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)

Epidemiology, risk factors and mechanism of breast cancer and atrial fibrillation

Cancer and cardiovascular diseases are leading causes of death worldwide. Among them, breast cancer is one of the most common malignancies in women, while atrial fibrillation is one of the most extensively studied arrhythmias, with significant public health implications. As the global population ages and advancements in cancer treatments continue, the survival rates of breast cancer patients have significantly improved, leading to an increasing coexistence of breast cancer and atrial fibrillation. However, the mechanisms underlying this coexistence remain insufficiently studied, and there is no consensus on the optimal treatment strategies for these patients. This review consolidates existing research to systematically explore the epidemiological characteristics, risk factors, and pathophysiological mechanisms of both breast cancer and atrial fibrillation. It focuses on the unique signaling pathways associated with different molecular subtypes of breast cancer and their potential impact on the mechanisms of atrial fibrillation. Additionally, the relationship between atrial fibrillation treatment medications and breast cancer is discussed. These insights not only provide essential evidence for the precise prevention and management of atrial fibrillation in breast cancer patients but also lay a solid theoretical foundation for interdisciplinary clinical management practices.

A Comprehensive Review of Catheter-Related Thrombosis

Catheter-related thrombosis (CRT) is a frequent and potentially serious complication associated with the widespread use of intravascular devices such as central venous catheters, including peripherally inserted central catheters and implantable port systems, pacemakers or implantable cardioverter-defibrillators. Although CRT management has been informed by guidelines extrapolated from lower extremity deep vein thrombosis (DVT), unique challenges remain due to the distinct anatomical, pathophysiological, and clinical characteristics of upper extremity DVT. Risk factors for CRT are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site. The diagnosis of CRT relies primarily on ultrasonography; however, computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected. Treatment strategies for CRT include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions. Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy. This article provides a detailed review of CRT, focusing on clinical features, diagnostic methods, and treatment strategies while addressing specific challenges in managing pacemaker and hemodialysis catheter-related thrombosis.

Validation of a High Bleeding Risk Definition in Cancer Patients undergoing Percutaneous Coronary Intervention

AIM

Due to the absence of validated bleeding risk tools in cancer patients undergoing percutaneous coronary intervention (PCI), we aimed to validate an adapted version of the Academic Research Consortium (ARC) High Bleeding Risk (HBR) criteria.

METHODS

Consecutive patients with active or remission cancer undergoing PCI between 2012 and 2022 at Mount Sinai Hospital (New York, USA) were included. Patients were considered at HBR if they met at least one of the major ARC-HBR criteria, other than cancer, or two minor criteria.The primary endpoint was a composite of periprocedural in-hospital or post-discharge bleeding at 1 year. The key secondary endpoint was major adverse cardiac and cerebrovascular events (MACCE), including death, myocardial infarction, or stroke.

RESULTS

Of the 2,007 cancer patients included in this study, 1,142 (56.9%) were classified as HBR. Moderate to severe anemia was the most prevalent major HBR criterion (35%). At 1 year, the incidence of bleeding was significantly higher in HBR compared to non-HBR patients (10.9% vs. 3.9%, adj. HR: 2.36, 95% CI: 1.57-3.53, p<0.001), mainly driven by higher periprocedural bleeding. Similarly, HBR patients were at higher risk of MACCE (11.0% vs. 3.2%, adj. HR: 2.78, 95% CI: 1.72-4.47, p<0.001) and death (8.8% vs. 2.2%, adj. HR: 3.28, 95% CI: 1.87-5.77, p<0.001) than non-HBR patients.

CONCLUSIONS

An adapted version of the ARC-HBR criteria, in which cancer is not a major criterion, effectively delineates cancer patients undergoing PCI who are at HBR. Cancer patients at HBR according to this definition also exhibited a higher mortality risk. .

Baseline echocardiographic variables as predictors of hemodynamically significant cytokine release syndrome in adults treated with CD19 CAR T-cell therapy for hematological malignancies

BACKGROUND

CD19 CAR T-cell therapy is a novel anti-cancer treatment that has produced remarkable responses in relapsed or refractory B-cell hematological malignancies. Cytokine Release Syndrome (CRS) is a dysregulated immune response that frequently occurs after CAR T-cell infusion. It can cause cardiac dysfunction and circulatory collapse negatively impacting outcomes and survival. To endure the insults of CRS, patients are typically screened for adequate cardiac reserve before treatment. The relationship between baseline cardiac function by echocardiography and the development of moderate to severe presentations of CRS is unclear.

METHODS

This study aimed to identify baseline echocardiographic variables that can predict the development of hemodynamically significant CRS (CRS ≥ 2), evaluate their behavior at follow-up, and investigate the incidence of cancer therapy-related cardiac dysfunction (CTRCD). An observational retrospective cohort study of patients treated with CD19 CAR T-cell therapy with a baseline echocardiogram was performed. Demographic, clinical and echocardiographic variables were abstracted from the electronic health record. Patients were grouped and compared by the occurrence of CRS < 2 and ≥ 2. Adjusted logistic regression analysis was used to evaluate the association between echocardiographic variables and the development of CRS ≥ 2.

RESULTS

291 patients were included in the study. Median age was 60 (IQR: 51, 67 years), 73% were male, and 71% had diffuse large B-cell lymphoma. Logistic regression analysis did not reveal any significant baseline echocardiographic predictors of CRS ≥ 2, including left ventricular ejection fraction and global longitudinal strain. Systolic and diastolic echocardiographic variables remained within normal limits at follow-up overall and in both CRS groups. The incidence of CTRCD was 4.5% and occurred mostly in the setting of CRS ≥ 2.

CONCLUSION

No specific echocardiographic variables predicted the development of CRS ≥ 2, and therefore the mechanism leading to hemodynamic decompensation and producing worsening hypoxia and hypotension could be multifactorial and not directly cardiac mediated.

Cancer Therapy-Related Cardiac Dysfunction: A Review of Current Trends in Epidemiology, Diagnosis, and Treatment

Cancer therapy-related cardiac dysfunction (CTRCD) has emerged as a significant concern with the rise of effective cancer treatments like anthracyclines and targeted therapies such as trastuzumab. While these therapies have improved cancer survival rates, their unintended cardiovascular side effects can lead to heart failure, cardiomyopathy, and arrhythmias. The pathophysiology of CTRCD involves oxidative stress, mitochondrial dysfunction, and calcium dysregulation, resulting in irreversible damage to cardiomyocytes. Inflammatory cytokines, disrupted growth factor signaling, and coronary atherosclerosis further contribute to this dysfunction. Advances in cardio-oncology have led to the early detection of CTRCD using cardiac biomarkers like troponins and imaging techniques such as echocardiography and cardiac magnetic resonance (CMR). These tools help identify asymptomatic patients at risk of cardiac events before the onset of clinical symptoms. Preventive strategies, including the use of cardioprotective agents like beta-blockers, angiotensin-converting enzyme inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors have shown promise in reducing the incidence of CTRCD. This review summarizes the mechanisms, detection methods, and emerging treatments for CTRCD, emphasizing the importance of interdisciplinary collaboration between oncologists and cardiologists to optimize care and improve both cancer and cardiovascular outcomes.

