfunction. Moreover, the TTE examination revealed an improvement in the LV systolic parameters in the DOX-treated groups that were simultaneously administered APJ agonists. Conclusions: Our findings support the use of apelin and elabela as potential cardioprotective agents against anthracycline-induced cardiotoxicity.

Chronic Lymphocytic Leukemia Care and Beyond: Navigating the Needs of Long-Term Survivors

Chronic lymphocytic leukemia (CLL) treatment has undergone a significant evolution with a shift from historical chemotherapeutic regimens to targeted therapies such as Bruton tyrosine kinase (BTK) and BCL-2 inhibitors. These advancements have been associated with a notable improvement in survival rates with a transformation of CLL into a chronic and manageable condition for most persons with this disease. However, as a consequence of improved outcomes, long-term CLL survivors now face emergent challenges which include a risk of infections, cardiovascular complications, and secondary malignancies. In this changed scenario, holistic models of care are essential to address emergent health risks. Such models of care for CLL patients require a multidisciplinary approach that integrates CLL treatment with the proactive management of frailty, comorbidities, and psychosocial well-being to enhance both survival and quality of life (QoL). CLL predominantly affects older persons, many of whom present with concurrent frailty and comorbidities that may complicate CLL treatment and impact QoL. Comprehensive geriatric assessments (GA) may play a critical role in the identification of persons at a heightened risk of treatment-related toxicity and may help guide rational therapy selection, particularly in very frail persons. In addition to the assessment of hematological responses, the prospective assessment of patient-reported outcomes (PROs) and frailty metrics may offer a more nuanced understanding of the global treatment benefits. A survivorship-focused care model is crucial to address the multifaceted needs of CLL patients with the extension of patient care into the broader domain of long-term health maintenance with associated improvements in QoL.

Atherosclerosis and the Bidirectional Relationship Between Cancer and Cardiovascular Disease: From Bench to Bedside, Part 2 Management

The first part of this review highlighted the evolving landscape of atherosclerosis, noting emerging cardiometabolic risk factors, the growing impact of exposomes, and social determinants of health. The prominent role of atherosclerosis in the bidirectional relationship between cardiovascular disease and cancer was also discussed. In this second part, we examine the complex interplay between multimorbid cardio-oncologic patients, cardiometabolic risk factors, and the harmful environments that lend a "syndemic" nature to these chronic diseases. We summarize management strategies targeting disordered cardiometabolic factors to mitigate cardiovascular disease and explore molecular mechanisms enabling more tailored therapies. Importantly, we emphasize the early interception of atherosclerosis through multifactorial interventions that detect subclinical signs (via biomarkers and imaging) to treat modifiable risk factors and prevent clinical events. A concerted preventive effort-referred to by some as a "preventome"-is essential to reduce the burden of atherosclerosis-driven chronic diseases, shifting from mere chronic disease management to the proactive promotion of "chronic health".

Considerations in screening for asymptomatic carotid artery stenosis in irradiated head and neck cancer survivors

Carpenter et al. add to the body of evidence demonstrating that irradiated head and neck cancer survivors are at high risk for carotid artery stenosis. In this editorial, the concept of screening for asymptomatic carotid artery stenosis in this subpopulation is explored.

A rare cardiac presentation of a lymphoma: case report

Background

Cardiac lymphoma is a rare disease that can present in various ways. Additionally, atypical clinical presentation makes the diagnosis even more challenging. The most common type of cardiac lymphoma is diffuse large B-cell lymphoma. With chemotherapy, the median survival rate can be up to 2 years. In this report, we focus on the diagnostic approach and differential diagnosis.

Case summary

A 56-year-old patient presented with complete heart block and B-symptoms. Implantation of a pacemaker (PM) was initially deferred due to a junctional rhythm (50 b.p.m.). Echocardiography showed thickening of the left heart with small pericardial effusion. For better visualization of the extent and infiltration cardiac magnetic resonance imaging and computer tomography (CT) were performed. In addition to the cardiac mass, enlarged mediastinal lymph nodes were found on staging CT scan, prompting a transbronchial biopsy. Histology revealed diffuse large B-cell non-Hodgkin lymphoma. The patient was referred to a hospital with a Hemato-oncology Department for initiation of chemotherapy.

Discussion

Cardiac lymphoma can be a rare cause of complete heart block. Prior to PM implantation, basic echocardiography is important. In rare conditions like cardiac lymphoma, multimodal imaging, and interdisciplinary decision-making are crucial for management. In the future, lead-less pacemakers could be a safe and effective option for oncology patients.

Cardiovascular Disease and Other Competing Causes of Death in Older Kidney Cancer Patients

Background

To study the risk of cardiovascular disease (CVD) and other competing causes of death in older kidney cancer patients.

Methods

Data on older patients (aged 65 and above) diagnosed with kidney cancer between 1975 and 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. We delved into the distribution of CVD and other competing causes of death across the entire cohort and in various patient subgroups. The competing risk analysis was used to produce cumulative mortality curves based on cumulative mortality for the primary outcomes by follow-up period. Utilizing the standardized mortality ratios (SMRs) and absolute excess risks (AERs), we contrasted the risk of CVD and other competing causes of death in older kidney cancer patients to that observed in the general population.

