Defining cardiovascular toxicities of cancer therapies: an International Cardio-Oncology Society (IC-OS) consensus statement

The Value of Troponin as a Biomarker of Chemotherapy-Induced Cardiotoxicity

In cancer survivors, cardiac dysfunction is the main cause of mortality. Cardiotoxicity represents a decline in cardiac function associated with cancer therapy, and the risk factors include smoking, dyslipidemia, an age of over 60 years, obesity, and a history of coronary artery disease, diabetes, atrial fibrillation, or heart failure. Troponin is a biomarker that is widely used in the detection of acute coronary syndromes. It has a high specificity, although it is not exclusively associated with myocardial ischemia. The aim of this paper is to summarize published studies and to establish the role of troponin assays in the diagnosis of cardiotoxicity associated with various chemotherapeutic agents. Troponin has been shown to be a significant biomarker in the diagnosis of the cardiac dysfunction associated with several types of chemotherapeutic drugs: anthracyclines, anti-human epidermal growth factor receptor 2 treatment, and anti-vascular endothelial growth factor therapy. Based on the data available at this moment, troponin is useful for baseline risk assessment, the diagnosis of cardiotoxicity, and as a guide for the initiation of cardioprotective treatment. There are currently clear regulations regarding the timing of troponin surveillance depending on the patient’s risk of cardiotoxicity and the type of medication administered, but data on the cut-off values of this biomarker are still under investigation.

Anthracycline-induced cardiotoxicity: From pathobiology to identification of molecular targets for nuclear imaging

Anthracyclines are a widely used class of chemotherapy in pediatric and adult cancers, however, their use is hampered by the development of cardiotoxic side-effects and ensuing complications, primarily heart failure. Clinically used imaging modalities to screen for cardiotoxicity are mostly echocardiography and occasionally cardiac magnetic resonance imaging. However, the assessment of diastolic and global or segmental systolic function may not be sensitive to detect subclinical or early stages of cardiotoxicity. Multiple studies have scrutinized molecular nuclear imaging strategies to improve the detection of anthracycline-induced cardiotoxicity. Anthracyclines can activate all forms of cell death in cardiomyocytes. Injury mechanisms associated with anthracycline usage include apoptosis, necrosis, autophagy, ferroptosis, pyroptosis, reactive oxygen species, mitochondrial dysfunction, as well as cardiac fibrosis and perturbation in sympathetic drive and myocardial blood flow; some of which have been targeted using nuclear probes. This review retraces the pathobiology of anthracycline-induced cardiac injury, details the evidence to date supporting a molecular nuclear imaging strategy, explores disease mechanisms which have not yet been targeted, and proposes a clinical strategy incorporating molecular imaging to improve patient management.

Traditional and Emerging Sex-Specific Risk Factors for Cardiovascular Disease in Women

Cardiovascular disease (CVD) remains a major health threat in women. While traditional CVD risk factors such as hypertension, hyperlipidemia, diabetes, and smoking have been recognized for over 50 years, optimal control of these risk factors remains a major challenge. Unique sex-specific risk factors such as adverse pregnancy outcomes, premature menopause and low estrogen states, and chronic autoimmune inflammatory disorders also contribute to increased CVD risk in women. In addition, psychological risk factors such as stress, depression, and social determinants of health may have a disproportionately adverse impact in women. An improved understanding of traditional and emerging sex-specific CVD risk factors and management of modifiable factors is critical for clinicians who provide care for women. Early recognition and treatment of risk factors may alter the trajectory of adverse CVD events. A multi-disciplinary approach with team-based care involving multiple specialists and improved, targeted educational efforts are needed to reduce CVD risk factors and its adverse consequences in women.

Cardiovascular Magnetic Resonance Imaging in the Early Detection of Cardiotoxicity Induced by Cancer Therapies

The significant progress in cancer treatment, including chemotherapy, immunotherapy, radiotherapy, and combination therapies, has led to higher long-term survival rates in cancer patients, while the cardiotoxicity caused by cancer treatment has become increasingly prominent. Cardiovascular magnetic resonance (CMR) is a non-invasive comprehensive imaging modality that provides not only anatomical information, but also tissue characteristics and cardiometabolic and energetic assessment, leading to its increased use in the early identification of cardiotoxicity, and is of major importance in improving the survival rate of cancer patients. This review focused on CMR techniques, including myocardial strain analysis, T1 mapping, T2 mapping, and extracellular volume fraction (ECV) calculation in the detection of early myocardial injury induced by cancer therapies. We summarized the existing studies and ongoing clinical trials using CMR for the assessment of subclinical ventricular dysfunction and myocardial changes at the tissue level. The main focus was to explore the potential of clinical and preclinical CMR techniques for continuous non-invasive monitoring of myocardial toxicity associated with cancer therapy.