Fully Automated Assessment of Cardiac Chamber Volumes and Myocardial Mass on Non-Contrast Chest CT with a Deep Learning Model: Validation Against Cardiac MR

Background: To validate the automated quantification of cardiac chamber volumes and myocardial mass on non-contrast chest CT using cardiac MR (CMR) as a reference. Methods: We retrospectively included 53 consecutive patients who received non-contrast chest CT and CMR within three weeks. A deep learning model created cardiac segmentations on axial soft-tissue reconstructions from CT, covering all four cardiac chambers and the left ventricular myocardium. Segmentations on CMR cine short-axis and long-axis images served as a reference. Standard estimates of diagnostic accuracy were calculated for ventricular volumes at end-diastole and end-systole (LVEDV, LVESV, RVEDV, RVESV), left ventricular mass (LVM), and atrial volumes (LA, RA) at ventricular end-diastole. A qualitative assessment noted segmentation issues. Results: The deep learning model generated CT measurements for 52 of the 53 patients (98%). Based on CMR measurements, the average LVEDV was 166 ± 64 mL, RVEDV was 144 ± 51 mL, and LVM was 115 ± 39 g. The CT measurements correlated well with CMR measurements for LVEDV, LVESV, and LVM (ICC = 0.85, ICC = 0.84, and ICC = 0.91; all p < 0.001) and RVEDV and RVESV (ICC = 0.79 and ICC= 0.78; both p < 0.001), and moderately well with LA and RA (ICC = 0.74 and ICC = 0.61; both p < 0.001). Absolute agreements likewise favored LVEDV, LVM, and RVEDV. ECG-gating did not relevantly influence the results. The CT results correctly identified 7/15 LV and 1/1 RV as dilated (one and six false positives, respectively). Major qualitative issues were found in three cases (6%). Conclusions: Automated cardiac chamber volume and myocardial mass quantification on non-contrast chest CT produced viable measurements in this retrospective sample. Relevance Statement: An automated cardiac assessment on non-contrast chest CT provides quantitative morphological data on the heart, enabling a preliminary organ evaluation that aids in incidentally identifying at-risk patients who may benefit from a more targeted diagnostic workup.

Atrial Fibrillation and Cancer-Epidemiology, Mechanisms, and Management

Atrial fibrillation (AF) and cancer are increasingly recognized as interrelated conditions, with cancer patients showing elevated incidences of AF, and there is evidence that AF may sometimes precede cancer diagnoses. This comprehensive review investigates the epidemiology, pathophysiology, and management challenges associated with AF in cancer patients. Epidemiologically, several cancers are more closely related to increased rates of AF, including lung, colorectal, gastrointestinal, and hematologic malignancies. Mechanistically, both AF and cancer share pathophysiological pathways centered on inflammation, oxidative stress, and common cardiovascular risk factors, such as hypertension, obesity, and diabetes. The inflammatory microenvironment in tumors, marked by increased cytokines and growth factors, promotes atrial remodeling and AF susceptibility. Elevated reactive oxygen species (ROS) levels, driven by the metabolic demands of cancer, further contribute to atrial fibrosis and structural changes. Moreover, many anticancer treatments exacerbate AF risk. Management of AF in cancer patients presents many unique challenges and requires a multidisciplinary approach. Rate and rhythm control strategies are complicated by potential drug-drug interactions and limited data surrounding early implementation of rhythm control strategies in cancer patients. Interventional approaches such as catheter ablation, though effective in maintaining sinus rhythm, carry significant perioperative risk in patients with malignancy. Stroke prevention with anticoagulants is essential but requires cautious administration to avoid heightened bleeding risks, particularly in patients undergoing chemotherapy. Further, the limited applicability of standard risk stratification tools like CHA2DS2-VASc in this population complicate decisions regarding anticoagulation. This review highlights the bidirectional relationship between AF and cancer, the difficulties in management, and the critical need for further research in this field.

Challenges in the implementation of cardio-oncology trials: lessons learnt from investigating statins in the prevention of anthracycline cardiotoxicity

Despite advanced in targeted cancer therapies, anthracyclines remain essential in treating various malignancies, albeit with risks of cancer therapy-related cardiac dysfunction (CTRCD). Out of the myriad of mitigation strategies for CTRCD, statins are an attractive preventive therapy for anthracycline associated CTRCD given their widespread availability, cheap costs and added benefit of atherosclerotic cardiovascular disease (ASCVD) risk reduction. Recent trials of PREVENT, SPARE-HF, and STOP-CA investigated atorvastatin's efficacy in preventing CTRCD, with mixed outcomes. While STOP-CA showed a significant reduction in CTRCD rates (22% vs. 8% in placebo), PREVENT and SPARE-HF found no statistical differences between statin and placebo groups. The trials faced challenges such as selection bias, exclusion of patients with comorbidities, and reliance on imaging-derived outcomes, which may not reflect clinically meaningful benefits. This calls for improved trial designs that prioritize diverse patient recruitment, longer follow-ups, and clinically relevant endpoints to enhance the translational impact of findings. Addressing these challenges collaboratively between oncology and cardiology will be crucial for optimizing patient outcomes in this vulnerable population. Future studies should emphasize both immediate cardioprotective effects and long-term cardiovascular benefits of statins, especially in the context of atherosclerotic cardiovascular disease in cancer survivors.

Current Status and Future Perspective of Onco-Hypertension

BACKGROUND

Hypertension and cancer are both increasing with age. Recently, the new concept of "Onco-Hypertension" has been proposed to address the mutual risks posed by hypertension and cancer and to provide comprehensive care for patients with these two conditions in an aging society.

METHODS

In this review, we provide an overview of the current status and future perspective of the "Onco-Hypertension," including our research findings.

RESULTS

Hypertension and cancer share common risk factors and may be interrelated in pathogenesis: Hypertension is involved in the development of certain cancers, and cancer survivors have a higher incidence of hypertension. With recent advances in cancer therapy, the number of cancer survivors has increased. Cancer survivors not only have a higher risk of incident hypertension but also an increased risk of future cardiovascular events, highlighting the growing importance of comprehensive care.

CONCLUSIONS

There exists a diverse array of epidemiological and pathophysiological relationships between hypertension and cancer. It is imperative to move the emerging scientific field of "Onco-Hypertension" forward through relentless research efforts.

Cardiac events and dynamic echocardiographic and electrocardiogram changes following osimertinib treatment in lung cancer

Osimertinib is first-line treatment for epidermal growth factor (EGFR)-mutated non-small cell lung cancer (NSCLC) and has been associated with cardiotoxicity. However, the nature of cardiac remodeling and associated risk factors remains incompletely understood. Retrospective analysis of NSCLC patients with ≥1 echocardiogram post-osimertinib between 2007 and 2022 was performed. The cumulative incidence of grade ≥2 cardiac common terminology criteria for adverse events (CTCAE) was estimated and Fine and Gray regressions performed (non-cardiac death as competing risk). Eighty-five patients [mean [interquartile range, IQR], 68 [60-75] years; 67% female; 12% with pre-existing heart conditions] met inclusion criteria. With a median follow up of 34.7 months, the 2-year cumulative incidence of grade ≥2 and grade ≥3 cardiac events were 19.2% and 8.5%, respectively. There was an increased risk of grade ≥2 cardiac CTCAE with pre-existing arrhythmia [hazard ratio(HR) 3.90, 95%CI, 1.11-13.72; p = 0.034] and higher body mass index (HR 1.07, 95%CI, 1.00-1.14; p = 0.04). Following osimertinib (vs. baseline), the median QTc was prolonged (451 vs. 437 ms; p < 0.001) and LVEF ≤50% was more common (10.6% vs. 5.3%; p = .046). Osimertinib treatment was associated with QTc prolongation and reduced LVEF. BMI was identified as a potentially modifiable risk factor for osimertinib-associated cardiotoxicity, worthy of further study.

Changes in sST2 and NT-proBNP levels predict early cardiac arrhythmia in breast cancer patients treated with anthracycline-containing chemotherapies

Background

Cardiovascular biomarkers are crucial for monitoring cancer therapy-related cardiac toxicity, but the effects on early stage are still inadequate. To screen biomarkers in patients with breast cancer who receive anthracycline-containing chemotherapy, we studied the behavior of six biomarkers during chemotherapy and their association with chemotherapy-related cardiac toxicity.

Methods

In a prospective cohort of 73 patients treated with anthracycline-containing chemotherapy, soluble suppression of tumorigenicity 2 (sST2), high-sensitivity cardiac troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), myoglobin, creatine kinase isoenzyme MB, and heart-fatty acid binding protein were measured at baseline, during chemotherapy cycle (C1-C6). According to whether arrhythmia occurred, patients were divided into two groups (healthy group or arrhythmias group), and basic clinical characteristics were collected and compared. Logistic regression analyses and receiver operating characteristic (ROC) curves were conducted to investigate the association between the changes in biomarkers and arrhythmia.