Results

The analysis included 29,349 older kidney cancer patients, of which included 4563 CVD deaths. As survival time extended, the proportion of non-cancer deaths increased in older kidney cancer patients, with CVD accounting for the largest share of non-cancer deaths. At 10-15 years after diagnosis, cumulative non-cancer mortality exceeded primary kidney cancer as the predominant cause of death, and cumulative CVD mortality is higher among all non-cancer causes. Older kidney cancer patients exhibited a greater risk of CVD and other non-cancer deaths than their counterparts in the general older population did (SMR: 1.38-2.81; AER: 1.1-143.69).

Conclusions

As survival time increases, the risk of non-cancer death in older kidney cancer patients gradually surpassed that of primary cancer, and CVD death accounted for the majority of non-cancer deaths. Among older kidney cancer patients, the risk of CVD mortality was higher than in the general population. Managing non-cancer deaths, especially CVD deaths, should be a focus in the care of older kidney cancer patients.

Left ventricular trabecular complexity for risk stratification of cancer therapy-related cardiac dysfunction in breast cancer

The left ventricular trabecular fractal dimension (LVTFD) derived from cardiac magnetic resonance reflects myocardial trabecular complexity, which is associated with cardiovascular disease risk. Baseline risk stratification of cancer therapy-related cardiac dysfunction (CTRCD) in patients with breast cancer who received anthracycline is a very important clinical issue. In this study, we used the Cox model to derive and validate a new score system based on LVTFD for baseline risk stratification of CTRCD in breast cancer patients receiving anthracycline. We also compare the performance of LVTFD-based score with the Heart Failure Association-International Cardio-Oncology Society (HFA-ICOS) score using C-index. This study enrolled 370 participants, of whom 73 participants developed CTRCD. The C-indices of LVTFD-based score integrating age, hypertension, previous cardiovascular disease, and maximal apical fractal dimension were higher than those of HFA-ICOS score for stratifying CTRCD (0.834 vs. 0.642 and 0.834 vs. 0.633, respectively, in derivation and validation cohort). LVTFD-based score can stratify the CTRCD risk, but HFA-ICOS score cannot. The above results reveal that the LVTFD-based score is an alternative method for baseline risk stratification of CTRCD in breast cancer who received anthracycline.

Cardiovascular Health Considerations for Primary Care Physicians Treating Breast Cancer Survivors

Breast cancer (BC) survivors are at increased risk for cardiovascular disease (CVD) and require their primary care physicians to manage their long-term general medical care, including cardiovascular (CV) health. Yet, evidence exists that some primary care physicians possess insufficient knowledge about survivorship care. With the goal of bridging these knowledge gaps, a PubMed review was conducted from July 7, 2020, through October 2, 2020, with an updated PubMed review from January 3, 2024, through April 28, 2024, focusing on CV health considerations in the primary care of BC survivors. Search terms included variations of "breast cancer survivors" and "cardiovascular." In total, 152 publications were included. Breasts cancer survivors may have increased CVD risk because some anticancer therapies are cardiotoxic and risk factors for BC often also increase the risk for CVD. Multiple risk factors overlap for BC and CVD such as older age, Western diet, early menarche, physical inactivity, high body mass index, and smoking. In this review, results are summarized from studies that report the presence of CV risk factors and CVD in BC survivors. Also described are the CV effects of BC therapies (chemotherapy, hormonal agents, targeted therapies, and radiotherapy) and the type of CV evaluation (cardiac imaging and measurement of biomarkers) that these patients may need. Primary care physicians have an important role in managing the CV health of BC survivors from preventing, assessing, and managing CV risk factors to referring patients to appropriate specialists when needed.

How We Monitor Cardiac Health in Breast Cancer Survivors

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Accelerated Coronary Artery Disease in a Patient With Advanced Lung Cancer: Interplay of Cancer, Inflammation, and Treatment Effects

Cardiovascular disease (CVD) and lung cancer are among the most prevalent causes of death worldwide, representing substantial public health challenges. The relationship between coronary artery disease (CAD) and lung cancer is potentially multifaceted, influenced by common risk factors and the adverse cardiac effects of cancer treatments. However, cases of accelerated CAD occurring within a year of cancer treatment initiation are rarely reported. We present a case of a Black American male undergoing combination therapy (chemotherapy/radiotherapy/immunotherapy) for small-cell lung cancer, who developed ST-elevation myocardial infarction (STEMI) seven months after beginning treatment. Although we do not have the official records, the patient reported that he had previously undergone a cardiac workup (including an echo/stress test) at an outside facility a year prior, due to persistent dyspnea, which was unremarkable. The patient underwent successful percutaneous coronary intervention and was discharged on apixaban and prasugrel. This study underscores the importance of maintaining a high index of suspicion for acute coronary syndromes (ACS) in patients receiving lung cancer treatments, emphasizes the need for early recognition of warning signs, and highlights the critical role of risk factor management and enhanced surveillance in this vulnerable population.

Multimodal Fusion Artificial Intelligence Model to Predict Risk for MACE and Myocarditis in Cancer Patients Receiving Immune Checkpoint Inhibitor Therapy

Background

Immune checkpoint inhibitor (ICI) therapy has dramatically improved the prognosis for some cancers but can be associated with myocarditis, adverse cardiovascular events, and mortality.

Objectives

The aim of this study was to develop an artificial intelligence (AI) model to predict the increased likelihood for the development of ICI-related myocarditis and adverse cardiovascular events.

