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)

The role of a cardio-oncology clinical nurse specialist in the United Kingdom

Cardio-oncology is a growing subspeciality of cardiology that involves the prevention and early detection of cancer therapy-related cardiovascular toxicity (CTR-CVT). Cardiovascular complications can occur before, during and after cancer treatment, due to de novo cardiotoxicity or an exacerbation of a previous cardiac condition. Therefore, cancer patients undergoing cancer treatment need to be assessed before, during and after their cancer treatment. This article describes the development and progress of a specialised nursing role, known as a Clinical Nurse Specialist (CNS), at the Royal Brompton Hospital in London, United Kingdom (UK).

The Digital Revolution in Medicine: Applications in Cardio-Oncology

Purpose of review

A critical evaluation of contemporary literature regarding the role of big data, artificial intelligence, and digital technologies in precision cardio-oncology care and survivorship, emphasizing innovative and groundbreaking endeavors.

Recent findings

Artificial intelligence (AI) algorithm models can automate the risk assessment process and augment current subjective clinical decision tools. AI, particularly machine learning (ML), can identify medically significant patterns in large data sets. Machine learning in cardio-oncology care has great potential in screening, diagnosis, monitoring, and managing cancer therapy-related cardiovascular complications. To this end, large-scale imaging data and clinical information are being leveraged in training efficient AI algorithms that may lead to effective clinical tools for caring for this vulnerable population. Telemedicine may benefit cardio-oncology patients by enhancing healthcare delivery through lowering costs, improving quality, and personalizing care. Similarly, the utilization of wearable biosensors and mobile health technology for remote monitoring holds the potential to improve cardio-oncology outcomes through early intervention and deeper clinical insight. Investigations are ongoing regarding the application of digital health tools such as telemedicine and remote monitoring devices in enhancing the functional status and recovery of cancer patients, particularly those with limited access to centralized services, by increasing physical activity levels and providing access to rehabilitation services.

Summary

In recent years, advances in cancer survival have increased the prevalence of patients experiencing cancer therapy-related cardiovascular complications. Traditional cardio-oncology risk categorization largely relies on basic clinical features and physician assessment, necessitating advancements in machine learning to create objective prediction models using diverse data sources. Healthcare disparities may be perpetuated through AI algorithms in digital health technologies. In turn, this may have a detrimental effect on minority populations by limiting resource allocation. Several AI-powered innovative health tools could be leveraged to bridge the digital divide and improve access to equitable care.

Association of thromboxane generation with the bleeding events in aspirin users

Coronary artery disease is among the leading causes of morbidity and mortality worldwide, posing a significant threat to human health and life. Aspirin is widely used in the treatment of coronary artery disease, however, long-term use may increase the risk of bleeding. Urinary 11-dehydro-TXB2, a biomarker indicative of platelet activation, has been associated with thrombotic events, but its association with bleeding events remains unexplored. This study aimed to assess the predictive value of TXB2-M levels for bleeding events in patients with coronary artery disease undergoing aspirin therapy. Multifactorial logistic regression analysis was employed to evaluate the potential of TXB2-M levels as a reliable marker for bleeding risk following aspirin use. Among patients with coronary artery disease treated with aspirin, those with lower TXB2-M levels exhibited an increased risk of bleeding events within three years (Hazard Ratio: 0.46; 95% Confidence Interval: 0.26-0.79; P < 0.05). Additionally, variations in TXB2-M levels were observed across different demographic groups. This study reinforces the validity of TXB2-M levels as a biomarker for identifying patients at elevated risk of bleeding, thus facilitating the implementation of personalized treatment strategies to minimize bleeding risks while preserving the efficacy of antithrombotic therapy.

Prediction for cardiac and pulmonary toxicity in a multicentric cohort of advanced stage NSCLC patients using sub-regions of the heart

Purpose

Follow-up investigations in locally advanced stage non-small cell lung cancer (NSCLC) patients treated with radiochemotherapy (RCHT) regularly focus around lung toxicity. However, Cardiac Adverse Events (CAE) can occur much earlier in patients than originally anticipated with serious repercussions for patient quality-of-life and survival.Therefore, here we investigated spatial dependencies of dose within the heart and their correlation with toxicity, with dosimetric parameters of sub-regions of the heart at the focus of this analysis.Additionally, we aimed to explore the connection between cardiac toxicity and pulmonary toxicity.

Methods

Patient treatment plans with dosimetric data for the lungs and the heart, as well as toxicity data for 502 NSCLC patients treated with either passively scattered proton therapy (PSPT), intensity modulated radiation therapy (IMRT), three-dimensional conformal radiation therapy (3DCRT) or volumetric arc therapy (VMAT) with or without chemotherapy was retrospectively retrieved from prospective clinical studies of three international centers. Cardiac toxicity data was not available for all patients. Data was randomly split into a training set (336) and validation set (166). Statistical analyses were performed using binomial logistic regression.

Results

In univariate modeling, the Mean Lung Dose (MLD) significantly predicted CAE grade ≥ 3 in the training-set (pMLD = 0.02, AUCtrain = 0.69), which was confirmed in validation (AUCval, = 0.77). No suitable candidates for the construction of multivariate models could be identified. Parameters of the heart and its subregions did not significantly predict CAE grade ≥ 3 in the investigated cohorts. No parameters were found to significantly predict CAE grade ≥ 2 or RP. Finally, no spatial dependency was found in the investigated toxicity data.

Conclusion

The pulmonary dosimetric parameter MLD successfully predicted CAE grade ≥ 3 in a cohort treated with either photons or protons. Cardiac dosimetric parameters as well as spatial parameters did not perform similarly. No parameters were found to significantly predict RP in the investigated cohorts.

Cardiogenic shock in patients with active onco-hematological malignancies: A multicenter retrospective study

PURPOSE

Onco-hematological (OH) patients face significant cardiovascular risks due to malignancy and drug toxicity. Data are limited on the characteristics and outcomes of OH patients with cardiogenic shock (CS) in intensive care units (ICUs).

METHODS

This multicenter retrospective study included 214 OH patients with CS across 22 ICUs (2010-2021). The objectives were to (i) identify risk factors for 30-day mortality, (ii) describe early and long-term outcomes, and (iii) assess the prognostic impact of malignancy by comparing OH patients to a control group of CS patients.

RESULTS

The 30-day survival rate was 44.8 %. Multivariate analysis identified previous cardiomyopathy (OR = 1.61), acute kidney injury (OR = 1.62), lactate levels (OR = 1.08 per 1 mmol/L), pulmonary embolism (OR = 3.04), invasive mechanical ventilation (OR = 3.48), and epinephrine use (OR = 2.09) as factors associated with 30-day mortality. Among ICU survivors, 54 % were alive at 1 year with a median left ventricular ejection fraction of 52 %. OH malignancy was significantly associated with 30-day mortality (HR 2.54).

CONCLUSION

The prognosis for OH patients with CS in the ICU is poor, with epinephrine use associated with worse outcomes. Further research is needed to refine risk stratification and improve treatments for this population.

Atrial fibrillation in cancer patients: Epidemiology, identification and management

Cancer and cardiovascular disease (CVD) are among the leading causes of death globally, and the rate of coexistence of the two diseases has been increasing in recent years, with the elevation of the susceptible population base in aging societies and the improvement of therapeutic approaches. Atrial fibrillation (AF), as a common type of cancer-related cardiovascular toxicity (CTR-CVT) in oncology patients, is a serious threat to patients' health and may lead to other cardiovascular complications. Therefore, early detection, timely recognition, and effective intervention of AF are essential to maintain long-term survival of tumor survivors. However, the causal mechanisms regarding its association are still inconclusive, and there is no consensus in the clinic on the optimal treatment. In this review, we will integrate existing guidelines and studies to summarize the current state of research on atrial fibrillation in oncology patients in terms of epidemiology, pathophysiological mechanisms, predictive diagnostics, and therapeutic measures, and propose some research directions to be improved. We hope to provide a more comprehensive review and provide assistance in clinical response.

Clonal hematopoiesis, cardiovascular disease and cancer treatment-induced cardiotoxicity

Clonal hematopoiesis (CH) arises when a substantial proportion of mature blood cells is derived from a single hematopoietic stem cell lineage. It is considered to be a premalignant state that predisposes individuals to an increased risk of cancers. Recently, emerging evidence has demonstrated a strong association between CH and both the incidence and mortality of cardiovascular diseases (CVD), with the relative risks being comparable to those attributed to traditional cardiovascular risk factors. In addition, CH has been suggested to play a role in CVD and anti-cancer treatment-related cardiotoxicity amongst cancer survivors. Moreover, certain forms of chemotherapy and radiation therapy have been shown to promote the clonal expansion of specific CH-related mutations. Consequently, CH may play a substantial role in the realm of cardio-oncology. In this review, we discuss the association between CH with cancer and CVD, with a special focus on anti-cancer treatment-related cardiotoxicity, discuss possible future research avenues and propose a systematic approach for clinical practice.