Results

sST2 levels increased significantly from baseline to C1 (P < 0.01). NT-proBNP levels decreased from baseline to C1 and C5 (P < 0.01). The logistic regression analysis showed a greater risk of arrhythmia was associated with interval changes in sST2 [odds ratio (OR): 1.27; 95% CI: 1.03-1.56; P = 0.024] and NT-proBNP (OR: 0.83; 95% CI: 0.70-0.98; P = 0.029). The ROC curves showed that ΔsST2, ΔNT-proBNP, and ΔsST2 + ΔNT-proBNP had good predictive value for arrhythmia (areas under the curves were 0.631, 0.633, and 0.735, respectively, P < 0.05).

Conclusions

Early changes in sST2 and NT-proBNP levels offer additive information for early arrhythmia prediction in breast cancer patients who receive anthracycline-containing chemotherapy.

How Close Are We to Patient-Side Troponin Testing?

Laboratory-based high-sensitivity cardiac troponin testing has been the pillar for emergency stratification of suspected acute coronary syndrome for well over a decade. Point-of-care troponin assays achieving the requisite analytical sensitivity have recently been developed and could accelerate such assessment. This review summarises the latest assays and describes their potential diverse clinical utility in the emergency department, community healthcare, pre-hospital, and other hospital settings. It outlines the current clinical data but also highlights the evidence gap, particularly the need for clinical trials using whole blood, that must be addressed for safe and successful implementation of point-of-care troponin analysis into daily practice. Additionally, how point-of-care troponin testing can be coupled with advances in biosensor technology, cardiovascular screening, and triage algorithms is discussed.

Association Between Amount of Physical Activity and Clinical Outcomes After Treatment for Cardiovascular Disease in Cancer Survivors

Background

The present study aimed to investigate the association between physical activity before the incidence of cardiovascular disease (CVD) and clinical outcomes in cancer survivors.

Methods and Results

We analyzed 904 cancer survivors (median age [interquartile range] 75 [68-80] years; 297 [32.9%] patients were female) who required hospitalization for treatment of CVD. The amount of physical activity 1 month before the admission was assessed using the 3-question (3Q) assessment tool, and categorized as minimal, low, adequate, and high according to physical activity level. The primary outcome was the composite events of all-cause death and/or rehospitalization for CVD up to 1 year after discharge. The total amount of physical activity was identified in 544 (60.2%) patients in the minimal group, 95 (10.5%) in the low group, 253 (28.0%) in the adequate group, and 12 (1.3%) in the high group. A total of 686 (75.9%) patients completed follow up, with 252 (27.9%) composite events occurring. Even after adjustment for various confounders, higher physical activity was significantly associated with a lower composite event rate (adjusted hazard ratio [95% confidence interval] 0.859 [0.833-0.900]).

Conclusions

High physical activity in cancer survivors was associated with a lower composite event rate after treatment for CVD. Assessment of prehospital physical activity using the 3Q score may be useful in their risk stratification.

The Complex Connection Between Myocardial Dysfunction and Cancer Beyond Cardiotoxicity: Shared Risk Factors and Common Molecular Pathways

Cardiovascular diseases and cancer represent the largest disease burden worldwide. Previously, these two conditions were considered independent, except in terms of cardiotoxicity, which links cancer treatment to subsequent cardiovascular issues. However, recent studies suggest that there are further connections between cancer and heart disease beyond cardiotoxicity. It has been revealed that myocardial dysfunction may promote carcinogenesis, indicating that additional common pathophysiological mechanisms might be involved in the relationship between cardiology and oncology, rather than simply a connection through cardiotoxic effects. These mechanisms may include shared risk factors and common molecular pathways, such as persistent inflammation and neurohormonal activation. This review explores the connection between myocardial dysfunction and cancer, emphasizing their shared risk factors, similar biological mechanisms, and causative factors like cardiotoxicity, along with their clinical implications.

Cardiooncology in the ICU - Cardiac Urgencies in Cancer Care

Cardiovascular disease is an increasing risk of morbidity and mortality in cancer patients, related to an growing number of aging survivors with pre-existing cardiovascular disease and the use of traditional and novel cancer therapies with cardiotoxic effects. While many cardiac complications are chronic processes that develop over time, there are many acute processes that may arise in hospitalized patients. It is important for hospitalists and critical care physicians to be familiar with the recognition and management of these conditions in this unique population. This article reviews the presentation and management of common cardiac urgencies in critically ill cancer patients including acute decompensated heart failure, acute coronary syndromes, arrhythmias, hypertensive crises, pulmonary embolism, pericardial tamponade and myocarditis.

The diabetic myocardial transcriptome reveals Erbb3 and Hspa2 as a novel biomarkers of incident heart failure

AIMS

Diabetes mellitus (DM) increases heart failure incidence and worsens prognosis, but its molecular basis is poorly defined in humans. We aimed to define the diabetic myocardial transcriptome and validate hits in their circulating protein form to define disease mechanisms and biomarkers.

METHODS AND RESULTS

RNA-sequencing data from the Genotype-Tissue Expression (GTEx) project was used to define differentially expressed genes (DEGs) in right atrial (RA) and left ventricular (LV) myocardium from people with vs. without DM (type 1 or 2). DEGs were validated as plasma proteins in the UK Biobank cohort, searching for directionally concordant differential expression. Validated plasma proteins were characterized in UK Biobank participants, irrespective of diabetes status, using cardiac magnetic resonance imaging, incident heart failure, and cardiovascular mortality. We found 32 and 32 DEGs associated with DM in the RA and LV, respectively, with no overlap between these. Plasma proteomic data were available for 12, with ERBB3, NRXN3, and HSPA2 (all LV hits) exhibiting directional concordance. Irrespective of DM status, lower circulating ERBB3 and higher HSPA2 were associated with impaired LV contractility and higher LV mass. Participants in the lowest quartile of circulating ERBB3 or highest quartile of circulating HSPA2 had increased incident heart failure and cardiovascular death vs. all other quartiles.

CONCLUSION

DM is characterized by lower Erbb3 and higher Hspa2 expression in the myocardium, with directionally concordant differences in their plasma protein concentration. These are associated with LV dysfunction, incident heart failure, and cardiovascular mortality.

Early experience with daratumumab-containing regimens in patients with light-chain cardiac amyloidosis

BACKGROUND

Immunoglobulin light-chain (AL) amyloidosis is a lethal condition resulting from misfolded immunoglobulin ALs produced by clonal CD38-positive plasma cells. Treatment with daratumumab, an anti-human CD38 monoclonal antibody, led to higher frequencies of complete hematologic response and better clinical outcomes compared with conventional treatment. This study sought to evaluate the survival benefit of daratumumab-containing regimens in patients with AL cardiac amyloidosis.

METHODS AND RESULTS

We examined 65 consecutive patients with AL cardiac amyloidosis (mean age: 67.2 ± 10.4 years, male: 69 %) who underwent chemotherapy. We divided patients into a daratumumab group, which used daratumumab-containing regimens before second-line treatment (n = 32), and a conventional treatment group (n = 33). Compared with the conventional treatment group, the daratumumab group tended to be older, but there were no significant differences between groups in biomarkers and echocardiographic parameters. A total of 26 patients (40 %) died (median follow-up duration: 395 days). Kaplan-Meier survival analysis showed that the daratumumab group had significantly lower mortality compared with the conventional treatment group (p = 0.04; log-rank test). Cox hazard analysis revealed that use of daratumumab-containing regimens was associated with lower mortality after adjustment for the revised Mayo staging of AL amyloidosis (hazard ratio: 0.32; 95 % confidence interval: 0.12 to 0.85; p = 0.02).

CONCLUSION

Daratumumab-containing regimens may be associated with improved survival in patients with AL cardiac amyloidosis.