Methods

Cancer patients treated with ICI at a tertiary institution from 2011 to 2022 were reviewed. Baseline characteristics, laboratory values, electrocardiograms, and cardiovascular clinical outcomes were extracted. A composite outcome of ICI-related myocarditis and major adverse cardiovascular events (transient ischemic attack/stroke, new diagnosis of heart failure, myocardial infarction, and cardiac death) was used to develop a multimodal joint fusion AI model by combining baseline tabular data with electrocardiogram (ECG) in a single end-to-end model. ECG data were parsed using 1-D convolution and tubular data using multilayer perceptron.

Results

Of 2,258 cancer patients who had ICI therapy and troponin measurement (mean age 68.5 ± 11.5 years, 59.7% male), the composite of cardiovascular clinical adverse events, including ICI-related myocarditis and major adverse cardiovascular events, occurred in 264 (11.7%) unique patients, with 428 events overall (including 59 [3%] ICI-related myocarditis events and 59 [3%] cardiac deaths). The proposed joint fusion model outperformed individual ECG and baseline electronic medical record data and laboratory value models with an area under the operating characteristics curve of 0.72 (0.64 true positive rate and 0.98 negative predictive value).

Conclusion

A multimodal fusion AI model to predict myocarditis and adverse cardiovascular events in cancer patients starting ICI therapy had good prognostic performance. It may have clinical utility in identifying at-risk patients who may benefit from closer surveillance.

Clinical, Analytical, and Echocardiographic Associations of Impaired Cardiorespiratory Fitness After Anthracycline Chemotherapy in Breast Cancer: EPIC Fitness Study

PURPOSE

This study explores the effects of anthracycline chemotherapy (AC) on breast cancer patients, focusing on changes in body composition, advanced echocardiographic parameters at rest and during exercise, and biomarkers; and subsequently assesses whether these parameters are associated with impaired cardiorespiratory fitness (CRF).

METHODS

In this prospective study, we evaluated women with early-stage breast cancer undergoing AC at three visits: before AC, 1 month after, and 6 months post-AC.

RESULTS

The study included 32 women with breast cancer, with functional disability increasing from 9.0% pre-AC to 43.8% at 1 month and 53.1% at 6 months post-AC. At 1 month, patients with functional disability exhibited higher rates of cancer therapy-related cardiac dysfunction (CTRCD) (85.7% vs. 55.5%) and, during exercise, showed lower left ventricular ejection fraction (LVEF), reduced contractile reserve and stroke volume (SV); along with elevated IL-6, PlGF, and MPO levels. By 6 months, these patients maintained higher CTRCD rates (35.3% vs. 0%), lower SV and cardiac output (CO), reduced global longitudinal strain (GLS), and decreased global work index (GWI). During exercise, they had lower SV; additionally, they exhibited higher MPO levels and increased body and visceral fat. In our multivariable model: age, body fat, resting GWI, exercise LVEF, and CO were independently associated with VO2peak.

CONCLUSION

Significant and persistent CRF reductions are common in breast cancer patients post-AC. While resting LVEF and GLS were not linked to VO2peak, resting MWI and exercise LVEF and CO were, potentially identifying patients at increased long-term heart failure risk who would benefit from cardioprotective strategies like cardio-oncology rehabilitation. It is important to recognize that impaired CRF is multifactorial, as demonstrated by age and body fat being independently associated with VO2peak, and the impact of non-cardiac factors should be better studied. Our findings highlight the need for further research on CTRCD definition, suggesting that CPET and advanced exercise echocardiography could enhance risk stratification.

Doxorubicin and cyclophosphamide mode of chemotherapy-related cardiomyopathy: Review of preclinical model

Over the past 70 years, there has been extensive research focused on preventing chemotherapy-related cardiovascular complications. However, the current state of cardio-oncology research has raised more questions than answers. Experimental studies often present data that are difficult to compare and, at times, contradictory. One notable limitation in translating experimental findings to clinical practice is the reliance on models that administer only one chemotherapeutic drug to experimental animals, despite the common use of multidrug cancer treatments in real clinical settings. This article aims to discuss our own experience in modeling an experimental rat model of cardiomyopathy induced by the administration of two chemotherapeutic drugs, doxorubicin (adriamycin) and cyclophosphamide (AC mode of chemotherapy) - Avagimyan A., et al model, along with a subsequent review of morphological changes based on our personal archive.

Cardiovascular health of patients with cancer: Challenges abound

Patients with cancer have elevated cardiovascular risks compared to those without cancer. As cancer incidence increases and cancer-related mortality decreases, cardiovascular diseases in patients with a history of cancer will become increasingly important. This in turn is reflected by the exponentially increasing amount of cardio-oncology research in recent years. This narrative review aims to summarize the key existing literature in several main areas of cardio-oncology, including the epidemiology, natural history, prevention, management, and determinants of the cardiovascular health of patients with cancer, and identify relevant gaps in evidence for further research.

Cardiovascular disease risk in cancer survivors: a population-based cohort study from the UK Biobank, and meta-analysis of cohort studies

Introduction

In addition to the well-recognised cardiotoxicity of cancer treatment, possible aetiological links between cancer diagnosis and cardiovascular disease (CVD) have gained growing research interests. We aimed to estimate the CVD burden among cancer survivors and illustrate population-level associations between these two conditions.