Diagnostic value of ROCK2 protein in immune checkpoint inhibitors-associated myocarditis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have advanced cancer treatment but are associated with serious cardiovascular side effects, including myocarditis, which is challenging to diagnose due to limited specificity of current biomarkers. Rho-associated kinase 2 (ROCK2) may play a role in myocarditis pathogenesis by mediating inflammation and myocardial remodeling. This study investigates the potential of ROCK2 protein detection as a diagnostic marker for ICIs-associated myocarditis.

OBJECTIVES

To evaluate ROCK2 protein levels in patients with ICIs-associated myocarditis and assess its diagnostic value, providing insights for improved identification and management of this condition.

METHODS

We conducted a study with 10 ICIs-treated gastric cancer patients diagnosed with myocarditis and a control group of 10 similar ICIs-treated patients without myocarditis. ROCK2 levels and inflammatory markers were measured via ELISA, and clinical assessments included cardiac imaging, electrocardiography, and echocardiography. Statistical analysis of group differences used independent t-tests and chi-square tests.

RESULTS

ROCK2 expression was significantly higher in myocarditis patients compared to controls (p < 0.001), alongside elevated inflammatory markers, specifically hypersensitive C-reactive protein (hs-CRP), interleukins1β (IL-1β) and IL-17. Diagnostic myocardial markers such as N-terminal pro B-type natriuretic peptide (NT-proBNP), and soluble suppression of tumorigenicity 2 (sST2) also showed substantial elevation. Following treatment discontinuation and glucocorticoid administration, both ROCK2 levels and inflammatory indicators declined.

CONCLUSIONS

Elevated ROCK2 protein levels could serve as a promising biomarker for ICIs-associated myocarditis. ROCK2 detection, combined with traditional markers, may enhance diagnostic accuracy. Further studies are warranted to explore ROCK2 inhibition as a potential therapeutic strategy for managing ICIs-associated myocarditis.

Sacubitril-valsartan in Cancer therapy-induced heart failure: A systematic review and meta-analysis of functional and hemodynamic parameters

BACKGROUND

Cancer therapy-induced cardiotoxicity (CTRCD), in the form of heart failure with reduced ejection fraction (HFrEF), is being increasingly recognized. However, the potential benefits of sacubitril/valsartan (S/V) in managing HFrEF secondary to CTRCD remain unclear.

OBJECTIVE

We performed a systematic review and meta-analysis to assess the effectiveness of S/V in preventing cardiotoxicity.

METHODS

We searched PubMed, Embase, and Cochrane databases for studies evaluating S/V in patients with HFrEF due to CTRCD and reporting the following outcomes: (1) NYHA class; (2) NT-ProBNP and (3) echocardiographic measurements, specifically left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and E/e' ratio. Statistical analyses were performed using RStudio software. Heterogeneity was assessed using I² statistics.

RESULTS

We included 257 patients from six studies. All patients received S/V. The mean patient age was 63 ± 8 years, and 85 % of patients had breast cancer. The mean LVEF was 34±7 % at baseline. S/V significantly improved NYHA class compared to baseline (MD -0.7; 95 % CI -1.2 to -0.3; p < 0.01), NT-proBNP (MD -985.1 pg/mL; 95 % CI -1231.3 to -739.1; p < 0.01), GLS (MD -2.5 %; 95 % CI -3.6 to -1.4; p < 0.01;), and E/e' (MD -1.99; 95 % CI 3.7 to -0.1; p = 0.03). LVEF (MD 7.3 %; 95 % CI 5.4 to 9.2; p < 0.01) with S/V treatment relative to baseline.

CONCLUSION

In patients with HFrEF due to CTRCD, S/V significantly improved the clinical and echocardiographic parameters of left ventricular systolic and diastolic functions.

Unveiling cardiovascular and respiratory toxicities with monoclonal antibodies in multiple myeloma: disproportionality analysis from the FDA Adverse Event Reporting System

INTRODUCTION

Monoclonal antibodies (mAbs) have revolutionized the treatment of multiple myeloma (MM), demonstrating remarkable effectiveness, despite potential adverse events (AEs). This study aims to identify unexpected signals of disproportionate reporting (SDRs) for cardiovascular (CV) and respiratory AEs associated with mAbs in MM treatment.

METHODS

From January 2015 to December 2023, reports involving suspected drugs (daratumumab, elotuzumab, elranatamab, isatuximab, belantamab mafodotin, teclistamab, and talquetamab) were analyzed in the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. Descriptive analysis was followed by disproportionality analyses first comparing mAbs to all other drugs (reference group, RG1), and subsequently conducting a sensitivity analysis against other MM drugs (RG2).

RESULTS

Out of 13,496,241 reports, 31,052 (0.2%) were associated with MM, with 6574 (0.1%) linked to CV and respiratory adverse events, primarily involving older population (n = 3441; 52.3%) and male (n = 3338; 50.8%) patients. Disproportionality analyses identified unexpected SDRs for daratumumab, including cardiac failure (n = 322; RG1: ROR = 4.74, CI 95% = 4.24-5.29; RG2: ROR = 4.42, 95% CI = 3.91-4.99), embolic and thrombotic event, such as pulmonary embolism (162; RG1: 2.44, 2.09-2.85), deep vein thrombosis (126; RG1: 2.95, 2.47-3.52), and respiratory failure (192; RG1: 4.06, 3.52-4.68; RG2: 4.2, 3.59-4.91). Isatuximab was linked to cardiac arrhythmia, such as atrial fibrillation (46; RG1: 2.54, 1.9-3.4; RG2: 1.35, 1.01-1.81), embolic and thrombotic event, including deep vein thrombosis (26; RG1: 2.93, 1.99-4.3) and pulmonary embolism (89; RG1: 6.56, 5.32-8.1; RG2: 2.93, 2.37-3.63). Elotuzumab showed also SDRs for atrial fibrillation (56; RG1: 3.68, 2.82-4.79; RG2: 1.96, 1.5-2.56) and deep vein thrombosis (41; RG1: 5.49, 4.03-7.47).

CONCLUSION

Unexpected CV and respiratory AEs with clinical relevance not previously reported in literature have been identified underlining the importance of pharmacovigilance.

A 2D-STI echocardiographic diagnostic model established for cardiac amyloidosis complicated with multiple myeloma

OBJECTIVE

This study aimed to investigate the clinical characteristics of multiple myeloma(MM) with amyloidosis(AL) and evaluate the diagnostic utility of two-dimensional speckle tracking imaging(2D-STI) echocardiography in MM with cardiac amyloidosis(CA), with the goal of providing guidance for early screening and differentiation.

METHODS

Among 616 newly diagnosed multiple myeloma (NDMM) patients, 359 met the inclusion and exclusion criteria, and divided into MM-AL and MM without AL according to the histopathological results. MM-AL patients were subdivided into MM-CA and MM without CA subgroups according to cardiac involvement criteria. Baseline characteristics and 2D-STI echocardiographic parameters were comparatively analyzed. Variables potentially predictive of MM-CA were identified through univariate analysis, with accuracy assessed by area under the curve (AUC). Variables were dichotomized using optimal cut-off values to construct a multivariate logistic regression model.

RESULTS

The initial symptoms of MM-AL were mainly bone pain and anemia, but the incidence of ostealgia was lower (45.7 %) and the prevalence of congestive heart failure (CHF) was higher (12.8 %) compared with MM without AL patients. No significant differences were observed in myocardial injury biomarkers, tumor burden, or t(11,14) translocation. MM-CA patients presented with 40.0 % severe heart failure (HF) NYHA class III-IV at diagnosis and experienced 33.3 % adverse cardiovascular events. An echocardiographic model incorporating left ventricular ejection fraction(LVEF), pulmonary artery systolic pressure(PASP), hydropericardium, and global longitudinal strain (GLS) demonstrated the highest diagnostic accuracy for MM-CA, with an AUC of 0.90 (95 % CI, 0.81-1.00) (sensitivity: 95.6 %, specificity: 80.0 %, accuracy: 90.8 %).

CONCLUSION

There was no specific difference between the clinical manifestations and routine examinations of MM with or without AL patients. This study introduces a novel multi-parameter echocardiographic model for MM-CA diagnosis, providing a clinically valuable tool for early screening and differentiation.