Adverse cardiovascular events and cardiac imaging findings in patients on immune checkpoint inhibitors

BACKGROUND

There is an urgent need to better understand the diverse presentations, risk factors, and outcomes of immune checkpoint inhibitor (ICI)-associated cardiovascular toxicity. There remains a lack of consensus surrounding cardiovascular screening, risk stratification, and clinical decision-making in patients receiving ICIs.

METHODS

We conducted a single center retrospective cohort study including 2165 cancer patients treated with ICIs between 2013 and 2020. The primary outcome was adverse cardiovascular events (ACE): a composite of myocardial infarction, coronary artery disease, stroke, peripheral vascular disease, arrhythmias, heart failure, valvular disease, pericardial disease, and myocarditis. Secondary outcomes included all-cause mortality and the individual components of ACE. We additionally conducted an imaging substudy examining imaging characteristics from echocardiography (echo) and cardiac magnetic resonance (CMR) imaging.

RESULTS

In our cohort, 44% (n = 962/2165) of patients experienced ACE. In a multivariable analysis, dual ICI therapy (hazard ratio [HR] 1.23, confidence interval [CI] 1.04-1.45), age (HR 1.01, CI 1.00-1.01), male sex (HR 1.18, CI 1.02-1.36), prior arrhythmia (HR 1.22, CI 1.03-1.43), lung cancer (HR 1.17, CI 1.01-1.37), and central nervous system (CNS) malignancy (HR 1.23, CI 1.02-1.47), were independently associated with increased ACE. ACE was independently associated with a 2.7-fold increased risk of mortality (P<0.001). Dual ICI therapy was also associated with a 2.0-fold increased risk of myo/pericarditis (P = 0.045), with myo/pericarditis being associated with a 2.9-fold increased risk of mortality (P<0.001). However, the cardiovascular risks of dual ICI therapy were offset by its mortality benefit, with dual ICI therapy being associated with a ~25% or 1.3-fold decrease in mortality. Of those with echo prior to ICI initiation, 26% (n = 115/442) had abnormal left ventricular ejection fraction or global longitudinal strain, and of those with echo after ICI initiation, 28% (n = 207/740) had abnormalities. Of those who had CMR imaging prior to ICI initiation, 43% (n = 9/21) already had left ventricular dysfunction, 50% (n = 10/20) had right ventricular dysfunction, 32% (n = 6/19) had left ventricular late gadolinium enhancement, and 9% (n = 1/11) had abnormal T2 imaging.

CONCLUSION

Dual ICI therapy, prior arrhythmia, older age, lung and CNS malignancies were independently associated with an increased risk of ACE, and dual ICI therapy was also independently associated with an increased risk of myo/pericarditis, highlighting the utmost importance of cardiovascular risk factor optimization in this particularly high-risk population. Fortunately, the occurrence of myo/pericarditis was relatively uncommon, and the overall cardiovascular risks of dual ICI therapy appeared to be offset by a significant mortality benefit. The use of multimodal cardiac imaging can be helpful in stratifying risk and guiding preventative cardiovascular management in patients receiving ICIs.

Immunotherapy-mediated myocarditis and concurrent vasospastic angina in a patient with established ischaemic heart disease: a case report

Background

Immunotherapy has become a pillar of modern oncological management but is associated with significant immunotherapy-related adverse events (IRAEs). While myocarditis is a prominent IRAE which clinicians are increasingly aware of, immunotherapy-related coronary vasospasm is far less appreciated and can be especially difficult to elucidate in pre-existing coronary artery disease. This case demonstrates the approach to diagnosis and management of multiple cardiovascular and non-cardiovascular IRAEs.

Case summary

A 57-year-old male with a history of metastatic melanoma on combined immunotherapy and ischaemic heart disease with multiple previous percutaneous coronary interventions presented with typical chest pain and troponin rise. Differential diagnoses for this presentation included a non-ST elevation myocardial infarction, myocarditis, and coronary vasospasm. Coronary angiogram did not reveal any new significant obstructive coronary artery disease while cardiac MRI did not reveal any radiological features consistent with myocarditis. However, empirical treatment for IRAEs resulted in both clinical and biochemical improvement and ability to discharge the patient on steroids and coronary vasodilators, having been GTN-infusion dependent as an inpatient.

Discussion

Cardiovascular IRAEs are important to be aware of when managing patients on immunotherapy and more than one IRAE can occur concurrently. Given the caveats of non-invasive imaging and invasive nature of endomyocardial biopsy, the clinical history is key in establishing these crucial diagnoses which will significantly impact ongoing oncological management.

The Good (Tumor Killing) and the Bad (Cardiovascular Complications) of Immunologic Checkpoint Inhibitors

PURPOSE OF REVIEW

This review details the significant advancement in knowledge of Immune-checkpoint inhibitor (ICI) and its potential deleterious cardiac immune-related adverse effects (irAE). We explore their mechanisms on the cardiac tissue, providing guidance on risk factors, clinical presentations, diagnostic strategies along with treatment.

RECENT FINDINGS

Recent findings have provided insights of cardiac irAEs that exist beyond the previously well-known ICI-induced myocarditis. We have a better understanding of the wide variety of cardiac irAEs pathologies both early and late onset. Moreover, there is more data on mechanisms of cardiotoxicity and patient and therapy-related risk factors, supporting closer routine cardiac monitoring with biomarkers and imaging for prevention and early detection. Diagnosing cardiac irAEs is a challenge given its broad clinical presentation. A high-level of suspicion in addition to early work-up is crucial to prevent serious cardiac events. A multi-disciplinary team including Cardiologists and Oncologists is essential for closely monitor patients' cardiac status on ICI therapy. There is a need of updated guidelines to establish clear recommendations in patients on ICIs.

Troponin Elevation in Asymptomatic Cancer Patients: Unveiling Connections and Clinical Implications

PURPOSE OF THE REVIEW

Elevated troponin levels are well established e.g., for the diagnosis of suspected acute coronary syndrome in symptomatic patients. In contrast, troponin elevations in asymptomatic cancer patients emerge as a complex phenomenon, challenging traditional perceptions of its association solely with cardiac events.

RECENT FINDINGS

Recent data support the predictive value of cardiac biomarker for all-cause mortality and cardiotoxicity in cancer patients. This review gives an overview about the current literature about cardiac troponins in prediction and identification of high-risk cancer patients. The overview is focusing on diagnostic challenges, biomarker significance, and gaps of knowledge. Latest publications highlight the relevance of cardiac troponin in risk analysis before cancer treatment as well as a potential diagnostic gatekeeper for further cardiological diagnostics and therapy.

Congestive heart failure after anthracycline-containing treatment for Hodgkin lymphoma: A Swedish matched cohort study

Introduction

Congestive heart failure (CHF) is a known complication after anthracyclines and radiotherapy for classical Hodgkin lymphoma (cHL). Contemporary cHL treatment may be associated with less risk because radiotherapy use and techniques have changed substantially over time.

Methods

In this study, Swedish cHL patients diagnosed in 2000-2018, and treated with adriamycin [doxorubicin], bleomycin, vinblastine, and dacarbazine (ABVD) or bleomycin, etoposide, Adriamycin [doxorubicin], cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP), were matched 1:10 to the general population on birth year and sex to investigate relative rates and cumulative risks of CHF.

Results

A total of 1994 cHL patients were included, with a median age of 34 years. The median follow-up was 8.1 years. The CHF rate was higher for patients versus comparators (adjusted hazard ratio [HR] = 3.02, 95% confidence interval [CI]: 2.26-4.02). Patients treated with ≤200 mg/m2 of anthracyclines had HR of 2.89 (95% CI: 1.51-3.47) versus 3.91 (95% CI: 2.72-5.60) for >200 mg/m2. Treatment with ABVD was associated with a significantly higher CHF rate (adjusted HR = 3.25, 95% CI: 2.31-4.23), while BEACOPP was not (adjusted HR = 1.95, 95% CI: 0.91-4.16). The increase in relative rates translated to the absolute scale, with an increased risk persisting up to 18 years for low cumulative doses.

Conclusion

These findings highlight that cHL survivors still face a substantial excess risk of CHF in the modern treatment era and that focus on cardiovascular health remains relevant.