Methods

We first conducted a prospective cohort study in the UK Biobank and a meta-analysis of previous population-based cohorts. HRs were estimated in the cohort study to evaluate the effect of cancer diagnosis on the subsequent risk of CVD compared with that of non-cancer individuals. We then systematically searched Pubmed, Embase and Cochrane Library to retrieve previous cohorts. Random-effect meta-analysis was performed to pool relative risk estimates. A combination of multiple statistical metrics was employed to appraise the evidence.

Results

A total of 39 755 811 participants (5 898 597 cancer survivors vs 33 857 214 cancer-free controls) were identified in our study. In the cohort study, a 51% higher hazard of CVD risk was found among cancer survivors (95% CI 1.48 to 1.55, p<0.001). The hazard decreased to 29% after adjusting competing risk. The meta-analysis identified 104 published cohorts. We found a 1.34-fold increased CVD risk among patients with cancer (95% CI 1.22 to 1.47, p<0.001). The association remains significant among multiple cancer sites and multiple CVD subtypes. This association was consistent, irrespective of chemo or radiotherapy use. Evidence appraisal identified one convincing association between hematologic/lymphatic malignancies and ischaemic heart disease, along with 29 highly suggestive associations.

Conclusions

Our study provided comprehensive estimates of CVD incidence in cancer survivors and identified a significantly elevated CVD risk among patients with cancer, regardless of chemotherapy or radiotherapy. These findings underscore the need for routine assessment of CVD risk factors at cancer diagnosis to enhance the well-being and survival of patients with cancer.PROSPERO registration numberCRD42022307056.

Non-coding RNAs and their potential exploitation in cancer therapy-related cardiotoxicity

Life expectancy in cancer patients has been extended in recent years, thanks to major breakthroughs in therapeutic developments. However, this also unmasked an increased incidence of cardiovascular diseases in cancer survivors, which is in part attributable to cancer therapy-related cardiovascular toxicity. Non-coding RNAs (ncRNAs) have received much appreciation due to their impact on gene expression. NcRNAs, which include microRNAs, long ncRNAs and circular RNAs, are non-protein-coding transcripts that are involved in the regulation of various biological processes, hence shaping cell identity and behaviour. They have also been implicated in disease development, including cardiovascular diseases, cancer and, more recently, cancer therapy-associated cardiotoxicity. This review outlines key features of cancer therapy-associated cardiotoxicity, what is known about the roles of ncRNAs in these processes and how ncRNAs could be exploited as therapeutic targets for cardioprotection. LINKED ARTICLES: This article is part of a themed issue Non-coding RNA Therapeutics. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v182.2/issuetoc.

Cancer survivors and cardiovascular diseases: from preventive strategies to treatment

During the last decades, progress in the treatment of oncological diseases has led to an increase in the survival of cancer patients: cancer survivors (CS). Thus, the incidence of CS has increased enormously, in both adult CS and childhood and adolescent CS. Unfortunately, CS treated with anthracyclines, chest radiotherapy (RT) and other potentially cardiotoxic drugs have a higher risk of cardiovascular (CV) toxicity: heart failure with reduced ejection fraction (HFrEF), valve diseases, coronary artery diseases, vascular diseases and pericardial diseases. In fact, chest irradiation can cause coronary artery diseases that can be latent until at least 10 years after exposure; also, valvular heart diseases can appear after >20 years following irradiation; heart failure may appear later, several years after anticancer drugs or RT. Therefore, it is very important to stratify the CV risk of cancer patients at the end of cardiotoxic drugs, to plan the most appropriate long-term surveillance program, in accordance with 2022 ESC Guidelines on Cardio-Oncology, to prevent late cardiovascular complications. Monitoring of cancer patients must not stop during anticancer treatment but it must continue afterwards, depending on the patient's CV risk. CV toxicity risk should be reassessed 5 years after therapy to organize long-term follow-up. Considering late cardiotoxicity in CS, our review aims to evaluate the incidence of cardiovascular diseases in CS, their mechanisms, surveillance protocols, preventive strategies, diagnosis and treatment.

Respiratory Pathology and Cardiovascular Diseases: A Scoping Review

Respiratory diseases and cardiovascular diseases (CVDs) have high prevalence and share common risk factors. In some respiratory diseases such as sleep apnoea and COPD, the evidence of their negative impact on the prognosis of CVDs seems clear. However, in other diseases it is less evident whether there is any direct relationship. With this in mind, our objective was to provide information that may be helpful to better understand the relationship between respiratory pathology and CVDs. There are different reasons for this relationship, such as shared risk factors, common pathophysiological mechanisms, side effects of treatment and the direct effect in the heart and great vessels of respiratory diseases. Indeed, aging and smoking are risk factors for CVDs and also for respiratory diseases such as obstructive sleep apnea (OSA), COPD and interstitial lung diseases (ILD). Furthermore, there are common pathophysiological mechanisms that affect both respiratory diseases and CVDs, such as accelerated atherosclerosis, microvascular dysfunction, endothelial dysfunction, inflammation, hypoxemia and oxidative stress. Besides that, it is well known that lung cancer, sarcoidosis and amyloidosis may directly affect the heart and great vessels. Finally, side effects of drugs for respiratory diseases and the discontinuation of treatments that are necessary for CVDs, such as β-blockers and aspirin, may have a deleterious impact on the cardiovascular system. In conclusion, the coexistence of respiratory diseases and CVDs is very common. It makes modifying diagnostic and therapeutic management necessary and is also a relevant prognostic factor.