Optimal follow-up duration of cardiac function tests in patients treated with trastuzumab: an analysis using the Japanese Adverse Drug Event Report (JADER) database

BACKGROUND

One of the most serious adverse events associated with trastuzumab treatment is cardiac dysfunction, including congestive heart failure. Therefore, regular cardiac screening with echocardiography is commonly performed during trastuzumab treatment, although it is unclear for how long the patient will continue to be evaluated. We investigated the time to the occurrence of trastuzumab-induced cardiac dysfunction using the Japanese Adverse Drug Event Report (JADER) database. We examined the optimal duration of cardiac function evaluation in patients treated with trastuzumab.

METHODS

This study used data registered between April 2004 and September 2023 in the JADER database. We investigated the time to onset of cardiotoxicity in patients treated with trastuzumab, trastuzumab emtansine, or trastuzumab deruxtecan. We considered the time to exclude outliers detected using the Smirnov-Grubbs test as the optimal follow-up duration for cardiac function tests.

RESULTS

Of 868,478 patients who reported adverse drug events, 977 experienced cardiac dysfunctions among those treated with trastuzumab. A total of 375 patients were included in the analysis after excluding patients for whom the time to onset of cardiotoxicity was unknown or those who experienced cardiac dysfunction after receiving trastuzumab followed by anthracycline. The median time to cardiotoxicity was 4.5 months (range 0-100 months). However, ≥ 19 months after the start of trastuzumab administration was detected as an outlier in the target population (P = 0.036).

CONCLUSION

The duration of regular follow-up of cardiac function using echocardiography during anti-HER2 therapy can be 18 months from the start of treatment.

Cardio-Oncology and Breast Cancer Therapies

OPINION STATEMENT

Assessing cardiac risk prior to initiating breast cancer treatment, monitoring cardiac function during treatment, and implementing appropriate follow-up strategies are essential components of managing cardiotoxicity in breast cancer patients. A comprehensive cardiovascular evaluation should be conducted before treatment, including a detailed medical history, physical examination, and baseline cardiac imaging. Risk stratification tools can aid in determining the individual patient's risk profile. Close monitoring of cardiac function, including regular assessment of left ventricular ejection fraction (LVEF) and monitoring for signs and symptoms of cardiac dysfunction, is crucial during treatment. Prompt action should be taken if an adverse cardiovascular event is detected, including considering discontinuing or modifying the treatment regimen. Appropriate follow-up care is essential to monitor for long-term cardiac effects and optimize cardiovascular health in breast cancer survivors. Regular cardiovascular assessments, lifestyle modifications, and collaboration between healthcare professionals are important in managing cardiotoxicity effectively.

Attributes and Health Care Resource Utilization of Patients on Enzalutamide or Abiraterone for Metastatic Castration-Resistant Cancer in England

PURPOSE

To compare demographics, clinical characteristics, health care resource utilization (HCRU), treatment duration, and overall survival (OS) with enzalutamide (ENZA) or abiraterone acetate (AA) in patients with metastatic castration-resistant prostate cancer (mCRPC) in England.

MATERIALS AND METHODS

This retrospective study analyzed data from the Cancer Analysis System database on patients receiving ENZA or AA (January 2014-March 2020) for chemotherapy-naïve mCRPC (mCRPC was the only funded indication for ENZA/AA during study period). Baseline characteristics were assessed using standardized mean difference (SMD) (<0.1: balanced); differences were adjusted for using propensity score weighting (PSW). Cox proportional hazard models were used for OS and treatment duration. Number needed to treat was calculated from HCRU incidence rate ratios (IRRs).

RESULTS

Overall, 8,485 patients were included (ENZA, 5,330; AA, 3,155). Diabetes mellitus was more prevalent in the ENZA group (SMD, 0.12) at treatment initiation. HCRU was comparable between groups before treatment initiation (SMD < 0.1), but HCRU IRR after treatment initiation favored ENZA. Compared with AA, ENZA was associated with significantly fewer inpatient stays, outpatient or accident and emergency (A&E) visits, and hospitalization days (P < .01), and significantly lower likelihood of treatment discontinuation (adjusted hazard ratio [aHR], 0.90 [95% CI, 0.86 to 0.96]; P < .01) and mortality risk (aHR, 0.92 [95% CI, 0.87 to 0.98]; P = .010). Assuming 8 months' treatment and comparable groups through PSW, 1.9 inpatient admissions, 17.3 outpatient visits, 1.4 A&E visits, and 19.5 hospitalization days could be avoided per 10 patients on ENZA versus AA.

CONCLUSION

Patients with mCRPC on ENZA or AA had generally similar baseline characteristics apart from diabetes prevalence. ENZA was associated with longer OS and treatment duration, and lower HCRU after treatment initiation than AA.

Identification of Anticancer Drugs Associated With Cancer Therapy-Related Cardiac Dysfunction in Pediatrics-Analysis of the WHO Pharmacovigilance Database

AIMS

Cardiovascular toxicities associated with anticancer drugs constitute a significant concern for pediatric patients undergoing cancer treatment. Comprehensive data on the burden of cancer therapy-related cardiac dysfunction (CTRCD) are lacking, particularly for this high-risk population susceptible to develop myocardial toxicity. By analyzing VigiBase, the World Health Organization's individual case safety report database, we sought to determine anticancer drugs associated with CTRCD in pediatric patients.

METHODS AND RESULTS

To evaluate the association between 249 anticancer drugs labeled by the FDA or EMA and CTRCD reporting, we performed a disproportionality analysis, calculating multivariable adjusted reporting odds ratios (aROR) with their 95% confidence intervals (CI) across four pediatric age classes (0-27 days, 28 days to 23 months, 2-11 years, 12-17 years); ClinicalTrial registration number: NCT05602103. We identified 796 cases of CTRCD associated with at least one anticancer drug in VigiBase. Multivariate analysis across the pediatric age spectrum revealed 16 anticancer drugs significantly associated with CTRCD, of which 10 (63%) are primarily used for hematologic malignancies. Two drugs, a topoisomerase 1 inhibitor (topotecan) and cytotoxic antibiotics (dactinomycin), represented novel associations with CTRCD not previously documented in the literature.

CONCLUSION

Within VigiBase, we pinpointed 16 anticancer drugs significantly associated with CTRCD reporting in pediatrics. Our research validated several associations already thoroughly reported in children (such as with anthracyclines), and unveiled novel signals for systemic exposure to topotecan and dactinomycin. The relevance of these findings, especially considering the frequency of co-administration of agents and the lack of information regarding radiation exposure and chemotherapy dosage, would need to be evaluated in the context of clinical trials that use or have used these agents.

Comprehensive review of non-invasive-treatment-related cardiovascular toxicity in breast cancer

Cardiovascular toxicity is a significant side effect of breast cancer treatment and has emerged as a leading cause of non-tumor-related deaths among breast cancer survivors, emphasizing the critical need for effective monitoring and management of these complications. As breast cancer remains the most prevalent cancer among women, advancements in survival rates have been achieved through treatments such as chemotherapy, targeted therapy, endocrine therapy, immunotherapy, and radiotherapy. This review provides a comprehensive understanding of the cardiovascular toxicity mechanisms associated with both established and emerging breast cancer therapies, identifies potential therapeutic targets and monitoring strategies, and highlights key deficiencies and challenges in the field. By offering insights into the early detection, prevention, and management of cardiovascular complications, this review aims to guide future research directions and clinical practices, ultimately improving outcomes for breast cancer patients.

Pacing Solutions for Immune Checkpoint Myocarditis and Associated Conduction Disorders

Myocarditis is a rare but serious immune-related adverse event associated with immune checkpoint inhibitors. Mortality from immune checkpoint inhibitor associated myocarditis (ICIMy) is high, and developing advanced atrioventricular block is associated with worse mortality. Among a single-center cohort of 103 patients diagnosed with ICIMy, we describe 9 patients who required cardiac pacing for complete heart block. We present our systematic approach to managing ICIMy with advanced atrioventricular block, emphasizing the use of an active fixation right ventricular lead and external pacemaker generator for temporary pacing. This allows for stable and prolonged temporary pacing over a period of 4 to 6 weeks before deciding on implantation of a permanent pacemaker. This strategy has the potential to minimize infection risk by avoiding the need for generator pocket formation while patients are undergoing immunosuppressive therapy for treatment of ICIMy and allows for patient mobility and participation in physical therapy.

Cardiovascular therapeutic targets of sodium-glucose co-transporter 2 (SGLT2) inhibitors beyond heart failure

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are oral antidiabetic agents that have shown significant improvements in cardiovascular and renal outcomes among patients with heart failure (HF), regardless of diabetic status, establishing them as a cornerstone therapy. In addition to glycemic control and the osmotic diuretic effect, the inhibition of SGLT2 improves endothelial function and vasodilation, optimizing myocardial energy metabolism and preserving cardiac contractility. Moreover, SGLT2 inhibitors may exhibit anti-inflammatory properties and attenuate acute myocardial ischemia/reperfusion injury, thereby reducing cardiac infarct size, enhancing left ventricular function, and mitigating arrhythmias. These pleiotropic effects have demonstrated efficacy across various cardiovascular conditions, ranging from acute to chronic coronary syndromes and extending to arrhythmias, valvular heart disease, cardiomyopathies, cardio-oncology, and cerebrovascular disease. This review provides an overview of the current literature on the potential mechanisms underlying the effectiveness of SGLT2 inhibitors across a wide range of cardiovascular diseases beyond HF.