Cardiovascular imaging in cardio-oncology

Advances in cancer treatment have improved in patient survival rate. On the other hand, management of cardiovascular complications has been increasingly required in cancer patients. Thus, cardio-oncology has attracted the attention by both oncologists and cardiologists. Cardiovascular imaging has played a key role for non-invasive assessment of cardiovascular alterations complimentary to biomarkers and clinical assessment. Suitable imaging selection and interpretation may allow early diagnosis of cardiovascular injury with potential implications for therapeutic management and improved outcomes after cancer therapy. Echocardiography has been commonly used to evaluate cardiac dysfunction in cardio-oncology area. Cardiac CT is valuable for assessing structural abnormalities of the myocardium, coronary arteries, and aorta. Molecular imaging has an important role in the assessment of the pathophysiology and future treatment strategy of cardiovascular dysfunction. Cardiac MRI is valuable for characterization of myocardial tissue. PET and SPECT molecular imaging has potential roles for quantitative assessment of cardiovascular disorders. Particularly, FDG-PET is considered as an elegant approach for simultaneous assessment of tumor response to cancer therapy and early detection of possible cardiovascular involvement as well. This review describes the promising potential of these non-invasive cardiovascular imaging modalities in cardio-oncology.

Use of heart failure medical therapy before and after a cancer diagnosis: A longitudinal study

AIMS

We aim to evaluate change in the use of prognostic guideline-directed medical therapies (GDMTs) for heart failure (HF) before and after a cancer diagnosis as well as the matched non-cancer controls, including renin-angiotensin-system inhibitors (RASIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs).

METHODS AND RESULTS

We conducted a longitudinal study in patients with HF in the UK Clinical Practice Research Datalink between 2005 and 2021. We selected patients with probable HF with reduced ejection fraction (HFrEF) based on diagnostic and prescription records. We described the longitudinal trends in the use and dosing of GDMTs before and after receiving an incident cancer diagnosis. HF patients with cancer were matched with a 1:1 ratio to HF patients without cancer to investigate the association between cancer diagnosis and treatment adherence, persistence, initiation, and dose titration as odds ratios (ORs) with 95% confidence intervals (CIs) using multivariable logistic regression models. Of 8504 eligible HFrEF patients with incident cancer, 4890 were matched to controls without cancer. The mean age was 75.7 (±8.4) years and 73.9% were male. In the 12 months following a cancer diagnosis, patients experienced reductions in the use and dosing of GDMT. Compared with the non-cancer controls, patients with cancer had higher risks for poor adherence for all three medication classes (RASIs: OR = 1.51, 95% CI = 1.35-1.68; beta-blockers: OR = 1.22, 95% CI = 1.08-1.37; MRAs: OR = 1.31, 95% CI = 1.08-1.59) and poor persistence (RASIs: OR = 2.04, 95% CI = 1.75-2.37; beta-blockers: OR = 1.35, 95% CI = 1.12-1.63; MRAs: OR = 1.49, 95% CI = 1.16-1.93), and higher risks for dose down-titration for RASIs (OR = 1.69, 95% CI = 1.40-2.04) and beta-blockers (OR = 1.31, 95% CI = 1.05-1.62). Cancer diagnosis was not associated with treatment initiation or dose up-titration. Event rates for HF hospitalization and mortality were higher in patients with poor adherence or persistence to GDMTs.

CONCLUSIONS

Following a cancer diagnosis, patients with HFrEF were more likely to have reduced use of GDMTs for HF.

Prognosis Prediction of Cardiovascular Event With Glucose-Albumin Ratio on Patients With Cancer and Prescribed With Anthracycline

AIMS

This study aimed to investigate the clinical value of the glucose-albumin ratio (GAR) in predicting the prognosis of cancer patients prescribed anthracycline-based chemotherapy.

METHODS

We included cancer patients who underwent anthracycline-based chemotherapy, drawn from the population-based cohort Clinical Data Analysis Reporting System of Hong Kong between January 2000 and December 2019. Demographics, medical history, baseline laboratory, and metabolic indicators, including GAR, were collected. We employed random survival forests (RSF) with the variable importance (VIMP) method to rank the importance of these variables. Cox proportional hazards regression was used to assess the association between GAR levels and event risks.

RESULTS

A total of 18,700 patients were included in the analysis. The top 2 factors for predicting overall cardiovascular event risk were GAR and fasting blood glucose (FBG). Our results revealed that a higher GAR was significantly associated with poorer cardiovascular prognosis in patients with cancer prescribed with anthracycline-based chemotherapy. Compared to the lowest quartile, higher GAR levels were significantly associated with increased risk of all-cause mortality, major adverse cardiovascular events, hospitalization of heart failure, and cardiovascular mortality regardless of the adjustments (all p trend < 0.001).

CONCLUSION

GAR is a potential biomarker for predicting the prognosis of cancer patients undergoing anthracycline-based chemotherapy. Monitoring GAR levels before and during treatment may help identify patients at higher risk of adverse outcomes, facilitating personalized treatment strategies and improving clinical management.

Subclinical cardiac damage monitoring in breast cancer patients treated with an anthracycline-based chemotherapy receiving left-sided breast radiation therapy: subgroup analysis from a phase 3 trial

OBJECTIVE

This study, derived from the phase 3 SAFE trial (ClinicalTrials.gov identifier: NCT2236806), explores subclinical cardiac damage in breast cancer patients receiving anthracycline-based chemotherapy and left-sided breast radiation therapy (RT).

MATERIALS AND METHODS

Eligible patients were randomized to a cardioprotective pharmacological therapy (bisoprolol, ramipril, or both) or placebo, with cardiac surveillance at multiple time-point using standard and 3-dimensional echocardiography. Dosimetric parameters were analysed, including mean heart dose (MHD) and various metrics for heart substructures, employing advanced contouring techniques and auto-contouring software.

RESULTS

In the analysis of left-sided breast RT patients, the study encompassed 39 out of 46 irradiated individuals, focusing on GLS and 3D-LVEF outcomes with ≥ 10% worsening, defined as subclinical heart damage. Distinct RT schedules were used, with placebo exhibiting the highest ≥ 10% worsening (36.4%). In terms of treatment arms, bisoprolol exhibited 11.1% worsening, while ramipril 16.7% and bisoprolol + ramipril 25%. For patients with no subclinical damage, the mean MHD was 1.5 Gy; for patients with subclinical heart damage, the mean MHD was 1.6 Gy (p = 0.94). Dosimetric parameters related to heart and heart substructures (left anterior descending artery, right and left atrium, right and left ventricle) showed no statistically significant differences between patients with and without subclinical damage.

CONCLUSION

Our results emphasize the crucial role of cardioprotective measures in mitigating adverse effects, highlighting RT as having negligible influence on cardiac performance. An extended follow-up assessment of the whole series is warranted to determine whether a subclinical effect could significantly influence clinical outcomes and cardiac events.

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

The administration of certain cancer therapies can be associated with the development of cardiovascular toxicity or complications. This spectrum of toxicities is broad and requires nuanced approaches for prevention, identification, and management. This expert panel summarizes the consensus of opinions of diverse health care professionals in several key areas: 1) cardioprotection involves strategies aimed at the primary prevention of cancer therapy-related cardiovascular toxicity; 2) surveillance entails monitoring for cancer therapy-related cardiovascular toxicity during cancer therapy; 3) permissive cardiotoxicity is the informed continuation of cancer therapy in the presence of cardiovascular toxicity, along with the implementation of mitigating cardiovascular treatments; and 4) special considerations include the invasive management of severe cardiovascular disease in patients receiving treatments for advanced cancer and the exploration of drug-drug interactions in cardio-oncology. In this expert panel, we also highlight gaps in evidence in an effort to continue to advance science in the cardiovascular care of our patients undergoing cancer therapy.