From the mechanism of action to clinical management: A review of cardiovascular toxicity in adult treated with CAR-T therapy

Chimeric antigen receptor T-cell therapy represents an innovative approach to immunotherapy and currently stands out, particularly for oncohematological patients refractory to traditional treatments. Ongoing trials are further expanding its clinical use for new oncological and non-oncological indications, potentially leading to newer treatment options soon. This new approach, however, also presents challenges, including cardiovascular toxicity. Little is reported in pivotal studies, and some recent retrospective observations suggest a non-negligible incidence of side effects with presentation ranging from mild adverse cardiovascular events to fatal complications in which, in most cases, there is a direct or indirect association with cytokine release syndrome. In this literature review, the hypotheses of an important interface between cytokine release syndrome and cardiotoxicity by chimeric antigen receptor T-cell therapy will be addressed, as will current knowledge about risk factors for cardiotoxicity and recommendations for pre-therapy evaluation, post-infusion monitoring and clinical management of these complications.

Cardiovascular Considerations After Cancer Therapy: Gaps in Evidence and JACC: CardioOncology Expert Panel Recommendations

Cancer survivors, particularly those treated with anthracyclines and chest radiation, face an elevated risk of cancer therapy-related cardiovascular toxicity. These complications affect not only physical health, but also life expectancy. Risk factors for cancer therapy-related cardiovascular toxicity include age at which cancer treatment was received, the use of (potentially) cardiotoxic cancer therapies, and the presence of concomitant cardiovascular risk factors. Current guidelines provide recommendations for cardiovascular surveillance after cancer therapy, including type and frequency. All cancer survivors are advised to undergo annual clinical screenings and optimization of cardiovascular risk factors. Those at higher risk should undergo additional cardiovascular testing. This document aims to summarize the available evidence, present practical recommendations, and outline existent gaps in the current literature regarding cardiovascular care after cancer therapies.

Artificial Intelligence-Enhanced Risk Stratification of Cancer Therapeutics-Related Cardiac Dysfunction Using Electrocardiographic Images

BACKGROUND

Risk stratification strategies for cancer therapeutics-related cardiac dysfunction (CTRCD) rely on serial monitoring by specialized imaging, limiting their scalability. We aimed to examine an application of artificial intelligence (AI) to ECG images as a surrogate for imaging risk biomarkers and its association with early CTRCD.

METHODS

Across a US-based health system (2013-2023), we identified 1550 patients (aged, 60 [interquartile range, 51-69] years, 1223 [78.9%] women) without cardiomyopathy who received anthracyclines or trastuzumab for breast cancer or non-Hodgkin lymphoma and had ECG performed ≤12 months before treatment. We deployed a validated AI model of left ventricular systolic dysfunction to baseline ECG images and defined low-, intermediate-, and high-risk groups based on AI-ECG left ventricular systolic dysfunction probabilities of <0.01, 0.01 to 0.1, and ≥0.1 (positive screen), respectively. We explored the association with early CTRCD (new cardiomyopathy, heart failure, or left ventricular ejection fraction <50%), or left ventricular ejection fraction <40%, up to 12 months after treatment. In a mechanistic analysis, we assessed the association between global longitudinal strain and AI-ECG left ventricular systolic dysfunction probabilities in studies performed within 15 days of each other.

RESULTS

Among 1550 patients without known cardiomyopathy (median follow-up, 14.1 [interquartile range, 13.4-17.1] months), 83 (5.4%), 562 (36.3%), and 905 (58.4%) were classified as high, intermediate, and low risk, respectively, by baseline AI-ECG. A high-risk versus low-risk AI-ECG screen (≥0.1 versus <0.01) was associated with a 3.4-fold and 13.5-fold higher incidence of CTRCD (adjusted hazard ratio, 3.35 [95% CI, 2.25-4.99]) and left ventricular ejection fraction <40% (adjusted hazard ratio, 13.52 [95% CI, 5.06-36.10]), respectively. Post hoc analyses supported longitudinal increases in AI-ECG probabilities within 6 to 12 months of a CTRCD event. Among 1428 temporally linked echocardiograms and ECGs, AI-ECG left ventricular systolic dysfunction probabilities were associated with worse global longitudinal strain (global longitudinal strain, -19% [interquartile range, -21% to -17%] for probabilities <0.1, to -15% [interquartile range, -15% to -9%] for ≥0.5 [P<0.001]).

CONCLUSIONS

AI applied to baseline ECG images can stratify the risk of early CTRCD associated with anthracycline or trastuzumab exposure in the setting of breast cancer and non-Hodgkin lymphoma therapy.

Translating Between Radiation Dose and Late Toxicity for Lymphoma Survivors: Implications on Toxicity Counseling and Survivorship

Radiation therapy (RT) is an important modality in the modern management of lymphoma. RT has long been recognized as a cause of late toxicity in lymphoma survivors, including serious morbidity and increased mortality from second cancers and cardiovascular disease. Many studies have quantified the relationships between radiation dose to normal tissues and the risk of late toxicities. These relationships offer the opportunity to estimate future risks for patients on an individual basis. This knowledge has the potential to effect up-front management decisions regarding the use of RT, optimize radiotherapy planning for treatment, guide the evolution of future RT technologies and identify past and future patients whose risk of late toxicity is sufficient to warrant specific screening and surveillance strategies. Despite these potential applications the challenges around translating between radiation dose and accurate predictions of late toxicities are many and substantial. This article summarizes the current state of knowledge, the inherent challenges and possible directions for future research to address this area.

