Cardio-Oncology: Vascular and Metabolic Perspectives: A Scientific Statement From the American Heart Association

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

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.

Cancer as an independent mortality risk in chronic thromboembolic pulmonary hypertension

BACKGROUND

The management of chronic thromboembolic pulmonary hypertension (CTEPH) has advanced significantly in recent years, thereby improving patient prognosis. However, the impact of cancer on the outcomes of patients with CTEPH under current treatment remains unclear. This study aimed to investigate the prevalence of cancer in patients with CTEPH and determine how comorbid cancer affects their prognosis and clinical course.

METHODS

Data from an ongoing Japanese prospective cohort study were analyzed. Prevalence and primary cancer sites were evaluated. The association of a history of cancer with a composite endpoint, including all-cause death, lung transplantation, and worsening of CTEPH, as well as venous thromboembolism and bleeding events, was assessed.

RESULTS

Of the 1,270 patients in the cohort, 134 (10.6%) had a history of cancer, with the most common primary sites being the breast in women and the prostate in men. The incidence of composite outcome and all-cause death was higher in those with a history of cancer (p < 0.001, log-rank test). In the Cox proportional hazard model, age- and sex-adjusted hazard ratios for the composite outcome and all-cause death were 2.69 (95% confidence interval, 1.48-4.89, p = 0.001) and 4.25 (95% confidence interval, 1.98-9.10, p < 0.001), respectively, for patients with a history of cancer. No significant differences in venous thromboembolism and bleeding events were observed between patients with and those without a history of cancer.

CONCLUSIONS

A history of cancer, with a prevalence of 10.6%, is an independent risk factor for mortality in patients with CTEPH undergoing the currently recommended treatment.

Long-term and short-term cardiovascular disease mortality among patients of 21 non-metastatic cancers

INTRODUCTION

Previous studies on cardiovascular disease (CVD) death risk in cancer patients mostly focused on overall cancer, age subgroups and single cancers.

OBJECTIVES

To assess the CVD death risk in non-metastatic cancer patients at 21 cancer sites.

METHODS

A total of 1,672,561 non-metastatic cancer patients from Surveillance, Epidemiology, and End Results (SEER) datebase (1975-2018) were included in this population-based study, with a median follow-up of 12·7 years. The risk of CVD deaths was assessed using proportions, competing-risk regression, absolute excess risks (AERs), and standardized mortality ratios (SMRs).

RESULTS

In patients with localized cancers, the proportion of CVD death and cumulative mortality from CVD in the high-competing risk group (14 of 21 unique cancers) surpassed that of primary neoplasm after cancer diagnosis. The SMRs and AERs of CVD were found higher in patients with non-metastatic cancer than the general US population (SMR 1·96 [95 %CI, 1·95-1·97]-19·85[95 %CI, 16·69-23·44]; AER 5·77-210·48), heart disease (SMR 1·94[95 %CI, 1·93-1·95]-19·25[95 %CI, 15·76-23·29]; AER 4·36-159·10) and cerebrovascular disease (SMR 2·05[95 %CI, 2·02-2·08]-24·71[95 %CI, 16·28-35·96]; AER 1·01-37·44) deaths. In the high-competing risk group, CVD-related SMR in patients with localized stage cancer increased with survival time but followed a reverse-dipper pattern in the low-competing risk group (7 of 21 cancers). The high-competing risk group had higher CVD-related death risks than the low-competing risk group.

CONCLUSION

The CVD death risk in patients with non-metastatic cancer varied by cancer stage, site and survival time. The risk of CVD mortality is higher in 14 out of 21 localized cancers (high-competing cancers). Targeted strategies for CVD management in non-metastatic cancer patients are needed.

Unraveling trends and disparities in acute myocardial infarction-related mortality among adult cancer patients: A nationwide CDC-WONDER analysis (1999-2020)

Background

Cancer patients are at an increased risk for the incidence and complications of acute myocardial infarction (AMI) due to shared risk factors and treatment-related adverse effects. Mortality trends for AMI-related deaths in adult cancer patients in the U.S. remain unexplored.

Methodology

This study used CDC WONDER data for death certificates from 1999 to 2020, identifying U.S. adults (≥25 years) with cancer (ICD-10: C00-D49) who died of AMI (ICD-10: I21) as the underlying cause. Age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) were calculated and stratified by gender, age, race, and geographic location.

Results

Between 1999 and 2020, there were 109,462 AMI-related deaths in adult cancer patients. The AAMR decreased from 4.3 per 100,000 in 1999 to 1.4 in 2020. A significant decline occurred from 1999 to 2015 (APC: 6.65; 95 % CI: 6.95 to -6.40; p < 0.001), followed by a stable trend from 2015 to 2020 (APC: 1.36; 95 % CI: 2.69 to 0.91; p = 0.152). Men had higher AAMRs than women (3.5 vs. 1.5). AAMRs were highest in older adults (10.5) compared to middle-aged (0.7) and young adults (0.1). Racial disparities showed the highest AAMRs in non-Hispanic (NH) Black patients (2.7), followed by NH Whites (2.4), NH American Indian/Alaska Native (1.6), Hispanic/Latino (1.3), and NH Asian/Pacific Islander (1.1). Non-metropolitan areas had higher AAMRs than metropolitan areas (2.8 vs. 2.2).