Patients with metastatic cancer have worse short-term coronary artery bypass grafting outcomes: A population-based study of National Inpatient Sample from 2015 to 2020

BACKGROUND

Metastasis is a hallmark for cancer progression. While patients with metastatic cancer (MC) have higher risk profiles, outcomes of coronary artery bypass grafting (CABG) in these patients have not been established, likely due to their smaller representation in the CABG patient population. This study aimed to examine the short-term outcomes of patients with MC who underwent CABG.

METHODS

Patients who underwent CABG were identified in National Inpatient Sample from Q4 2015-2020. Exclusion criteria included age <18 years, concomitant procedures, and non-metastatic malignancies. A 1:3 propensity-score matching was used to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status between MC and non-MCC patients. In-hospital post-CABG outcomes were evaluated.

RESULTS

There were 379 (0.23 %) patients with MC who underwent CABG. All MC patients were matched to 1161 out of 164,351 non-MC patients who underwent CABG during the same period. Patients with MC had higher risks of mortality (4.76 % vs 2.58 %, p = 0.04), pacemaker implantation (2.91 % vs 1.12 %, p = 0.03), venous thromboembolism (1.85 % vs 0.43 %, p = 0.01), and hemorrhage/hematoma (61.11 % vs 55.04 %, p = 0.04). In addition, MC patients had a longer time from admission to operation (3.35 ± 4.19 vs 2.82 ± 3.54 days, p = 0.03) and longer hospital length of stay (11.86 ± 8.17 vs 10.65 ± 8.08 days, p = 0.01).

CONCLUSION

Patients with MC had higher short-term mortality and morbidities after CABG. These findings can help provide insights for clinicians in the management of patients with concurrent coronary artery disease and MC, particularly in terms of preoperative risk stratification and therapeutic decision-making.

Multimodality Imaging in the Diagnostic Work-Up of Patients With Cardiac Masses: JACC: CardioOncology State-of-the-Art Review

Cardiac masses encompass a diverse range of benign and malignant tumors as well as pseudotumors. Accurate histologic identification is essential for guiding appropriate treatment, yet the diagnostic process remains challenging. Although biopsy is traditionally the diagnostic gold standard, its invasive nature and associated risks limit its application. A noninvasive multimodality imaging approach has recently emerged as an alternative, but standardized protocols and supporting evidence are still lacking. Echocardiography is typically the initial imaging modality, with cardiac magnetic resonance recognized as the noninvasive diagnostic gold standard. Cardiac computed tomography provides complementary data to aid in diagnosis and management, while positron emission tomography serves as a third-level imaging option. This state-of-the-art review highlights the role of current multimodality imaging techniques in diagnosing and managing cardiac masses and explores future directions for their applications.

Radiation Oncology Opinions and Practice on Cardiotoxicity in Lung Cancer: A Cross-sectional Study by the International Cardio-oncology Society

AIMS

Symptomatic radiation cardiotoxicity affects up to 30% patients with lung cancer and several heart substructure doses are associated with reduced overall survival. A greater focus on minimising cardiotoxicity is now possible due to advancements in radiotherapy technology and the new discipline of cardio-oncology, but uptake of emerging data has not been ascertained. A global cross-sectional analysis of Radiation Oncologists who treat lung cancer was therefore conducted by the International Cardio-Oncology Society in order to establish the impact of recently published literature and guidelines on practice.

MATERIALS AND METHODS

A bespoke questionnaire was designed following an extensive review of the literature and from recurring relevant themes presented at Radiation Oncology and Cardio-Oncology research meetings. Six question domains were retained following consensus discussions among the investigators, comprising 55 multiple choice stems: guidelines, cardiovascular assessment, cardiology investigations, radiotherapy planning strategies, primary prevention prescribing and local cardio-oncology service access. An invitation was sent to all Radiation Oncologists registered with ICOS and to Radiation Oncology colleagues of the investigators.

RESULTS

In total 118 participants were recruited and 92% were consultant physicians. The ICOS 2021 expert consensus statement was rated as the most useful position paper, followed by the joint ESC-ESTRO 2022 guideline. The majority (80%) of participants indicated that a detailed cardiovascular history was advisable. Although 69% of respondents deemed the availability of cardiac substructure auto-segmentation to be very/quite important, it was implemented by only a few, with the most common being the left anterior descending coronary artery V15. A distinct cardio-oncology service was available to 39% participants, while the remainder utilised general cardiology services.

CONCLUSION

The uptake of recent guidelines on cardiovascular optimisation is good, but access to cardiology investigations and consultations, and auto-segmentation, represent barriers to modifying radiotherapy practices in lung cancer to reduce the risk of radiation cardiotoxicity.

Determining sensitivity and specificity of risk scores for QTc interval prolongation in hemato-oncology patients prescribed systemic antifungal therapy: a retrospective cross-sectional study

BACKGROUND

QTc interval prolongation can result in potentially lethal arrhythmias. One risk factor is QTc-prolonging drugs, including some antifungals often used in hemato-oncology patients. Screening tools for patients at risk have not yet been investigated in this patient population.

AIM

Our aim was to evaluate the sensitivity and specificity of five QTc risk scores in hemato-oncology patients receiving systemic antifungal therapy.

METHOD

Data were retrieved from an internal study database including adult hemato-oncology patients prescribed systemic antifungal therapy. Data on QTc-prolonging medication, risk factors for QTc prolongation, and electrocardiograms (ECG) were collected retrospectively for a period of 12 months. The QTc risk scores according to Tisdale, Vandael, Berger, Bindraban, and Aboujaoude as well as their sensitivity and specificity were calculated.

RESULTS

During the evaluated period, 77 patients were prescribed systemic antifungals resulting in 187 therapy episodes. Regarding therapy episodes, median age was 56 years (IQR 44-68), 41% (77) were female, and a median of 3 QTc-prolonging drugs were prescribed (range 0-6). ECGs were available for 45 (24%) of the therapy episodes 3-11 days after initiation of the antifungal therapy, 22 of which showed QTc prolongation. Regarding these 45 therapy episodes, sensitivity and specificity of the risk scores were calculated as follows: Tisdale 86%/22%, Vandael 91%/35%, Berger 32%/83%, Bindraban 50%/78%, Aboujaoude 14%/87%.

CONCLUSION

The QTc risk scores according to Tisdale and Vandael showed sufficient sensitivity for risk stratification in the studied patient population. In contrast, risk scores according to Berger, Bindraban, and Aboujaoude cannot be considered suitable due to poor sensitivity.

Trends in cancer and heart failure related mortality in adult US population: A CDC WONDER database analysis from 1999 to 2020

BACKGROUND

With the advent of novel chemotherapy, survival of patients with cancer has improved. However, people with cancer have an increased risk of heart failure (HF). Conversely, HF-related mortality may undermine survival among people with cancer. We aim to analyze the trends of mortality in people with HF and cancer in the adult US population.

METHODS

We conducted an examination of death certificates sourced from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) database, from the years 1999 to 2020. Mortality in adults with HF and cancer was assessed. Age-adjusted mortality rates (AAMRs) per 100,000 persons and annual percent change were reported.

RESULTS

Between 1999 and 2020, 621,783 deaths occurred from HF in people with cancer. The AAMR declined from 16.4 in 1999 to 11.9 in 2017, after which an increase to 14.5 was observed in 2020. Men had consistently higher overall AAMR as compared to women (men = 18.1 vs women = 9.9). Similar AAMR was observed between non-Hispanic (NH) Blacks/African Americans (13.9) and NH Whites (13.3), with lower in American Indian/Alaska Native (9.6) and Hispanics (7.4). Asian/Pacific Islanders reported the lowest AAMR (5.7). The Midwestern region reported the highest AAMR (14.8). We observed the highest AAMR amongst the older population (61.4).

CONCLUSION

The mortality rates of people with HF and cancer are increasing in the adult U.S.

POPULATION

This underscores the need for increased screening, aggressive management, and subsequent surveillance of people at risk or with manifested HF in people with cancer.

Incident Myocardial Infarction, Heart Failure, and Oncologic Outcomes in Breast Cancer Survivors

Background

Cardiovascular disease (CVD) is associated with higher rates of incident cancer. Data are scarce regarding the association of incident CVD with oncologic outcomes after a cancer diagnosis.