Cardiovascular Toxicity in Patients Treated for Childhood Cancer: A Scientific Statement From the American Heart Association

The field of cardio-oncology has expanded over the past 2 decades to address the ever-increasing issues related to cardiovascular disease in patients with cancer and survivors. There is increasing recognition that nearly all cancer treatments pose some short- or long-term risk for development of cardiovascular disease and that pediatric patients with cancer may be especially vulnerable to cardiovascular disease because of young age at treatment and expected long life span afterward. Anthracycline chemotherapy and chest-directed radiotherapy are the most well-studied cardiotoxic therapies, and dose reduction, use of cardioprotection for anthracyclines, and modern radiotherapy approaches have contributed to improved cardiovascular outcomes for survivors. Newer treatments such as small-molecule inhibitors, antibody-based cytotoxic therapy, and immunotherapy have expanded options for previously difficult-to-treat cancers but have also revealed new cardiotoxic profiles. Application of effective surveillance strategies in patients with cancer and survivors has been a focus of practitioners and researchers, whereas the prevention and treatment of extant cardiovascular disease is still developing. Incorporation of new strategies in an equitable manner and appropriate transition from pediatric to adult care will greatly influence long-term health-related outcomes in the growing population of childhood cancer survivors at risk for cardiovascular disease.

Immune checkpoint inhibitor-related myocarditis in patients with lung cancer

BACKGROUND

The clinical characteristics of immune checkpoint inhibitors (ICIs)-related myocarditis in lung cancer remains uncertain. The purpose of this study was to evaluate the incidence, clinical characteristics, risk factors, and prognosis of myocarditis in lung cancer patients treated with ICIs. Therefore, this study would enhance the understanding of immune related myocarditis in lung cancer population.

METHODS

A total of 1004 patients were analyzed, among those who developed elevated serum creatine kinase isoenzyme, MB form (CK-MB) and/or high-sensitivity troponin I (hs-cTnI) with electrocardiographic or clinical symptoms after immunotherapy were enrolled in the myocarditis group. The same number of patients who had received immunotherapy but didn't develop myocarditis was randomly selected as the control group. Clinicopathologic features, risk factors, and prognostic factors were evaluated in this study.

RESULTS

66 patients (6.6%) developed ICIs-related myocarditis. In these patients, there were 60 case of possible myocarditis (90.9%), 5 probable myocarditis (7.6%), and 1 definite myocarditis (1.5%). The median time to the occurrence of myocarditis was 3.8 months. The median progression-free survival (PFS) for NSCLC and SCLC patients were 24.4 months and 13.0 months, while the median overall survival (OS) for NSCLC and SCLC patients were 43.3 months and 44.6 months. The grade of myocarditis (OR: 5.79; 95%CI: 1.14-29.41, P = 0.034), immunotherapy cycle (OR: 0.38; 95% CI: 0.16-0.92, P = 0.032), and combination of immune-related adverse events (irAEs) (OR: 3.63; 95% CI: 1.55-8.48, P = 0.003) were the influencing factors of PFS in NSCLC patients. In SCLC patients, the immunotherapy cycle was the influential factor for PFS (OR: 0.16; 95%CI: 0.04-0.61, P = 0.007) and OS (OS: 0.12; 95% CI: 0.03-0.48, P = 0.002). Anti-PD1 therapy (OR: 0.4, 95% CI: 0.13-0.97, P = 0.043) and age (OR: 0.36, 95% CI: 0.16-0.84, P = 0.018) might be the protective factors of myocarditis patients compared with the control group.

CONCLUSIONS

The presentations of ICIs-related myocarditis in lung cancer are mainly possible myocarditis and probable myocarditis, which have a mild impact on the prognosis. More cycles of ICI treatment accompany the longer the PFS and OS, as a protective factor. Anti-PD1 therapy and older age may be protective factors for ICI-related myocarditis.

Effects of taxane-anthracycline and taxane only treatment on cardiac function in breast cancer-a retrospective cohort study

INTRODUCTION

Cardiotoxic, anthracycline-based therapies have high value in selected patients with breast cancer. We aimed to describe the effect of anthracycline plus taxane and single taxane chemotherapies on echocardiographic parameters in women with breast cancer.

METHODS

We retrospectively analysed data of 68 women (> 18 years old) treated for breast cancer in 2018-2021 in the Cardiology Outpatient Clinic of Semmelweis University, Department of Internal Medicine and Oncology. Cardiovascular medical history was collected at baseline and transthoracic echocardiography was completed at each visit. Also, we reviewed electronic medical records for other relevant medical information. Measured echocardiography parameters were assigned to five periods (0-14 days, then every half year and beyond day 545) based on the time since the first treatment. Trajectories of ejection fraction and diastolic function associated markers over the follow-up periods were analysed by linear mixed models.

RESULTS

Mean age of the anthracycline plus taxane group was 52.7 ± 14.1 years, of the single taxane group 55.2 ± 13.1 years. The mean anthracycline dose was equivalent to 240 mg/m2 of doxorubicin. Overall pre-existing cardiovascular burden was low. Statistically significant changes were found only in the anthracycline plus taxane group: ejection fraction decreased mildly from 65.5 ± 3.1% at baseline to 62.1 ± 3.2% at 181-365 days (p = 0.007) while deceleration time decreased mildly from 227.9 ± 33.9 msec to 197.4 ± 29.4 msec at 15-180 days (p = 0.028). Both drops were only temporary and values neared baseline values over follow-up (p = NS vs. baseline). Other important determinants of ejection fraction were age and hypertension among the investigated risk factors.

CONCLUSION

Our study confirms the overall safety on cardiac function of both single taxane and anthracycline plus taxane chemotherapy, as we found no changes in echocardiographic parameters associated with single taxane therapy, while anthracycline plus taxane chemotherapy was associated with a temporary and clinically insignificant reduction of ejection fraction and deceleration time over 1.5 years of follow-up. Our study is limited by its retrospective nature and the low number of participants.

Predicting 30-Day Cardiotoxicity in Patients Receiving Immune Checkpoint Inhibitors: An Observational Study Utilizing XGBoost

Immune Checkpoint Inhibitor (ICI)-related cardiotoxicity has a high mortality rate, making early prediction crucial for improving patient prognosis. However, early prediction models are currently lacking in clinical practice. This study aims to develop an early prediction model for ICI-related cardiotoxicity using the eXtreme Gradient Boosting (XGBoost) algorithm. Retrospective analysis was conducted on patients who received ICI therapy between January 2020 and December 2023. The population was categorized into a cardiotoxicity group and a non-cardiotoxicity group based on the presence of cardiac biomarkers and electrocardiogram abnormalities that could not be attributed to other diseases within 30 days after initiation ICI therapy. The dataset was split into training (70%) and testing (30%) sets. Logistic Regression (LR), Random Forest (RF), and XGBoost models were constructed in Python, with variables selected based on each model's characteristics. The models were compared based on predictive performance, which was measured by area under the curve (AUC) and decision curve analysis (DCA). The best model was explained using SHapley Additive exPlanation (SHAP). A total of 419 patients were included. The XGBoost model demonstrated the highest predictive performance with an AUC of 0.83, outperforming LR (AUC: 0.80) and RF (AUC: 0.74) models. DCA confirmed the XGBoost model's superior net benefit. Among the selected predictors, cardiac troponin T (cTnT) emerged as the most important variable, demonstrating the highest feature importance. The XGBoost model proposed could assist clinicians in personalized risk stratification for patients on ICI therapy, facilitating precise monitoring of cardiotoxicity and tailored treatment strategies.