Advanced Echocardiographic Techniques in Cardio-Oncology: the Role for Early Detection of Cardiotoxicity

PURPOSE OF REVIEW

Implementation of advanced echocardiographic techniques in cardio-oncology is a growing need as they are the cornerstone of early detection of cancer therapy-related cardiovascular toxicity (CTR-CVT).

RECENT FINDINGS

Three-dimensional echocardiography and myocardial deformation techniques have shown more accuracy and reproducibility than classic 2D measurements in detecting cardiovascular adverse effects in patients undergoing anticancer therapies. Application of advanced echo techniques to daily monitoring of patients with cancer helps to identify those at risk of developing CTR-CVT during and after cancer treatment. Furthermore, advanced echo parameters improve early initiation of cardioprotective treatments in order to minimize cardiovascular events and cancer treatment interruption.

Myocardial Ischemia Related to Common Cancer Therapy-Prevention Insights

Modern antineoplastic therapy improves survival and quality of life in cancer patients, but its indisputable benefits are accompanied by multiple and major side effects, such as cardiovascular ones. Endothelial dysfunction, arterial spasm, intravascular thrombosis, and accelerated atherosclerosis affect the coronary arteries, leading to acute and chronic coronary syndromes that negatively interfere with the oncologic treatment. The cardiac toxicity of antineoplastic agents may be mitigated by using adequate prophylactic measures. In the absence of dedicated guidelines, our work provides the most comprehensive, systematized, structured, and up-to-date analyses of the available literature focusing on measures aiming to protect the coronary arteries from the toxicity of cancer therapy. Our work facilitates the implementation of these measures in daily practice. The ultimate goal is to offer clinicians the necessary data for a personalized therapeutic approach for cancer patients receiving evidence-based oncology treatments with potential cardiovascular toxicity.

Role of Myocardial Strain Imaging in Cancer Therapy-Related Cardiac Dysfunction

PURPOSE OF REVIEW

This review aims to provide a contemporary perspective on the role of myocardial strain imaging in the management of patients on cardiotoxic therapy.

RECENT FINDINGS

Risk/benefit evaluation of cardiotoxic cancer treatment remains challenging, weighing life-saving cancer therapy with fatal cardiac dysfunction potentially caused by cancer therapy. The serial change in left ventricular ejection fraction (LVEF) was conventionally used for the detection of cancer therapy-related cardiac dysfunction (CTRCD). Peak systolic global longitudinal strain (GLS) by speckle-tracking echocardiography has turned into a vital pre- and post-chemotherapy assessment for the early detection of cardiotoxicity. Complexity in cardiotoxic therapy regimen, different definition of CTRCD by LVEF, variations in GLS values, timings, and variable cutoffs make it challenging to standardize the protocol for the detection of CTRCD. GLS > 15% relative reduction from baseline has been widely used. Evidence suggests that GLS could predict early subclinical LV dysfunction, and initiation of cardioprotective therapy led to less decline of LV function. Most of the studies used an echocardiographic endpoint, and the impact of GLS on the long-term clinical outcome is not established. GLS has emerged as a reliable measure to identify early subclinical LV dysfunction by detecting myocardial deformation in patients on cardiotoxic chemotherapy. To date, a significant decline in GLS suggests the initiation of cardioprotective therapy with close monitoring. Interruption of prognostically important cardiotoxic chemotherapies requires a multidisciplinary team approach guided mainly by LVEF and other clinical factors. Further randomized control trials with hard clinical endpoints and longer follow-ups may help to determine the role of GLS in CTRCD.

