Beyond hypertension: Diastolic dysfunction associated with cancer treatment in the era of cardio-oncology

Pharmacotherapy for Cancer Treatment-Related Cardiac Dysfunction and Heart Failure in Childhood Cancer Survivors

The number of childhood cancer survivors is increasing rapidly. According to American Association for Cancer Research, there are more than 750,000 childhood cancer survivors in the United States and Europe. As the number of childhood cancer survivors increases, so does cancer treatment-related cardiac dysfunction (CTRCD), leading to heart failure (HF). It has been reported that childhood cancer survivors who received anthracyclines are 15 times more likely to have late cancer treatment-related HF and have a 5-fold higher risk of death from cardiovascular (CV) disease than the general population. CV disease is the leading cause of death in childhood cancer survivors. The increasing need to manage cancer survivor patients has led to the rapid creation and adaptation of cardio-oncology. Cardio-oncology is a multidisciplinary science that monitors, treats, and prevents CTRCD. Many guidelines and position statements have been published to help diagnose and manage CTRCD, including those from the American Society of Clinical Oncology, the European Society of Cardiology, the Canadian Cardiovascular Society, the European Society of Medical Oncology, the International Late Effects of Childhood Cancer Guideline Harmonization Group, and many others. However, there remains a gap in identifying high-risk patients likely to develop cardiomyopathy and HF in later life, thus reducing primary and secondary measures being instituted, and when to start treatment when there is echocardiographic evidence of left ventricular (LV) dysfunctions without symptoms of HF. There are no randomized controlled clinical trials for treatment for CTRCD leading to HF in childhood cancer survivors. The treatment of HF due to cancer treatment is similar to the guidelines for general HF. This review describes the latest pharmacologic therapy for preventing and treating LV dysfunction and HF in childhood cancer survivors based on expert consensus guidelines and extrapolating data from adult HF trials.

Report from the Cardio-Oncology Symposium at the Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) Annual Congress

Overview of the meeting The Cardio-Oncology Symposium at the Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) Annual Meeting mainly focused on the diagnosis, management and prevention of cardiovascular toxicity of cancer drugs, in particular, cardiac dysfunction induced by anthracyclines. Although a variety of cardiac biomarkers and imaging modalities are available, there remains no consensus regarding their appropriate use to identify early and late cardiotoxicity and to guide preventive strategies. At the same time, the multitude of pharmacological trials, aimed at preventing cardiac damage through a neurohormonal blockade, provided conflicting results. Nevertheless, the advent of novel heart failure medications can change the decision-making of the cardio-oncologist. This symposium attempted to harmonize these issues.

Cardiac Imaging in Childhood Cancer Survivors: A State-of-the-Art Review

Childhood cancer survival has improved significantly in the past few decades, reaching rates of 80% or more at 5 years. However, with improved survival, early- and late-occurring complications of chemotherapy and radiotherapy exposure are becoming progressively more evident. Cardiovascular diseases represent the leading cause of non-oncological morbidity and mortality in this highly vulnerable population. Therefore, the necessity of reliable, noninvasive screening tools able to early identify cardiac complications early is now pre-eminent in order to implement prevention strategies and mitigate disease progression. Echocardiography, may allow identification of myocardial dysfunction, pericardial complications, and valvular heart diseases. However, additional imaging modalities may be necessary in selected cases. This manuscript provides an in-depth review of noninvasive imaging parameters studied in childhood cancer survivors. Furthermore, we will illustrate brief surveillance recommendations according to available evidence and future perspectives in this expanding field.

Incidence of adverse cardiovascular events associated with immune checkpoint inhibitors and risk factors for left ventricular dysfunction: A single-center prospective clinical study

Background

The incidence of immune checkpoint inhibitors (ICI)-related adverse cardiovascular events (ACEs) may be underestimated, and there are few reports on the incidence and risk factors of ICI-induced left ventricular dysfunction (LVD).

Objectives

This study aimed to investigate the incidence of ACEs caused by ICI, in particular to analyze the incidence and risk factors of LV systolic and diastolic dysfunction.

Materials and methods

A prospective clinical study was performed on patients who received ICI in our hospital from November 2020 to October 2021. They received regular cardiovascular examinations, including echocardiography, ECG, cTnT, and NT-proBNP, etc. The incidence of various ACEs was counted, and the risk factors of LVD were analyzed.

Results

A total of 106 cancer patients treated with ICI were recruited. During the follow-up, 41 patients (38.68%) developed various ECG abnormalities, 39 patients (36.79%) developed LVDD, 9 patients (8.49%) developed CTRCD, and 2 patients (1.89%) developed new pericardial effusion. The patients with elevated cTnT, CK-MB, and NT-proBNP were 10 (9.43%), 8 (7.55%), and 8 (7.5%), respectively. Thirteen of the 52 patients with LVD had hypertension, while 4 of the 54 patients without LVD had hypertension (OR = 4.17, 95% CI: 1.26-13.78; P = 0.019). The baseline LVEF and LVFS of patients with LVD were 61.54 ± 4.15% and 33.78 ± 2.73%, while those of the control group were 64.16 ± 3.68% and 34.95 ± 2.84, respectively (P = 0.003 and P = 0.048). Compared with patients without LVD, patients with LVD had lower e' (6.99 ± 1.33 cm/s vs. 7.64 ± 1.39 cm/s, P = 0.029) and higher E to e' ratio (11.89 ± 3.15 cm/s vs. 10.43 ± 2.52, P = 0.024). Multiple regression analysis showed that a history of hypertension (HR = 26.52, 95% CI: 2.479-283.667, P = 0.007) and lower baseline e' (HR = 0.04, 95% CI: 0.003-0.709, P = 0.028) were risk factors for developing LVD.

Conclusion

Patients treated with ICI may develop multiple ACEs, including acute myocarditis, pericarditis, ECG abnormalities, and elevated cardiac biomarkers. ICI may lead to a high incidence of LVD, and echocardiography is helpful for early detection of LVD. Patients with hypertension or poor LV systolic or diastolic function at baseline were predictors of LVD after ICI treatment.