Objectives

This study sought to determine whether incident myocardial infarction (MI) or heart failure (HF) in breast cancer survivors is associated with oncologic outcomes.

Methods

This was a population-based cohort study in Ontario, Canada, using linked administrative data sets of women diagnosed with first breast cancer between April 1, 2007, and March 31, 2015. A landmark analysis was conducted of women alive 2 years after breast cancer diagnosis, aged ≥40 years, and with available staging data and without recurrent/distant disease or preceding CVD. The exposure was a composite of MI and/or HF after the landmark date. The outcomes were cancer mortality, new non-breast malignancy diagnosis, and new chemotherapy initiation. Multivariable cause-specific hazards regression was used to determine the association of incident MI/HF (time-varying exposure) with outcomes.

Results

A total of 30,694 women (median age of 60 years) were included, of whom 1,346 developed incident MI/HF at a median of 3.9 years after the landmark date. At 5 years, the cumulative incidence was 5.9% (95% CI: 5.6%-6.1%) for cancer death, 4.3% (95% CI: 4.1%-4.6%) for non-breast malignancy, and 25.7% (95% CI: 25.2%-26.2%) for new chemotherapy. Incident MI/HF was associated with a higher hazard of cancer death (HR: 3.94; 95% CI: 3.38-4.59), non-breast malignancy (HR: 1.39; 95% CI: 1.06-1.82), and new chemotherapy (HR: 1.25; 95% CI: 1.02-1.53).

Conclusions

Incident MI and/or HF after breast cancer treatment are associated with higher hazards of adverse oncologic outcomes, highlighting the need to prioritize care for these patients.

Cardio-oncology and radiation oncology: How collaboration between cardiologists and oncologists can be realised in radiation oncology

Increased survivorship, improvements in cancer treatments, and the potential for cardiac side effects from cancer treatments have resulted in increased collaboration between oncologists and cardiologists and the development of cardio-oncology clinics. This collaboration is important given its role in ensuring greater patient satisfaction, aiding teams of clinicians in making complex treatment decision, and ensuring cardiac complications are diagnosed at an early stage. The particularities of implementing this collaboration in the field of radiation oncology and how this setting is different from other areas of cardio-oncology have not been well detailed in the literature. This paper will discuss what is currently understood about the need for and role of cardio-oncology and what a cardio-oncology services involves, with a particular emphasis on patient and clinician needs in the field of radiation oncology. The literature and recent guidelines do advocate for a detailed baseline assessment of cancer patients undergoing radiotherapy, especially patients with treatment or patient risk factors that increase their risk of cancer-therapy related cardiotoxicity. Advancements in cardiac imaging techniques will be discussed as these may help to diagnose cardiac side effects of certain cancer treatments, including radiotherapy, at an early stage. A multi-disciplinary and collaborative approach is well received by patients and such an approach, guided by the aim of maintaining a patient's cancer treatment wherever possible, should be the cornerstone of cardio-oncology clinics regardless of the patient's treatment regime.

Short- and long-term outcomes of patients with active cancer presenting with an acute coronary syndrome

BACKGROUND

Management of cancer patients presenting with an acute coronary syndrome (ACS) may be challenging. In this study, we sought to examine whether and how a concomitant diagnosis of active cancer affects patients' management and outcomes following an event of ACS.

METHODS

We used a retrospective cohort data analysis of patients from the Acute Coronary Syndrome Israeli Survey (ACSIS) carried out between the years 2016-2021 to compare patients with and without a concomitant diagnosis of active cancer.

RESULTS

Of 4913 patients who presented with an ACS, 90 (1.8%) patients had a concomitant active cancer. Cancer patients were older, with a higher prevalence of hypertension and chronic renal failure. The rate of ST-elevation myocardial infarction (STEMI) was similar (40%) between both groups. Cancer patients were less likely to undergo coronary angiography during hospitalization; but once it was performed, the rate of percutaneous coronary intervention was similar. The presence of cancer during an ACS was associated with an increased short- and long-term mortality. In a multivariate analysis, the risk for 1-year mortality remained significantly higher in cancer patient (HR 2.72, 95% CI 1.74-4.24, p < 0.001), and was most prominent in patients presenting with STEMI (HR 5.00, 95% CI 2.40-10.39, p < 0.001). Short- and long-term death rates were also higher in cancer patients after a propensity score matching and adjustment for comorbidities other than cancer.

CONCLUSION

Despite significant advances in oncologic and cardiac care, the presence of active cancer in patients with an ACS is still associated with significantly increased risk for 1-year mortality.

Elevations of Cardiac Troponin in Patients Receiving Immune Checkpoint Inhibitors: Data From a Prospective Study

Background

Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. However, immune-related adverse events are prevalent in patients receiving ICI therapy. A serious immune-related adverse event is ICI-myocarditis, which is complex to diagnose given that the significance of early symptoms and biomarker trajectories, such as high-sensitivity troponin T (hs-TnT) are unclear.

Objectives

The purpose of the study was to evaluate kinetics of hs-TnT in cancer patients receiving ICI and to identify patients at risk of developing ICI-myocarditis.

Methods

This prospective, observational, single-center study included 164 patients receiving ICI therapy. Patients' history, demographics, and clinical characteristics, as well as survival statistics, were collected from electronic patient records and used to analyze associations between elevated hs-TnT (≥14 ng/L) and a significant rise in hs-TnT (100% rise from baseline, with an absolute value ≥2x upper limit of normal (ie, ≥28 ng/L) with ICI-myocarditis.

Results

We included 164 patients with a mean follow-up time of 1.60 ± 0.91 years. Melanoma was the most common type of cancer in the patient population, and most patients received treatment with programmed cell death protein 1 (PD-1). Twenty-six patients (16%) exhibited significant hs-TnT elevations, while 8 patients (5%) developed ICI-myocarditis. In 18 of 26 (69%) patients, ICI-myocarditis could not be diagnosed with certainty, while 10 of 26 (38%) patients had no other signs of symptoms of cardiac damage. All 8 myocarditis cases were preceded by significantly higher hs-TnT elevations than asymptomatic patients. Despite a high ICI-myocarditis incidence in our study population, cardiac mortality remained low (4%).

Conclusions

Significant hs-TnT elevations occur more often than previously reported, are often asymptomatic, and do not always lead to myocarditis diagnosis.

The Incremental Value of Native T1 Mapping-Derived Radiomics for The Diagnosis of Amyloid Light-Chain Cardiac Amyloidosis

RATIONALE AND OBJECTIVES

This study aimed to assess the incremental diagnostic value of non-contrast T1 mapping-derived radiomics in patients with amyloid light-chain cardiac amyloidosis (AL-CA).

METHODS

We retrospectively collected 86 patients with suspected AL-CA and 28 control patients who underwent cardiac MRI at 3.0 T in our institution, and the MRI data were divided into a training set and a test set. Radiomic features were extracted based on native T1 maps using a freely available software package. We applied LASSO logistic regression method to select radiomic features with high diagnostic value of AL-CA and develop a predictive model. The diagnostic performance of the radiomics model was evaluated using receiver operating characteristic curve analysis and compared to T1 values.

RESULTS

A total of 70 people were diagnosed with AL-CA, and cardiac involvement was observed in 202 myocardial slicers. The accuracy of T1 values for the diagnosis of myocardial involvement was 0.886, with a threshold value of 1375 ms. The radiomics score comprised a total of three features. The radiomics score demonstrated significantly higher sensitivity in detecting myocardial involvement compared to T1 values in both the training set (AUC 0.886 vs. 0.924, P = 0.025) and the test set (0.862 vs 0.915, P = 0.026). The combined model comprising T1 values and a radiomic feature named S(4,-4) Correlat showed higher diagnostic performance in comparison to T1 values alone both in the training and test sets, with AUC values of 0.929 and 0.909, respectively.