Baseline Electrocardiographic and Echocardiographic Assessment May Help Predict Survival in Lung Cancer Patients-A Prospective Cardio-Oncology Study

Cardiovascular disease and cancer coexist and lead to exertional dyspnea. The aim of the study was to determine the prognostic significance of cardiac comorbidities, ECG and baseline echocardiography in lung cancer patients with varying degrees of reduced performance status. This prospective study included 104 patients with histopathologically confirmed lung cancer, pre-qualified for systemic treatment due to metastatic or locally advanced malignancy but not eligible for thoracic surgery. The patients underwent a comprehensive cardio-oncological evaluation. Overall survival negative predictors included low ECOG 2 (Eastern Cooperative Oncology Group) performance status, stage IV (bone or liver/adrenal metastases in particular), pleural effusion, the use of analgesics and among cardiac factors, two ECG parameters: atrial fibrillation (HR = 2.39) and heart rate >90/min (HR = 1.67). Among echocardiographic parameters, RVSP > 39 mmHg was a negative predictor (HR = 2.01), while RVSP < 21 mmHg and RV free wall strain < −30% were positive predictors (HR = 0.36 and HR = 0.56, respectively), whereas RV GLS < −25.5% had a borderline significance (HR = 0.59; p = 0.05). Logistical regression analysis showed ECOG = 2 significantly correlated with the following echocardiographic parameters: increasing RVSP, RV GLS, RV free wall strain and decreasing ACT, FAC (p < 0.05). Selected echocardiographic parameters may be helpful in predicting poor performance in lung cancer patients and, supplemented with ECG evaluation, broaden the possibilities of prognostic evaluation.

Shining Damaged Hearts: Immunotherapy-Related Cardiotoxicity in the Spotlight of Nuclear Cardiology

The emerging use of immunotherapies in cancer treatment increases the risk of immunotherapy-related cardiotoxicity. In contrast to conventional chemotherapy, these novel therapies have expanded the forms and presentations of cardiovascular damage to a broad spectrum from asymptomatic changes to fulminant short- and long-term complications in terms of cardiomyopathy, arrythmia, and vascular disease. In cancer patients and, particularly, cancer patients undergoing (immune-)therapy, cardio-oncological monitoring is a complex interplay between pretherapeutic risk assessment, identification of impending cardiotoxicity, and post-therapeutic surveillance. For these purposes, the cardio-oncologist can revert to a broad spectrum of nuclear cardiological diagnostic workup. The most promising commonly used nuclear medicine imaging techniques in relation to immunotherapy will be discussed in this review article with a special focus on the continuous development of highly specific molecular markers and steadily improving methods of image generation. The review closes with an outlook on possible new developments of molecular imaging and advanced image evaluation techniques in this exciting and increasingly growing field of immunotherapy-related cardiotoxicity.

Automated Global Longitudinal Strain Assessment in Long-Term Survivors of Childhood Acute Lymphoblastic Leukemia

There is limited evidence that supports the use of the global longitudinal strain (GLS) in long-term cardiac monitoring of childhood acute lymphoblastic leukemia survivors (CLSs). Our aim was to assess the utility of automated GLS to detect left ventricular systolic dysfunction (LVSD) in long-term CLSs. Asymptomatic and subclinical LVSD were defined as LVEF < 50% and GLS < 18.5%, respectively. Echocardiographic measurements and biomarkers were compared with a control group. Inverse probability weighting was used to reduce confounding. Regression models were used to identify factors associated with LVEF and GLS in the survivors. Ninety survivors with a median follow-up of 18 (11−26) years were included. The prevalence of LVSD was higher using GLS than with LVEF (26.6% vs. 12.2%). The measurements were both reduced as compared with the controls (p < 0.001). There were no differences in diastolic parameters and NT-ProBNP. Survivors were more likely to have Hs-cTnI levels above the detection limit (40% vs. 17.2%, p = 0.006). The dose of anthracycline was associated with LVEF but not with GLS in the survivors. Biomarkers were not associated with GLS or LVEF. In conclusion, LVSD detection using automated GLS was higher than with LVEF in long-term CLSs. Its incorporation into clinical routine practice may improve the surveillance of these patients.

Cancer Therapies and Vascular Toxicities

OPINION STATEMENT

Vascular events have become an important issue in the overall management of cancer patients. They usually result from a combination of (i) direct or indirect toxicity of anticancer treatments, (ii) a higher prevalence of cardiovascular risk factors in cancer patients, and (iii) prolonged exposure to treatments due to an increasing patient survival rate. In addition to conventional chemotherapies and radiotherapy, targeted therapies and immunotherapies have been developed which improve the prognosis of cancer patients but sometimes at the cost of vascular toxicity, which can lead to systemic or pulmonary hypertension and arterial/venous thromboembolic events. Endothelial dysfunction, a procoagulant state and metabolic disorders are the three main pathophysiological patterns leading to cancer treatment-related vascular toxicity. This issue is challenging because serious vascular adverse events can necessitate cancer treatment being put on hold or stopped, which could compromise patient survival. In addition to increasing the risk of thrombotic adverse events, cancer therapies may lead to an increased risk of bleeding, especially in treatments with vascular endothelial growth factor inhibitors. Therefore, we can define vasculo-oncology as a part of the cardio-oncology specialty; its aims are to predict, prevent, screen, and treat vascular toxicity related to cancer treatments. While the level of evidence is low regarding the management of vascular toxicity during cancer therapy, cardiologists and specialists in vascular diseases should closely collaborate with oncologists and hematologists to determine the optimal strategy for each patient.