Immune Checkpoint Inhibitors and Cardiovascular Adverse Events

In the last years, we assisted to a tremendous increase in therapeutic options for the management of cancers, with immunotherapy at the forefront of this innovation. Immune checkpoint inhibitors (ICIs) have been developed to enhance the activity of the immune system against cancer cells (1) and the number of approvals for ICIs has rapidly increased. ICIs have also been associated with disinhibited cytotoxic T cells that damage healthy tissue in multiple organs, causing immune-related adverse events (AEs). Cardiovascular AEs (CVAe) are increasingly reported: myocarditis, Takotsubo syndrome, pericarditis and pericardial effusion, worsening of atherosclerosis, acute coronary syndromes, non-inflammatory heart failure, and ischaemic stroke. They are classified into five grades, based on presenting symptoms, level of cardiac biomarkers, and imaging. Even though myocarditis occurs more frequently than previously thought, clinically relevant myocarditis is a rare irAE compared to other irAE (0.5-1.2%). The clinical manifestations range from mild symptoms such as to chest pain, heart failure, and cardiogenic shock. The prognosis is severe, with mortality rates ranging from 25% to 50%. It is frequently associated with the concomitant use of combination of checkpoint inhibitors. The treatment strategies are tripartite: (i) holding ICI to prevent further toxicity, (ii) immunosuppression to alleviate inflammatory changes, and (iii) supportive therapy to address cardiac complications. Glucocorticoids represent the first-line treatment. In hemodynamically unstable patients, treatment with high-dose steroids should be initiated (intravenous methylprednisolone 1000 or 1250 mg oral methylprednisolone during 4 days). ICI-associated pericarditis can be accompanied by no/mild pericardial effusion up to cardiac tamponade. The treatment is made of nonsteroidal anti-inflammatory drugs and colchicine, corticosteroids if needed, and pericardiocentesis for the large effusions. ICIs could be continued for Grade 1 pericarditis, while temporary suspension of ICI is warranted for more severe cases. There is significant potential for accelerated atherosclerosis with ICIs as a long-term effect, but atherosclerosis-related CVAEs are not frequent, especially during treatment; increasing evidence associates ICIs with progression of atherosclerosis and increased atherosclerotic cardiovascular disease. ICIs can lead to arrhythmias: atrial fibrillation, supraventricular and ventricular tachycardias. Non-inflammatory heart failure syndrome have been observed in ICI-treated patients. Immune checkpoint inhibitors seem to be involved in the development of right ventricular dysfunction and pulmonary arterial hypertension. It is of the outmost importance to improve the collaboration among the different medical figures, such as cardiologists, oncologists, endocrinologists, and immunologists, both in clinical practice and in basic science research, to better recognize these adverse events, to understand their pathophysiological mechanisms, and to improve the overall survival and quality of life of the affected patients.

Predictors of Cardiac Recovery in Adults With AML Who Develop Heart Failure During Treatment

PURPOSE

Heart failure is a leading cause of death in patients with AML, who face higher risks of cardiac complications than nonleukemic cancer patients treated with anthracyclines. This study examines factors associated with myocardial dysfunction and recovery occurring during treatment of AML.

METHODS

We retrospectively analyzed patients with AML who sustained reduced left ventricular ejection fraction (LVEF) during induction therapy at the University of Washington/Fred Hutchinson Cancer Center (2008-2022). Multivariable analysis compared characteristics between patients who eventually recovered LVEF and those who did not, with survival analysis performed by landmark censoring.

RESULTS

Of 86 patients with AML diagnosed with systolic dysfunction, 41 (48%) failed to recover LVEF. These patients were more frequently male, older than 60 years, had preexisting cardiovascular risk factors, and leukemias of higher risk. Ischemia-related systolic failure was associated with nonrecovery (B = -2.89, P = .005), whereas chemotherapy-related dysfunction was associated with eventual recovery (B = 1.15, P = .014). Frequent use and higher doses of guideline-directed medical therapy (GDMT) were found among patients who recovered LVEF. Failure to recover cardiac function was associated with a greater incidence of cardiac-specific mortality (51% v 23%, P = .042), although impact on overall survival was unclear.

CONCLUSION

Our retrospective single-center analysis suggests that approximately half of the patients with AML who experience LVEF decline during induction will not recover. Ischemic events during treatment were predictive of nonrecovery. The use of GDMT may improve prognosis for some patients. Given the impact of recovery, we propose the prospective verification and establishment of cardiac management algorithms in patients with AML.

Updates in Diagnosis and Treatment of Immune Checkpoint Inhibitor Myocarditis

PURPOSE OF REVIEW

To provide an update on the literature regarding diagnosis and management of immune checkpoint inhibitor myocarditis.

RECENT FINDINGS

The diagnosis of immune checkpoint inhibitor myocarditis has evolved to include more reliance on performing endomyocardial biopsy to clarify the diagnosis in selected cases. Additionally, there is recognition of a spectrum of disease both clinically and on endomyocardial biopsy suggesting that there is a range of severity from mild to fulminant. The treatment of immune checkpoint inhibitor myocarditis is shifting towards increased use of additional immunosuppressive medications as steroid sparing agents. There are increased studies including two randomized controlled trials evaluating abatacept in the treatment of immune checkpoint inhibitor myocarditis. This review summarizes the latest literature regarding diagnosis and management of immune checkpoint inhibitor myocarditis and provides our experience and approach to this rare but potentially fatal condition.

Vascular endothelial growth factor inhibitor-induced cardiotoxicity: prospective multimodality assessment incorporating cardiovascular magnetic resonance imaging

BACKGROUND

Vascular endothelial growth factor inhibitors (VEGFIs) are effective anticancer agents, but are associated with cancer therapy-related cardiac dysfunction (CTRCD) and hypertension. The timing, frequency and magnitude of these toxicities are poorly defined. The objective of this study is therefore to investigate the incidence, time course and mechanisms of VEGFI-associated CTRCD and hypertension.

METHODS

Patients commencing VEGFI underwent blood pressure (BP) monitoring, echocardiography and cardiac biomarker measurement at baseline and prospectively over 24 weeks. Serial adenosine stress perfusion cardiovascular MRI (CMR) was performed in a substudy. CTRCD was defined as left ventricular ejection fraction (LVEF) decline by ≥10 percentage points from baseline to a value <50%.

RESULTS

78 patients participated (68% men; age 63±11 years). 15 patients (19%) developed CTRCD, and it was evident at 4 weeks in 93% of cases. Overall, LVEF was 4.2% (95% CI: -6.2% to -2.3%, p<0.001) lower than baseline at 4 weeks. At 4 weeks, N-terminal pro-brain natriuretic peptide, but not troponin, was higher in patients with CTRCD. 62 (77%) patients developed hypertension. Home systolic and diastolic BP increased by 7.2 mm Hg (4.7-9.8, p<0.001) and 4.8 mm Hg (3.1-6.5, p<0.001), respectively, at 1 week. There was no association between change in LVEF and BP.CMR-derived LVEF, T1 relaxation times and resting myocardial blood flow (n=46) were 5.2% (-7.3% to -3.1%, p<0.001), 27 ms (-40 to -14, p<0.001) and 14.7 mL/100mL/min (-24.2 to -5.1, p=0.004), respectively, lower at 4 weeks.

CONCLUSION

VEGFI-associated CTRCD is frequent and occurs early. This finding has implications for prioritising early cardiac imaging follow-up after commencing treatment. Underlying mechanisms include myocardial and microvascular effects that are at least partly independent of hypertension.

The inflammation burden index can predict the cardiac injury following antitumour therapy in lung cancer patients with diabetes

Lung cancer is a leading cause of cancer-related morbidity and mortality worldwide. Diabetes, as a common metabolic disorder, further increases the risk of cardiovascular damage. Studies have shown that myocardial cells in diabetic patients are more vulnerable to the toxic effects of cancer treatments, thereby raising the risk of heart failure. Therefore, cardiovascular risk assessment in lung cancer patients with diabetes is particularly important. The Inflammatory Burden Index (IBI) is a biomarker that reflects systemic inflammation, combining the levels of C-reactive protein (CRP), neutrophils, and lymphocytes. It has been shown to be a significant prognostic indicator in various cancer populations. This study aims to investigate the predictive ability of IBI and the triglyceride-glucose (TyG) index for cardiac injury in lung cancer patients with diabetes undergoing antitumor therapy. A single-center retrospective case-control study was conducted, including clinical data of 192 lung cancer patients with diabetes who received anti-tumor therapy from July 2018 to January 2023.Cardiac injury was assessed by measuring high-sensitivity cardiac troponin T (hs-cTnT) levels. The Inflammatory Burden Index (IBI) was calculated using the formula: IBI = (C-reactive protein [CRP] × Neutrophils)/Lymphocytes. Univariate and multivariate logistic regression analyses were performed to assess the relationship between clinical factors, IBI, TyG index, and cardiac injury. The clinical predictive value of these factors was further evaluated using receiver operating characteristic (ROC) curves, and the relationship between IBI and cardiac injury was explored using the Restricted Cubic Spline (RCS) model. In the 192 patients, 101 (52.6%) developed cardiac injury during follow-up. Univariate analysis showed that age, male, hypertension, smoking, D-dimer, CKMB, IBI, TNM stage: III/IV, and Immunotherapy were significantly associated with cardiac injury (P < 0.001). Multivariate analysis identified IBI (P = 0.007), age (P = 0.01), smoking (P < 0.001), CKMB (P < 0.001), TNM stage (P = 0.014), and hypertension (P = 0.007) as independent predictors of cardiac injury. ROC analysis revealed an area under curve (AUC) of 0.722 for IBI (cut-off: 8.408), indicating good predictive value. RCS analysis showed a significant nonlinear positive correlation between IBI and cardiac injury (P = 0.0079), with the risk of cardiac injury increasing significantly as IBI levels rose. The TyG index was not significantly associated with cardiac injury. IBI, as a simple and accessible biomarker, can effectively predict cardiac injury in lung cancer patients with diabetes undergoing antitumor therapy. Although the TyG index did not show a significant association with cardiac injury in this study, IBI demonstrated strong predictive ability in this patient group. Future studies should further validate the use of IBI across different cancer types and evaluate its prognostic role in long-term follow-up.