Case report of entrectinib associated fulminant myocarditis

Background

ROS1 tyrosine kinase inhibitors are one of the primary immunotherapies for ROS1 fusion-positive cancers. Tyrosine kinase inhibitors have markedly improved outcomes for advanced cancers previously with poor prognosis. Entrectinib is an example of an ROS1 inhibitor that can be used for lung adenocarcinoma. There are numerous adverse effects with rare cardiac side effects reported, such as heart failure and myocarditis.

Case summary

A 27-year-old male being treated for lung adenocarcinoma who presented new congestive heart failure 2 weeks after starting Entrectinib. He developed refractory ventricular tachycardia, cardiogenic shock with an endomyocardial biopsy that showed active lymphohistiocytic myocarditis. With antiarrhythmic therapy, heavy sedation, mechanical circulatory support, and high-dose steroids, the patient had complete resolution of symptoms and return to baseline status.

Discussion

This is a rare case with a severe complication after starting Entrectinib for lung adenocarcinoma. In the literature, this is the first case of its kind presenting with myocarditis and severe heart failure after treatment with Entrectinib. This case highlights not only using cardiac imaging, and biopsy to help guide the diagnosis, but also describe the appropriate management.

How to Use Imaging: Complex Cases of Atherosclerosis, Myocardial Inflammation, and Cardiomyopathy in Cardio-Oncology

It is well understood that cancer therapies including chemotherapy, tyrosine kinase inhibitors, immune checkpoint inhibitors, and radiation can increase the risk of cardiovascular disease in patients with cancer. This can manifest as a multitude of pathologies including left ventricular dysfunction, myocarditis, cardiomyopathy, accelerated atherosclerosis, and coronary vasospasm. Multimodal cardiac imaging plays a critical role in diagnosing such pathologies by relying on noninvasive tools including echocardiograms, cardiac magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, and coronary computed tomography angiography. These methods have unique considerations and in recent years have made significant progress in their diagnostic capabilities in this patient population. As the field of cardio-oncology continues to expand rapidly, guidance on the management of such toxicities and the development of imaging technologies is crucial. In this review, we present 2 complex cases of atherosclerosis and myocarditis in patients with cancer, highlighting our rationale for management and discussing the nuances of various cardiac imaging modalities.

Optimizing Postneoadjuvant Treatment of Residual Breast Cancer With Adjuvant Bevacizumab Alone, With Metronomic or Standard-Dose Chemotherapy: A Combined Analysis of DFCI 05-055 and DFCI 09-134/TBCRC 012/ABCDE Clinical Trials

BACKGROUND

Breast cancer patients with residual disease after neoadjuvant therapy have increased risk of recurrence. Novel therapies to decrease this risk are urgently needed.

METHODS

Two clinical trials (05-055 and 09-134) offered adjuvant bevacizumab-based therapy to stage I-III breast cancer patients with residual disease after neoadjuvant chemotherapy. Study 05-055 evaluated four treatment regimens: bevacizumab (cohort A); bevacizumab with metronomic cyclophosphamide and methotrexate (CM) (cohort B); and bevacizumab with body surface area-dosed capecitabine (cohorts C); or flat-dosed capecitabine (cohort D). The primary endpoint was feasibility and tolerability. In 09-134, patients were randomized to bevacizumab with or without CM; the primary endpoint was recurrence-free survival (RFS). Study 09-134 closed prematurely for lack of accrual. A pooled survival analysis with participants from 05-055 and 09-134 was conducted.

RESULTS

Among 213 total patients (05-055, n = 163; 09-134, n = 50), the most common adverse events (AEs) of any grade were headache (49.3%) and fatigue (57.3%). Grade 3-4 AEs were highest in cohorts C (71.4%) and D (72.5%). The 36-month RFS was 58.0% with bevacizumab monotherapy, 62.3% with bevacizumab plus CM, and 72.7%-75.0% with bevacizumab plus capecitabine (depending on schedule). Treatment with capecitabine was independently associated with improved RFS in triple-negative breast cancer (TNBC) (HR: 0.47; 95% CI, 0.23-0.96).

CONCLUSION

This pooled analysis demonstrates that postneoadjuvant bevacizumab plus capecitabine may be associated with improved RFS, especially in TNBC. Each regimen carries moderate toxicity, and despite these treatments, patients with residual disease after neoadjuvant therapy still experience high rates of recurrence, indicating that new strategies are warranted.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT00121134 (DFCI Protocol Number: 05-055); NCT00925652 (DFCI Protocol Number: 09-134).

The Role of Advanced Cardiac Imaging in Monitoring Cardiovascular Complications in Patients with Extracardiac Tumors: A Descriptive Review

Cardiac involvement in cancer is increasingly important in the diagnosis and follow-up of patients. A thorough cardiovascular evaluation using multimodal imaging is crucial to assess any direct cardiac involvement from oncological disease progression and to determine the cardiovascular risk of patients undergoing oncological therapies. Early detection of cardiac dysfunction, particularly due to cardiotoxicity from chemotherapy or radiotherapy, is essential to establish the disease's overall prognostic impact. Comprehensive cardiovascular imaging should be integral to the clinical management of cancer patients. Echocardiography remains highly effective for assessing cardiac function, including systolic performance and ventricular filling pressures, with speckle-tracking echocardiography offering early insights into chemotoxicity-related myocardial damage. Cardiac computed tomography (CT) provides precise anatomical detail, especially for cardiac involvement due to metastasis or adjacent mediastinal or lung tumors. Coronary assessment is also important for initial risk stratification and monitoring potential coronary artery disease progression after radiotherapy or chemotherapeutic treatment. Finally, cardiac magnetic resonance (CMR) is the gold standard for myocardial tissue characterization, aiding in the differential diagnosis of cardiac masses. CMR's mapping techniques allow for early detection of myocardial inflammation caused by cardiotoxicity. This review explores the applicability of echocardiography, cardiac CT, and CMR in cancer patients with extracardiac tumors.