CONCLUSION

The radiomic features derived from native T1 mapping demonstrated incremental value for the diagnosis of AL-CA, which may be an alternative to T1-derived ECV to avoid the use of contrast in patients with suspected myocardial involvement in systemic amyloidosis.

Follow-up of early breast cancer in a public health system: A 2024 AIGOM consensus project

Breast cancer stands as the most frequently diagnosed cancer and the primary cause of cancer-related mortality among women worldwide, including Italy. With the increasing number of survivors, many are enrolled in regular follow-up programs. However, adherence to recommendations from scientific societies (such as ASCO, ESMO, AIOM) for breast cancer follow-up management varies in daily clinical practice across different cancer centers, potentially resulting in unequal management and escalating costs. To address these concerns, the Italian Association of Multidisciplinary Oncology Groups (AIGOM) orchestrated a Consensus on early Breast Cancer follow-up utilizing the Estimate-Talk-Estimate methodology. Following the identification of 18 Items and 38 statements by a select Board, 46 out of 54 (85.1%) experts comprising a multidisciplinary and multiprofessional panel expressed their degree of consensus (Expert Panel). The Expert Panel underscores the potential for the multidisciplinary team to tailor follow-up intensity based on the individual risk of recurrence. In selected cases, the general practitioner may be recommended as the clinical lead for breast cancer follow-up, both after completion of adjuvant treatment and at early initiation of endocrine therapy in low-risk patients. Throughout follow-up, and alongside oncologic surveillance, the expert panel advises osteometabolic, cardiologic, and gynecologic surveillance for the early detection and management of early and late treatment toxicities. Moreover, preserving quality of life is emphasized, with provisions for psycho-oncologic support and encouragement to adopt protective lifestyle behaviors.

CD19-targeting chimeric antigen receptor T-cell therapy is safe and effective for intra-cardiac B cell non-Hodgkin lymphoma

Introduction

Chimeric antigen receptor T-cell (CAR-T) therapy is highly effective in B-cell blood cancers, but there is limited data on its safety and efficacy in intra-cardiac lymphoma, due to the potential risks of cardiotoxicity and pseudo-progression.

Discussion

We discuss four high-risk cases that were managed with a multi-disciplinary approach, including baseline cardiac risk assessment and surveillance with multimodal cardiac imaging and serum cardiac biomarkers, elective supportive care in the intensive care unit, and early treatment of cytokine release syndrome.

Conclusion

CAR-T therapy can be effective and safe in the treatment of B-cell blood cancers with intra-cardiac disease.

Is ibrutinib-related atrial fibrillation dose dependent? Insights from an individual case level analysis of the World Health Organization pharmacovigilance database

Whether ibrutinib-related atrial fibrillation (IRAF) is a dose-dependent adverse drug reaction (ADR) and whether ibrutinib should be discontinued or dose-reduced in case of IRAF occurrence remains unknown. Using the World Health Organization individual case safety report pharmacovigilance database, VigiBase®, we aimed to determine the association between ibrutinib dosing regimens and IRAF reporting. Ibrutinib daily dose was extracted from IRAF cases from VigiBase® and was divided into 5 ibrutinib dosing regimen (140-280-420-560 and >560 mg/day). Disproportionality analysis was used to evaluate the association between IRAF reporting and ibrutinib daily dose, through logistic regression. Single term deletions produced the ibrutinib daily dose global p-value. Then, a multivariable adjusted reporting odds-ratio with its 95% confidence interval was calculated for each ibrutinib dosing regimen, against the lowest dosing regimen (140 mg/day) as reference. A total of 1162 IRAF cases were identified in VigiBase® (n = 62 for ibrutinib 140 mg/day, 114 for ibrutinib 280 mg/day, 811 for ibrutinib 420 mg/day, 164 for ibrutinib 560 mg/day and 11 for ibrutinib >560 mg/day). After adjustment on several variables of interest, IRAF reporting was not significantly associated with ibrutinib dosing regimen (p = 0.09). Our results from Vigibase® do not support IRAF as a dose-dependent ADR (ClinicalTrial registration number: NCT06224452).

[Cardiovascular adverse effects of Bruton tyrosine kinase inhibitors: Pathophysiological mechanisms, screening, and management]

The covalent Bruton tyrosine kinase inhibitors (iBTKs) have profoundly transformed the management of B-cell lymphoid malignancies, particularly chronic lymphocytic leukemia (CLL). These targeted therapies, with ibrutinib as the pioneer, have paved the way for significant improvement in the prognosis of many patients. With second-generation iBTKs such as acalabrutinib and zanubrutinib, the therapeutic landscape has expanded, offering potential new options for patients with CLL. This review focuses on the cardiovascular adverse effects associated with these treatments. It delves into the underlying pathophysiological mechanisms of these effects, highlighting the complex interactions between these molecules and the cardiovascular system. Additionally, it examines the frequency of adverse effects according to the type of iBTK, drawing on data from clinical trials and real-world clinical practice. Finally, the importance of close cardio-oncological monitoring is emphasized, with essential collaboration between hematologists and cardiologists. Strategies for screening and managing cardiovascular adverse effects are also discussed, emphasizing the need for a proactive approach in managing these complications. Experts propose a pragmatic follow-up of these patients, through a central illustration and a figure adapted from European cardio-oncology guidelines, to simplify hematologists' practice.

A roadmap for modelling radiation-induced cardiac disease

Cardiac risk mitigation is a major priority in improving outcomes for cancer survivors as advances in cancer screening and treatments continue to decrease cancer mortality. More than half of adult cancer patients will be treated with radiotherapy (RT); therefore it is crucial to develop a framework for how to assess and predict radiation-induced cardiac disease (RICD). Historically, RICD was modelled solely using whole heart metrics such as mean heart dose. However, data over the past decade has identified cardiac substructures which outperform whole heart metrics in predicting for significant cardiac events. Additionally, non-RT factors such as pre-existing cardiovascular risk factors and toxicity from other therapies contribute to risk of future cardiac events. In this review, we aim to discuss the current evidence and knowledge gaps in predicting RICD and provide a roadmap for the development of comprehensive models based on three interrelated components, (1) baseline CV risk assessment, (2) cardiac substructure radiation dosimetry linked with cardiac-specific outcomes and (3) novel biomarker development.

SGLT2i and Primary Prevention of Cancer Therapy-Related Cardiac Dysfunction in Patients With Diabetes

Background

Specific cancer treatments can lead to cancer therapy-related cardiac dysfunction (CTRCD). Sodium glucose cotransporter-2 inhibitors (SGLT2is) can potentially prevent these cardiotoxic effects.

Objectives

This study sought to determine whether SGLT2i use is associated with a lower incidence of CTRCD in patients with type 2 diabetes mellitus (T2DM) and cancer, exposed to potentially cardiotoxic antineoplastic agents, and without a prior documented history of cardiomyopathy or heart failure.

Methods

We conducted a retrospective analysis of patients aged ≥18 years within the TriNetX database with T2DM, cancer, exposure to cardiotoxic therapies, and no prior documented history of cardiomyopathy or heart failure. Patients were categorized by SGLT2i use. After propensity score matching, outcomes were compared over 12 months using Cox proportional HRs. Subgroup analyses focusing on different cancer therapy classes were performed.

Results

The study included 8,675 propensity-matched patients in each cohort (mean age = ∼65 years, 42% females, 71% White, ∼19% gastrointestinal malignancy, and ∼25% anthracyclines). Patients prescribed SGLT2is had a lower risk of developing CTRCD (HR: 0.76: 95% CI: 0.69-0.84). SGLT2is also reduced heart failure exacerbations (HR: 0.81; 95% CI: 0.72-0.90), all-cause mortality (HR: 0.67; 95% CI: 0.61-0.74), and all-cause hospitalizations/emergency department visits (HR: 0.93; 95% CI: 0.89-0.97). Subgroup analyses also demonstrated reduced CTRCD risk across various classes of cancer therapies in patients prescribed SGLT2is.

Conclusions

SGLT2i administration was associated with a significantly decreased risk of developing CTRCD in patients with T2DM and cancer.