Assessment and stratification of cardiovascular disease risk in people diagnosed with breast cancer: A scoping review

BACKGROUND

Breast cancer patients are at increased risk of cardiovascular disease, which often are associated with cardiotoxic breast cancer treatment or overlapping risk factors between the two diseases. Pre-treatment cardiovascular risk assessment can enable accurate risk stratification and prevention of cardiovascular disease. Several tools have been suggested, described or used in research to assess baseline (pre-treatment) risk to determine appropriate cardiovascular disease care before, during and after cancer treatment. This scoping review aims to identify and describe key features of baseline cardiovascular disease risk assessment tools for breast cancer patients.

METHODS

PubMed, Embase and Google Scholar were searched for articles published January 2013 - March 2024 to identify publications reporting cardiovascular disease risk assessment tools in breast cancer patients. Publications included research articles (observational and experimental studies) and position/policy, commentary and review papers. Eligibility was assessed and key data were extracted independently by two reviewers. Conflicts were discussed and resolved with the authorship team.

RESULTS

A total 144 articles were identified. Of these, 57 reported original data for the development, validation or recommendations of cardiovascular disease risk assessment tools and 87 reported the use of such tools. From these articles, 13 tools were identified that assessed the risk of cardiovascular disease broadly (n = 3) or death due to cardiovascular disease (n = 1) or specifically of cardiotoxicity or heart failure (n = 8) or venous thromboembolism (n = 1) in people diagnosed with breast cancer. Fourteen tools assessed cardiovascular disease risk in people diagnosed with mixed cancer types, including breast cancer. The planned development of four tools and/or surveillance pathways were described in protocol papers. Among all these tools identified (n = 31), seven tools (among these, four tools assessed people diagnosed with breast cancer only) went through external validation and performed poorly or moderately in stratifying cancer patients effectively into risk categories. Risk factors included in the assessment tools were age, breast cancer treatment type and pre-existing cardiovascular disease. While clinical guidelines and recommendations about baseline cardiovascular disease risk assessment were identified, these were either for cancer patients broadly or for cancer treatment types, and not specifically for people diagnosed with breast cancer.

CONCLUSION

Several tools to assess baseline cardiovascular disease in people diagnosed with breast cancer were identified but only seven tools had gone through a validation process, and none were found to be very effective in differentiating people by baseline cardiovascular disease risk. Further work is needed to optimise the effectiveness of baseline cardiovascular disease risk assessments for breast cancer patients to enable appropriate stratification and monitoring of risk before, during and after treatment to improve cardiovascular health and outcomes.

Predictive Value of Neutrophil-to-Lymphocyte Ratio for Immune Checkpoint Inhibitor-Related Myocarditis Among Patients Treated for Non-Small-Cell Lung Cancer

Background

The predictive value of the neutrophil-to-lymphocyte ratio (NLR) for immune checkpoint inhibitors (ICIs) in various tumors remains uncertain despite its use in forecasting the effectiveness of immunotherapy. The purpose of our research was to determine the prognostic significance of NLR for immune checkpoint inhibitor-related myocarditis in non-small-cell lung cancer (NSCLC) patients.

Methods

We enrolled and monitored patients with NSCLC who received ICI therapy at the Fifth Medical Center of Chinese PLA General Hospital between January 1, 2018, and February 20, 2021. NLR was determined before and soon after each cycle of ICIs. All participants in this study were periodically examined for troponin and brain natriuretic peptide (BNP), and an electrocardiogram (ECG) and echocardiography were done. Cox's proportional hazards regression model and receiver operating characteristic (ROC) were used to assess the predictive value for ICI-related myocarditis.

Results

A total of 146 patients received ICI treatment and completed a follow-up. Of these, 17 patients (11.64%) developed ICI-related myocarditis that met the diagnostic criteria. The initial cycle revealed that the NLR was a reliable predictor of potential myocarditis related to ICIs, with an area under the curve (AUC) of 0.833 and a 95% confidence interval (CI) of 0.721-0.945. Following the initial round of ICI treatment, an NLR elevation (NLR ≥ 3.25) appeared to be the most significant standalone indicator of ICI-related myocarditis (HR: 11.094; 95% CI: 3.186-38.631; p < 0.001).

Conclusions

Our study confirmed that NLR elevation in the early phase after ICI treatment of NSCLC is a reliable predictive factor of ICI-related myocarditis. Regular and frequent cardiac monitoring may help to avoid the occurrence of severe and fatal cases.

What Is the Impact of Novel Systemic Anticancer Therapy on Acute Oncology Education and Service Delivery?

OBJECTIVES

To discuss the importance of educating healthcare professionals about oncological emergencies linked to novel systemic anticancer therapy (SACT) and the impact on acute oncology (AO) services.

METHODS

This discussion is based on clinical expertise and informed by current literature.

RESULTS

Novel SACT, such as immune-checkpoint inhibitors, have more complex toxicity profiles and can be challenging to recognize and treat. An increasing prevalence of toxicity is expected as new drugs are developed and the numbers of patients living with and beyond cancer expand; more data are required to capture the full extent of this. There are knowledge gaps within the healthcare workforce, particularly outside oncology-specialist settings. Focused research in this area will provide direction for targeted educational interventions.

CONCLUSIONS

Insufficient SACT education is a safety issue; severe toxicities can be fatal but initial symptoms can be subtle and may be missed. We argue that emergency care pathways can help to streamline the appropriate management of patients with SACT toxicity, but awareness of AO issues remains "everyone's business." Continuing clinical education is key to maintaining awareness of newly developed SACT. AO service models may vary, but AO competence assessment passports can provide a standardized method of evidencing AO knowledge and skills.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses, as a highly specialized and knowledgeable part of the healthcare workforce, are key in supporting interprofessional education. By using existing cancer nursing frameworks, this can support the implementation of the AO Passports. The learning and development of AO services in the UK can be transferred internationally.

A Shift in Practice: A Discussion of the Impact of Immunotherapy on Cancer Nursing

OBJECTIVE

This paper aims to explore the impact of checkpoint inhibitors, a novel cancer therapy, on cancer nursing, including aspects of education, research, and practical application.

METHODS

Our discussion is grounded in clinical expertise and supported by relevant literature from peer-reviewed journals.

RESULTS

This focused discussion on the nursing implications of immune checkpoint inhibitors as a novel cancer therapy highlights a significant transformation in cancer nursing practice. There is a pressing need to enhance the skills of the cancer nursing workforce and expand their knowledge regarding the mechanisms of action of immunotherapies, their toxicity profiles, including late effects, potential drug interactions, principles of administration, and the assessment and management of immune-related adverse reactions. The introduction of immunotherapy necessitates not only a collaborative multidisciplinary approach but also a multispecialty strategy due to the diverse nature of immune-related side effects affecting various body systems. The complexity of managing toxicities associated with immunotherapy, particularly when used in conjunction with other treatment modalities, imposes additional costs and strains on existing healthcare services. Some organizations, depending on their healthcare models, encounter challenges when these additional services are not appropriately funded.

CONCLUSION

In the case of immunotherapy as a novel cancer treatment, there are clear benefits to patients in terms of survival, but this has come with safety issues for patients and staff. The nursing workforce is key to safety around immunotherapy with regard to the safe delivery of treatment and the management of toxicity. This cannot be achieved without the education of the nursing workforce and underpinning research.

Cardiovascular toxicity induced by TKIs in patients with chronic myeloid leukaemia: Are women and men different?

AIMS

Knowledge of the effects of sex in cardio-oncology is limited, particularly in patients treated with tyrosine kinase inhibitors (TKIs) for chronic myeloid leukaemia (CML). This study aims to evaluate the influence of gender differences on the incidence of cardiovascular toxicity in patients with CML.

METHODS

The study population consisted of 148 patients (45% women, mean age: 58 ± 14.2 years) diagnosed with CML treated with TKIs. The HFA-ICOS score estimated cardiovascular risk. The HFA-ICOS score revealed that 12% of men and 6% of women were categorized as very high risk while 45% of men and 50% of women fell into the high-risk group. Myocardial ischaemia, peripheral artery disease, venous thromboembolism, pulmonary hypertension and new-onset arterial hypertension during treatment with TKIs were recorded.