Early Myocardial Strain Reduction and miR-122-5p Elevation Associated with Interstitial Fibrosis in Anthracycline-Induced Cardiotoxicity

Echocardiographic myocardial strain is crucial for early detection of anthracycline-induced cardiotoxicity, particularly in patients at moderate or high risk.

BACKGROUND/OBJECTIVES

This study investigates changes in global longitudinal strain (GLS) in breast cancer patients with low baseline risk for cardiotoxicity during cancer therapy. We also examined the relationship between echocardiographic strain, structural myocardial changes, and microRNA (miRNA) dysregulation associated with cancer treatment using an animal model.

METHODS

Echocardiography and blood tests were examined in 33 breast cancer patients with low baseline risk for cardiotoxicity during anthracycline treatment, with a follow-up at 12 months. Additionally, 16 Wistar rats received epirubicin (20 mg/kg over 4 weeks) to examine cardiac strain and structural changes. Moreover, circulating miRNA levels were assessed in patients' serum using microarray at the end of the treatment and further analyzed in peripheral blood from the animal model.

RESULTS

Pathological GLS values were observed in 27.27% of patients after four cycles, with 15.15% showing reduced left ventricular ejection fraction (LVEF) after 12 months. In the animal model, epirubicin-induced circumferential strain (CS) decrease correlates with myocardial fibrosis assessed histologically and by a significant increase in COL1 and TGFB2 expression. Furthermore, we found a significant decrease in aquaporin1 expression associated with the presence of vacuoles in treated rats. Furthermore, dysregulation in the expression of miRNAs was observed in patients with cardiotoxicity. Among them, hsa-miR-122-5p is increased in both patient and rat serum post-treatment.

CONCLUSIONS

A notable percentage of low-risk patients exhibited cardiac strain reduction due to cardiotoxicity. Epirubicin treatment caused structural heart changes in rats, highlighting miR-122-5p as a potential fibrosis marker that correlated with echocardiographic parameters.

[The Influence of Antithrombotic Therapy on the Risk Factors for Cardiovascular Complications in Patients With Coronary Artery Disease And Diabetes Mellitus. Emphasis on Hypercoagulation]

Comorbid diabetes mellitus (DM) in patients with ischemic heart disease (IHD) is a serious factor that significantly impairs the life prognosis and increases the risk of cardiovascular complications (CVC) as well as the likelihood of death. The residual risk of developing CVC in such patients is largely determined by the high thrombotic status, that is associated with hypercoagulation characteristic of DM. Hypercoagulation causes activation of both platelet and coagulation pathways, which leads to an increased susceptibility to thrombosis. In this context, the combined administration of the anticoagulant rivaroxaban (Xarelto®) 2.5 mg and acetylsalicylic acid (ASA) can significantly reduce this risk by affecting both mechanisms of thrombus formation and thereby improving the prognosis. Rivaroxaban 2.5 mg in combination with ASA is the only available strategy to intensify the antithrombotic therapy in patients with stable IHD and DM with no history of ischemic events. Importantly, such therapy should be initiated as early as possible to prevent clinically significant CVCs and improve patients' quality of life.

Insight of immune checkpoint inhibitor related myocarditis

As the understanding of immune-related mechanisms in the development and progression of cancer advances, immunotherapies, notably Immune Checkpoint Inhibitors (ICIs), have become integral in comprehensive cancer treatment strategies. ICIs reactivate T-cell cytotoxicity against tumors by blocking immune suppressive signals on T cells, such as Programmed Death-1 (PD-1) and Cytotoxic T-lymphocyte Antigen-4 (CTLA-4). Despite their beneficial effects, ICIs are associated with immune-related adverse events (irAEs), manifesting as autoimmune side effects across various organ systems. A particularly alarming irAE is life-threatening myocarditis. This rare but severe side effect of ICIs leads to significant long-term cardiac complications, including arrhythmias and heart failure, and has been observed to have a mortality rate of up to 50% in affected patients. This greatly limits the clinical application of ICI-based immunotherapy. In this review, we provide a comprehensive summary of the current knowledge regarding the diagnosis and management of ICI-related myocarditis. We also discuss the utility of preclinical mouse models in understanding and addressing this critical challenge.

Risk classification for non-cancer death in middle-aged cancer patients

INTRODUCTION

Non-cancer events are important causes of competing mortality among cancer patients. However, the risk of non-cancer death and risk classification in middle-aged cancer patients is not clear. To comprehensively analyze the risk of non-cancer deaths in 24 different cancers among middle-aged patients.