Conclusions

This analysis highlights a significant decline in AMI-related mortality among cancer patients in the U.S., with persistent disparities by gender, age, race and geographical location.

Cancer and myocardial injury in patients with suspected acute coronary syndrome

BACKGROUND

Cancer and cardiovascular diseases are the leading causes of mortality worldwide, as they share common risk factors and exacerbate cardiovascular outcomes when they coexist. This study aimed to assess the clinical characteristics and cardiovascular outcomes of patients with a history of cancer and myocardial injury (MI) presenting with suspected acute coronary syndrome (ACS) in an emergency setting.

METHODS

This retrospective cohort study included 3,626 patients admitted to the emergency department with suspected ACS between 2012 and 2013. Patients were categorized on the basis of their cancer history and the presence of MI. Clinical variables and the associations between cancer history and MI with all-cause mortality were analyzed over a four-year follow-up period via univariate and multivariate Cox regression models.

RESULTS

Of the cohort, 10.6% (n = 384) had a history of cancer. Compared with other groups, cancer patients with MI were older, had more comorbidities, and presented a higher incidence of type 2 myocardial infarction (T2MI). At the four-year follow-up, all-cause mortality was significantly greater among cancer patients with MI (68.8%) than among cancer patients without MI (32.4%) and noncancer patients with or without MI (42.5% vs. 11.3%, respectively). Multivariate analysis identified cancer patients, particularly those with MI, as independent predictors of mortality.

CONCLUSIONS

Patients who present to emergency departments with suspected ACS, a history of cancer, or the presence of MI face greater cardiovascular risk and mortality than other patients do. The higher prevalence of T2MI in this population underscores the need for tailored management strategies.

CARDIAC TUMORS: UPDATED CLASSIFICATIONS AND MAIN CLINICO-PATHOLOGIC FINDINGS

This review article - which is devoted to a wide range of physicians, e.g., pathologists, clinicians, radiologists, and general practitioners - is an up-to-date clinico-pathological description of cardiac tumours. Although rare, cardiac tumours are key components in oncology practice since both their early diagnosis and appropriate management denote urgent needs. Primary cardiac tumours (PCTs) are categorized in recent WHO classifications as well as in other scientific contributions. Their incidence is around 0.02% while their prevalence is between 0.001% and 0.03%. Among PCTs, benign lesions account for 85% of cases, while malignant neoplasms for 15%. Compared to PCTs, secondary cardiac tumours are 20-30-fold more common. The most frequent PCTs in adulthood are papillary fibroelastoma and cardiac myxoma, while, in childhood, cardiac rhabdomyoma. Heart metastases may occur through direct extension, or, indirectly, via bloodstream, lymphatics or intracavitary diffusion. Thoracic cancers (e.g. from pleura, lung, breast) are the most frequent cause of cardiac metastasis followed by oesophageal and haematological malignancies. Symptoms of PCTs (e.g. arrhythmias, dyspnoea, chest discomfort, syncope) are usually the result of both their regional involvement and location. Non-invasive imaging techniques (e.g. echocardiography, MRI, CT) and biopsy are key means in delineating tumour characteristics, size, and adjacent structure involvement. Most PCTs require surgery, which is recommended to prevent life-threatening complications. While many benign cardiac neoplasms may be completely resected, the treatment of choice for malignant PCTs and metastases is a combination of surgery, radio- and/or chemotherapy, as well as new alternative treatments, which may prolong survival in a small patient subset.

The role of imaging in defining cardiovascular risk to help cancer patient management: a scoping review

OBJECTIVE

This scoping review explores the potential role of cancer-staging chest CT scans in assessing cardiovascular (CV) risk in cancer patients. It aims to evaluate: (1) the correlation between non-gated chest CT and the conventional Agatston score from cardiac CT; (2) the association between coronary calcium scores from non-gated chest CT and CV risk in non-oncological patients; (3) the link between coronary calcium assessed by non-gated chest CT and CV events or endothelial damage in cancer patients.

METHODS

Three different searches were performed on PubMed, according to the three steps described above. Both original articles and systematic reviews were included.

RESULTS

Many studies in the literature have found a strong correlation between coronary calcium scores from non-gated chest CTs and the conventional Agatston scores from gated cardiac CTs. Various methodologies, including Agatston scoring, ordinal scoring, and the "extent" and "length" methods, have been successfully adapted for use with non-gated chest CTs. Studies show that non-gated scans, even those using iodinated contrast, can accurately assess coronary calcification and predict CV risk, with correlations as high as r = 0.94 when compared to cardiac CTs. In oncological settings, studies demonstrated a significant link between coronary calcium levels on non-gated chest CTs and higher CV risk, including MACE and overall mortality.