RESULTS

The incidence of global events between men and women was comparable (35% vs 32%, P = 0.68). There were 33% who experienced a cardiovascular event during TKI therapy, with a significant sex difference in arterial thrombosis incidence (P = 0.02) and venous thrombosis incidence (P = 0.02). Patients treated with ponatinib had a 41% event rate, followed by nilotinib (32%) and imatinib (32%). The HFA-ICOS score demonstrated greater predictive efficacy for events in the female group [area under the curve (AUC) = 0.797] compared with the male group (AUC = 0.537). Very high [hazard ratio (HR) 3.07; confidence interval (CI) 1.11, 8.47 P = 0.03] and high (HR 3.29; CI 1.17, 9.26 P = 0.02) HFA-ICOS scores were associated with increased event risk, particularly in women. Diabetes was women's strongest predictor of events (HR 5.40; CI 1.37, 21.3 P = 0.01).

CONCLUSIONS

Our study showed a similar frequency of cardiovascular events between men and women. Accurate cardiovascular risk stratification with HFA-ICOS score in cancer patients is crucial. Diabetes and the HFA-ICOS score were significant predictors of events in the female groups. A sex approach in clinical practice could be pursued to improve the appropriateness of care.

Influence of radiotherapy on cardiac implantable devices and leads-a single-institution analysis and critical evaluation of current guidelines

PURPOSE

Increasing life expectancy and advances in cancer treatment will lead to more patients needing both radiation therapy (RT) and cardiac implantable electronic devices (CIEDs). CIEDs, including pacemakers and defibrillators, are essential for managing cardiac arrhythmias and heart failure. Telemetric monitoring of CIEDs checks battery status, lead function, settings, and diagnostic data, thereby identifying software deviations or damage. This study evaluates the German Society for Radiation Oncology (DEGRO)/German Society for Cardiology (DGK) guideline, assessing real-world complications and risk factors and analyzing pacemaker and implantable cardioverter-defibrillator (ICD) lead function for their predictive value concerning device malfunction.

METHODS

A total of 54 patients with pacemakers or ICDs who underwent radiation therapy were identified. Demographics, treatment courses, and device information from physical and digital records were extracted. DEGRO/DGK risk groups and pacemaker dependency at the start of RT were assessed. Delineation of the devices and lead insertion sites was performed in the treatment planning system. Dosimetric information from the treatment plans was then correlated with reports of standardized device checks.

RESULTS

Over 80% of patients were treated with dual-chamber pacemakers or cardiac resynchronization therapy (CRT), and 16.7% had ICDs. One third of patients were pacemaker dependent. 59.3% of patients were in the low-risk category, 29.3% in the medium-risk, and 11.1% in the high-risk category. Thoracic irradiation resulted in the highest median dose to devices. Lead parameter deviations exceeding thresholds were found in 14.8% for the stimulation threshold and 13.5% for sensing. Device malfunctions occurred in 3.7% of cases, both involving electrical resets and neutron-producing radiation (beam energy 10 megaelectron volt (MV) or higher).

CONCLUSION

Collecting lead parameters in addition to secure malfunctions like electrical restarts and memory erasure revealed a significant proportion of treatment courses with temporary changes, though no correlation with individual treatment plans or adverse events was found. The focus on reducing neutron-producing radiation could be further supported.

Risk Stratification for Trastuzumab-Induced Cardiac Dysfunction and Potential Implications for Surveillance

BACKGROUND

Although patient factors and sequential anthracycline use contribute to risk for cancer therapy-related cardiac dysfunction (CTRCD) with HER2-directed cancer therapy, frequent (every 3 months) left ventricular ejection fraction (LVEF) surveillance is recommended irrespective of baseline risk.

OBJECTIVES

The aim of this study was to examine the incidence of trastuzumab-associated CTRCD in a contemporary cohort with HER2-positive breast cancer and assess the performance of a risk assessment tool to identify patients at low risk for CTRCD to guide risk-based surveillance strategies.

METHODS

A retrospective cohort of patients with HER2-positive breast cancer treated with trastuzumab at a tertiary cancer center was examined. Patients were categorized as low, medium, and high or very high risk for CTRCD by Heart Failure Association/International Cardio-Oncology Society risk assessment.

RESULTS

Of 496 patients treated with trastuzumab, 29.8% also received anthracyclines. Over a median follow-up period of 51 months, 8.7% developed CTRCD, but only 1.6% had associated heart failure (HF). CTRCD rates were 3.6%, 12.8%, and 32.1% in low-risk, medium-risk, and high or very high risk groups, respectively. HF incidence was 0.4% in the low-risk group and 2.1% in the medium-risk group, with no HF in patients at low- or medium-risk who received trastuzumab without anthracyclines. HF was observed in 11% of high-risk patients. The risk assessment had a negative predictive value for CTRCD in low vs moderate- or high-risk patients of 96.4% (95% CI: 93.5%-98.3%).

CONCLUSIONS

The findings support the exploration of a prospective personalized risk-based approach to cardiac LVEF surveillance during trastuzumab therapy. Less frequent LVEF monitoring in low-risk patients may optimize resource use and reduce patient burden without compromising safety.

Increased prevalence of coronary atherosclerosis in cancer survivors: A retrospective matched cross-sectional study with coronary CT angiography

BACKGROUND

Cancer and cancer treatment may accelerate the development of cardiovascular disease. With the improved prognosis of cancer survivors, cardiovascular events are increasing in this patient group. However, it is unknown whether the prevalence of coronary atherosclerosis is increased in patients with a history of cancer. This study aims to evaluate the prevalence and severity of coronary atherosclerosis in different age groups of cancer survivors compared to matched controls.

METHODS

Consecutive cancer survivors aged > 30 years who underwent evaluation for stable coronary artery disease with coronary computed tomography angiography (CCTA) were included in this retrospective study. Propensity score matching was performed and cancer survivors were matched 1:2 to a control population without oncological history. The presence of coronary atherosclerosis was assessed in both groups.

RESULTS

The study population consisted of 312 cancer survivors and 624 matched controls. Median age at CCTA scan was 59.2 [50.3-67.5] years and 66.0% was female. Coronary atherosclerosis was observed in 257 (82.4%) cancer survivors compared to 459 (73.6%) control patients with an Odds Ratio (OR) of 1.68 [95% CI: 1.19-2.36], P = .003. Mainly younger cancer survivors aged between 30 and 59 years had an increased prevalence of coronary atherosclerosis with an OR of 2.21 [95% CI: 1.40-3.49] compared to control patients (P = .001). In addition, thoracic radiotherapy showed a significant association with increased prevalence of atherosclerosis in the younger population with an OR of 3.29 ([95% CI: 1.70-6.38], P < .001).

CONCLUSIONS

Patients with a history cancer have an increased prevalence of coronary atherosclerosis on CCTA compared to matched patients without cancer. This effect was most pronounced in younger patients aged 30 to 59 years.

Cardiac MRI-based Subclinical Cardiac Dysfunction during 2 Years after Breast Cancer Irradiation: The MEDIRAD EARLY-HEART Study

Purpose To evaluate the relationship between cardiac radiation doses and subclinical changes in cardiac function using cardiac MRI during 2 years of follow-up in patients with breast cancer treated with radiation therapy without chemotherapy after lumpectomy. Materials and Methods This prospective multicenter study (NCT03297346) enrolled female individuals with breast cancer treated with radiation therapy between December 2017 and September 2019. Participants underwent cardiac MRI at baseline, 6 months, and 24 months. Cardiac radiation doses were assessed for the whole heart (WH) and right and left ventricles (LV). A persistent decrease in LV global longitudinal strain (GLS) from baseline to the other two measurement points over the 2-year follow-up was considered an adverse subclinical change in cardiac function. Statistical analysis included Wilcoxon tests for continuous variables and odds ratios for risk assessment. Results The study included 138 female participants (mean age, 58.4 years ± 8.0 [SD]). Mean WH and LV doses were 1.42 Gy (IQR, 1.03-2.01) and 1.46 Gy (IQR, 0.64-2.34). At the 2-year follow-up, all participants had reduced LV end-diastolic volume (EDV) (-4.0% ± 13.2; P < .001) and stroke volume (-3.4% ± 15.2; P < .001), preserved LV ejection fraction, and increased LV remodeling (LV mass/EDV ratio) (4.2% ± 18.1; P < .04) without associated symptoms. Twenty-three (16.6%) participants showed a persistent decrease in LV GLS and received higher mean WH and LV doses compared with participants without persistent decrease in LV GLS (WH: 2.09 Gy [IQR, 1.50-2.45] vs 1.36 Gy [IQR, 1.01-1.87], P < .001; LV: 2.40 Gy [IQR, 1.09-2.88] vs 1.34 Gy [IQR, 0.63-2.02], P = .002). The relative changes in LV EDV and LV mass/EDV were -12.7% ± 9.0 versus -2.2% ± 13.3 (P < .001) and 14.2% ± 15.5 versus 2.2% ± 18.1 (P = .002), respectively, in participants with and without a persistent decrease in LV GLS. A higher WH cardiac radiation dose was associated with a higher risk of a persistent decrease in LV GLS (odds ratio, 1.09 [95% CI: 1.02, 1.16]). Conclusion In participants with recent breast cancer radiation therapy, a modest but persistent reduction in LV GLS over a 2-year follow-up period was associated with the cardiac radiation dose. Keywords: Radiotherapy, Magnetic Resonance Imaging, Cardiotoxicity, Strain Clinical trial registration no. NCT03297346 Supplemental material is available for this article. © RSNA, 2025.