METHODS

Standardized mortality rate (SMR), absolute excess risk (AER), proportion of deaths, age-adjusted mortality rate (AAMR), and the competing model were used to assess the risk of non-cancer death in middle-aged cancer patients. A non-cancer death risk classification was developed for the 24 cancer types based on the competing risk of non-cancer death and the risk of non-cancer death (hazard ratio).

RESULTS

A total of 1,082,030 middle-aged cancer patients of 24 cancer types was identified. The risk of non-cancer death was elevated in middle-aged cancer patients compared to the general middle-aged population (SMR = 3.37, 95 % CI 3.35-3.39, AER = 99.18). The cumulative mortality was higher for non-cancer causes compared to primary cancer in 15 cancer types. The AAMR for non-cancer causes declined from 2.3 % in 1975 to 1.4 % in 2017. A risk classification was developed to classify different cancers into 6 risk categories.

CONCLUSION

The risk of non-cancer death was elevated in middle-aged cancer patients and varied for different cancer types. A new risk classification system was developed to estimate the risk of non-cancer deaths in different cancers, and the 24 cancer types were classified into 6 distinct categories. These results highlight the necessity for risk stratification management for non-cancer death in middle-aged cancer patients.

Left ventricular global longitudinal strain in patients treated with immune checkpoint inhibitors

Background

Immune checkpoint inhibitors (ICI) are generally associated with rare cardiac side effects, yet instances like myocarditis can be fatal. Therefore, detecting and managing left ventricular dysfunction early in ICI therapy is vital.

Objectives

This study aims to evaluate whether left ventricular global longitudinal strain (LV GLS) is a predictor for early detection of cardiac dysfunction in patients receving ICI.

Methods

This retrospective cohort study included 44 cancer patients who received ICI therapy and underwent pre- and post- treatment assessments of left ventricular ejection fraction (LVEF) and LV GLS between May 2022 and November 2023. Retrospective comparisons and evaluations were conducted on pre-treatment and 3-month interval LVEF and LV GLS measurements during the first year of treatment.

Results

The median follow-up duration was 5.3 months (0.5-18.9). No statistically significant difference between baseline and subsequent time points was observed in LVEF and LV GLS values (p>0.05). At the 3-month evaluation, a notable decrease in LVEF and LV GLS was observed in two patients. One patient with reduced LVEF and LV GLS succumbed to myocarditis, and another experienced sudden death of unknown etiology. The other two patients had decreased LV GLS with normal LVEF. Subsequent follow-ups of the patients exhibiting decreased LV GLS alone revealed no further decline in LVEF or LV GLS.

Conclusion

In our study, a reduction in LV GLS did not demonstrate a significant role in the early prediction of ICI-related myocarditis or cardiac dysfunction. Further validation through multicenter, large-scale, prospective studies with extended follow-up periods is needed to confirm these findings.

The Interplay Between High Cumulative Doses of Radioactive Iodine and Type 2 Diabetes Mellitus: A Complex Cardiovascular Challenge

Starting from the metabolic profile of type 2 diabetes mellitus (T2DM), we hypothesized that the mechanisms of ¹³¹I-induced cardiotoxicity differ between patients diagnosed with differentiated thyroid cancer (DTC) with/without T2DM, with metformin potentially acting as a cardioprotective agent by mitigating inflammation in patients with T2DM. To address this hypothesis, we quantified, using ELISA, the serum concentration of several key biomarkers that reflect cardiac injury (NT-proBNP, NT-proANP, ST2/IL-33R, and cTn I) in 74 female patients with DTC/-T2DM and 25 with DTC/+T2DM treated with metformin. All patients received a cumulative oral dose of 131I exceeding 150 mCi (5.55 GBq) over approximately 53 months. Our results showed the following: (i) In DTC/-T2DM patients, high-cumulative 131I doses promote a pro-inflammatory state that accelerates the development of cardiotoxicity. Monitoring NT-proBNP, ST2/IL-33R, and cTn I in these patients may help identify those at risk of developing cardiac complications. (ii) In patients with DTC/+T2DM, high-cumulative 131I doses lead to the release of NT-proANP (r = 0.63), which signals that the atria are under significant stress. (iii) In patients with DTC/+T2DM, metformin suppresses inflammation, leading to a dose-dependent reduction in cTn I (r = -0.59). Monitoring cTn I and NT-proANP, and considering the use of metformin as part of the therapeutic strategy, could help manage cardiotoxicity in T2DM patients undergoing 131I therapy.

Cardiovascular toxicities associated with novel cellular immune therapies

ABSTRACT

Over the past decade, T-cell-directed therapies, including chimeric antigen receptor T-cell (CAR-T) and bispecific T-cell engager (BTE) therapies, have reshaped the treatment of an expanding number of hematologic malignancies, whereas tumor-infiltrating lymphocytes, a recently approved cellular therapy, targets solid tumor malignancies. Emerging data suggest that these therapies may be associated with a high incidence of serious cardiovascular toxicities, including atrial fibrillation, heart failure, ventricular arrhythmias, and other cardiovascular toxicities. The development of these events is a major limitation to long-term survival after these treatments. This review examines the current state of evidence, including reported incidence rates, risk factors, mechanisms, and management strategies of cardiovascular toxicities after treatment with these novel therapies. We specifically focus on CAR-T and BTE therapies and their relation to arrhythmia, heart failure, myocarditis, bleeding, and other major cardiovascular events. Beyond the relationship between cytokine release syndrome and cardiotoxicity, we describe other potential mechanisms and highlight key unanswered questions and future directions of research.