Mechanistic and Clinical Overview Cardiovascular Toxicity of BRAF and MEK Inhibitors: JACC: CardioOncology State-of-the-Art Review

Rapidly accelerated fibrosarcoma B-type (BRAF) and mitogen-activated extracellular signal-regulated kinase (MEK) inhibitors have revolutionized melanoma treatment. Approximately half of patients with melanoma harbor a BRAF gene mutation with subsequent dysregulation of the RAF-MEK-ERK signaling pathway. Targeting this pathway with BRAF and MEK blockade results in control of cell proliferation and, in most cases, disease control. These pathways also have cardioprotective effects and are necessary for normal vascular and cardiac physiology. BRAF and MEK inhibitors are associated with adverse cardiovascular effects including hypertension, left ventricular dysfunction, venous thromboembolism, atrial arrhythmia, and electrocardiographic QT interval prolongation. These effects may be underestimated in clinical trials. Baseline cardiovascular assessment and follow-up, including serial imaging and blood pressure assessment, are essential to balance optimal anti-cancer therapy while minimizing cardiovascular side effects. In this review, an overview of BRAF/MEK inhibitor-induced cardiovascular toxicity, the mechanisms underlying these, and strategies for surveillance, prevention, and treatment of these effects are provided.

Cardiac monitoring during trastuzumab therapy in metastatic breast cancer: early incidence of cardiac dysfunction

Trastuzumab therapy has dramatically changed breast cancer prognosis. Consensus documents recommend a close monitoring during therapy, not always feasible, especially in metastatic breast cancer. The purpose of this study is to describe trastuzumab cardiotoxicity in metastatic breast cancer patients to understand how to improve cardiovascular monitoring. We retrospectively studied metastatic breast cancer patients scheduled for trastuzumab therapy (2001-2018). All patients underwent a baseline evaluation and monitoring during therapy. Cardiotoxicity was defined as symptomatic heart failure or asymptomatic decrease in left ventricular ejection fraction > 10% from baseline and < 53%. Ninety-two women were included, mean age 61 years (±14.43), median follow-up 42.5 months (IQR 26-74). Fourteen percent developed cardiotoxicity:  two heart failure with preserved left ventricular ejection fraction, three heart failure with reduced left ventricular ejection fraction, and eight asymptomatic decreased in left ventricular ejection fraction. Eighty-one percent of cardiac dysfunction cases occurred within the first 4 years and on median of 31 months from trastuzumab initiation. Thus, in metastatic breast cancer patients, trastuzumab-mediated cardiotoxicity occurred more frequently during the first 4 years. These data should be considered to optimize follow-up protocols.

The year in cardiovascular medicine 2021: heart failure and cardiomyopathies

In the year 2021, the universal definition and classification of heart failure (HF) was published that defines HF as a clinical syndrome with symptoms and/or signs caused by a cardiac abnormality and corroborated by elevated natriuretic peptide levels or objective evidence of cardiogenic congestion. This definition and the classification of HF with reduced ejection fraction (HFrEF), mildly reduced, and HF with preserved ejection fraction (HFpEF) is consistent with the 2021 ESC Guidelines on HF. Among several other new recommendations, these guidelines give a Class I indication for the use of the sodium-glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin and empagliflozin in HFrEF patients. As the first evidence-based treatment for HFpEF, in the EMPEROR-Preserved trial, empagliflozin reduced the composite endpoint of cardiovascular death and HF hospitalizations. Several reports in 2021 have provided novel and detailed analyses of device and medical therapy in HF, especially regarding sacubitril/valsartan, SGLT2 inhibitors, mineralocorticoid receptor antagonists, ferric carboxymaltose, soluble guanylate cyclase activators, and cardiac myosin activators. In patients hospitalized with COVID-19, acute HF and myocardial injury is quite frequent, whereas myocarditis and long-term damage to the heart are rather uncommon.