Quality-of-Care Measures for Cardio-Oncology: An IC-OS and ACC Cardio-Oncology Leadership Council Perspective

This document serves as a perspective on quality assessments in the discipline of cardio-oncology. We aim to define the current landscape, identify needs for quality and outcome improvements, and propose a roadmap for establishing viable metrics to improve patient care. Specifically, this document: 1) addresses the current lack of measurable high-quality metrics in cardio-oncology and their implications; 2) highlights needs and topic-specific barriers; 3) illustrates the process and application of a measurable quality metric; and 4) provides a framework to demonstrate measurable value for the growing population of patients with cancer and cardiovascular diseases.

Pegylated liposomal doxorubicin does not affect cardiac function in patients treated for gynecologic malignancies

Objective

Although pegylated liposomal doxorubicin (PLD) has a more favorable side-effect profile compared to doxorubicin, the FDA label for PLD includes a warning listing cardiotoxicity. Our objective was to evaluate predictors of pre- and post-treatment cardiac testing and quantify the effect of PLD on cardiac function in patients treated for gynecologic malignancies.

Methods

Retrospective chart review of gynecologic oncology patients who received PLD over a 10-year period at a single institution. Cardiac studies were aligned to PLD treatment and ejection fractions (EF) were compared pre- and post-treatment.

Results

A total of 453 patients who had received PLD were identified; 216 (48 %) had pre-PLD treatment cardiac function testing. Predictors of pre-chemotherapy testing were diabetes (p = 0.015), higher ECOG score (p = 0.004), and cardiac disease (p = 0.032). Eighty-three (18.3 %) patients had pre- and post-PLD treatment cardiac function testing. Predictors of pre- and post- testing were number of cycles of PLD (p < 0.0001) and total dose of PLD (p < 0.0001). Seventy-five (90 %) patients had no change in EF (defined as < 10 %), while 2 (2.4 %) had improvement in EF > 10 %, and 6 (7.2 %) had a decrease in EF > 10 %. Initial EF in patients with > 10 % decrease was higher than in those without change or improvement (p = 0.0004). One (1.2 %) patient had a clinically significant decrease in EF (32.5 %) resulting in interruption of treatment.

Conclusion

Risk of cardiac toxicity from administration of PLD for patients undergoing treatment for gynecologic cancers appears to be low. Selective screening of cardiac function should be employed for these patients.

Clinical Study of Post-Chemotherapy Cardiotoxicity in Breast Cancer Patients Based on Ultrasound Radiomics

PURPOSE

The aim of this study is to develop and validate a combined model based on ultrasound radiomics to detect cardiotoxicity after chemotherapy in patients with breast cancer.

METHODS

In this paper, we included 208 patients with breast cancer diagnosed pathologically and after chemotherapy, of whom had high-quality echocardiographic images; among them, 105 cases experienced cardiotoxicity, while 103 cases did not, which were divided into a training set and a validation set using a wholly randomized method according to a ratio of 7:3. Then, the left ventricular myocardium in the parasternal long-axis view of echocardiography was manually traced, the myocardial features of each image were extracted and filtered, and then a radiomics model was established; lastly, we plotted the receiver operating characteristic (ROC) curve; calculated the area under the curve (AUC); and assessed the diagnostic performance of the model.

RESULTS

The AUC of the combined model in the training set was 0.88 (95%CI,0.828-0.936), which was higher than the clinical model at 0.73 (95%CI,0.646-0.807) and the radiomics model at 0.84 (95%CI,0.774-0.903). In the validation set, the AUC of the combined model was 0.87 (95%CI,0.783-0.959), which was higher than the clinical model at 0.75 (95%CI,0.631-0.877) and the radiomics model at 0.81 (95%CI,0.698-0.917). The combined model of the training group and the validation group had statistical significance compared to both the clinical model and the radiomics model (Z = -4.066, p < 0.001; Z = -1.977, p = 0.048); (Z = -1.986, p = 0.047; Z = -2.142, p = 0.032). Meanwhile, the results of Hosmer-Lemeshow goodness-of-fit test were favorable (the training group: X2 = 6.776, p = 0.561; the validation group: X2 = 11.949, p = 0.154).

CONCLUSION

The combined model based on radiomics is an effective tool for the early diagnosis of cardiac toxicity in breast cancer patients after chemotherapy. It helps to detect cardiotoxicity of breast cancer patients during chemotherapy.

Applications, challenges and future directions of artificial intelligence in cardio-oncology

BACKGROUND

The management of cardiotoxicity related to cancer therapies has emerged as a significant clinical challenge, prompting the rapid growth of cardio-oncology. As cancer treatments become more complex, there is an increasing need to enhance diagnostic and therapeutic strategies for managing their cardiovascular side effects.

OBJECTIVE

This review investigates the potential of artificial intelligence (AI) to revolutionize cardio-oncology by integrating diverse data sources to address the challenges of cardiotoxicity management.

METHODS

We explore applications of AI in cardio-oncology, focusing on its ability to leverage multiple data sources, including electronic health records, electrocardiograms, imaging modalities, wearable sensors, and circulating serum biomarkers.

RESULTS

AI has demonstrated significant potential in improving risk stratification and longitudinal monitoring of cardiotoxicity. By optimizing the use of electrocardiograms, non-invasive imaging, and circulating biomarkers, AI facilitates earlier detection, better prediction of outcomes, and more personalized therapeutic interventions. These advancements are poised to enhance patient outcomes and streamline clinical decision-making.

CONCLUSIONS

AI represents a transformative opportunity in cardio-oncology by advancing diagnostic and therapeutic capabilities. However, successful implementation requires addressing practical challenges such as data integration, model interpretability, and clinician training. Continued collaboration between clinicians and AI developers will be essential to fully integrate AI into routine clinical workflows.

Associations Between Social Determinants of Health, Allostatic Load, and Anthracycline Cardiotoxicity in a Diverse Patient Population

BACKGROUND

Allostatic load (AL) is a measurement of physiological burden of chronic stress, operationalized using a composite score derived from biomarkers from multiple physiologic systems. The relationship between AL and anthracycline cardiotoxicity is unclear.

METHODS AND RESULTS

We included consecutive adult patients who underwent anthracycline-based chemotherapy from 2016 to 2019 for any type of cancer. Patients with preexisting heart failure and lack of AL score measures were excluded from the analysis. A composite AL score was calculated using 9 biomarkers tested before initiating chemotherapy. The end point was the development of cardiotoxicity (defined as clinical heart failure or drop in left ventricular ejection fraction≥10% to <50%). A total of 718 patients were included in the analysis (29% Non-Hispanic White, 31% Non-Hispanic Black, 40% Hispanic). The mean AL score was 2.4±1.4 and it was significantly higher in Non-Hispanic Black and Hispanic patients compared with Non-Hispanic White patients (2.5±1.3 in Non-Hispanic Black versus 2.4±1.3 in Hispanic versus 2.1±1.5 in Non-Hispanic White, P=0.031). In patients who developed cardiotoxicity, AL score was significantly higher than patients without cardiotoxicity (2.7±1.4 versus 2.3±1.3, P=0.006). AL score was independently associated with incident anthracycline cardiotoxicity after adjusting for race and ethnicity, age, sex, cardiovascular risk factors, anthracycline dose, baseline left ventricular ejection fraction, cancer type, and cancer metastasis (hazard ratio 1.20 per 1 AL score increase [95% CI, 1.02-1.43], P=0.033). AL score remained significantly associated with anthracycline cardiotoxicity after additional adjustment of social determinants of health.

CONCLUSIONS

AL score can be a potential important prognostic marker in the prediction of cardiotoxicity in patients with cancer undergoing cardiotoxic treatment independent of social determinants of health.