CONCLUSIONS

Radiological assessment of coronary calcium on non-gated CT scans shows potential for improving CV risk prediction.

CRITICAL RELEVANCE STATEMENT

Non-gated chest CT scans can detect endothelial damage in cancer patients, highlighting the need for standardized radiological practices to assess CV risks during routine oncological follow-up, thereby enhancing radiology's role in comprehensive cancer care.

KEY POINTS

Cancer therapies improve outcomes but increase cardiovascular risk, requiring balanced management. Coronary calcification on non-gated CT correlates with Agatston scores, predicting cardiovascular risk. Routinely performed CTs predict cardiovascular risk, optimizing the management of cancer patients.

Clinical outcomes of cancer-associated isolated distal deep vein thrombosis: a comparison between asymptomatic and symptomatic thrombosis-findings from the ONCO DVT Study

Background

The risk of recurrent venous thromboembolism (VTE) in patients with isolated distal deep vein thrombosis (IDDVT) is generally low, particularly when IDDVT is asymptomatic. However, cancer patients with IDDVT, even asymptomatic IDDVT, may be at a higher risk of recurrent VTE.

Objectives

To compare the clinical outcomes of cancer patients with asymptomatic and symptomatic IDDVT.

Methods

The ONCO DVT trial is a randomized clinical trial that compared 12-month versus 3-month edoxaban treatment regimens in cancer patients with IDDVT. In this post hoc analysis, 601 patients were categorized into the asymptomatic (n = 479) and symptomatic (n = 122) groups based on IDDVT-related symptoms at diagnosis. The primary outcome was the composite of symptomatic recurrent VTE or VTE-related death at 12 months, while the major secondary outcome was major bleeding at 12 months.

Results

The cumulative 12-month incidence of the primary outcome was lower in the asymptomatic group than that in the symptomatic group (2.9% vs 13.4%; P < .001; hazard ratio, 0.21; 95% CI, 0.10-0.47). Among the 12 patients with symptomatic recurrent VTE in the asymptomatic group, 8 (67%) had recurrent IDDVT, and 11 (92%) experienced recurrence after discontinuing anticoagulation therapy. The cumulative 12-month incidence of major bleeding was lower in the asymptomatic group than that in the symptomatic group (7.8% and 13.2%; P = .048).

Conclusion

The risk of recurrent symptomatic VTE was lower in cancer patients with asymptomatic IDDVT than in those with symptomatic IDDVT. Most recurrent VTE events were recurrent IDDVT, with the majority occurring after discontinuing anticoagulation therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusions

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

A look into the cancer continuum for the development of a physical activity intervention: qualitative investigation of the physical activity experiences and preferences of female cancer survivors

PURPOSE

Clinical guidelines recommend cancer survivors (i.e., people with a cancer diagnosis) engage in regular physical activity (PA) during and post treatment, yet most do not. Additionally, PA promotion for cancer survivors has primarily focused on post treatment, calling for an understanding of PA promotion during treatment. This study explores the PA experiences and preferences of both in-treatment and post-treatment breast and gynecologic cancer survivors (BGCS) to inform the design of a PA intervention.

METHODS

Semi-structured interviews were conducted with postmenopausal women aged ≥ 50 years, diagnosed with breast or gynecological cancer (stages 1-3), who were undergoing, or recently completed (12 to 24 months) chemotherapy and/or primary treatment. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to explore themes.

RESULTS

Participants (N = 26; Mage: 63.9 years) had a breast (92.3%) and gynecologic (7.7%) cancer diagnosis and 46.2% (n = 12) were in treatment whereas 53.8% (n = 14) were post treatment. BGCS experienced several side effects of cancer treatment and both groups felt PA was an important goal. In-treatment BGCS focused on managing side effects (e.g., fatigue) and recognized energy fluctuated around treatments, making those periods less ideal for PA. In-treatment BGCS strongly endorsed a flexible, at-home intervention. Post-treatment BGCS emphasized recovery and relapse prevention, also favoring at-home, flexible interventions but showing greater interest towards support groups to aid with their recovery journey. Preferred activities included walking, dancing, and muscle-strengthening.

CONCLUSION

Findings highlight the unique challenges postmenopausal BGCS face in participating in PA, especially in-treatment, emphasizing the importance of a tailored PA intervention.

Cancer Therapy and Exercise Intolerance: The Heart Is But a Part: JACC: CardioOncology State-of-the-Art Review

The landscape of cancer therapeutics is continually evolving, with successes in improved survivorship and reduced disease progression for many patients with cancer. Improved cancer outcomes expose competing comorbidities, some of which may be exacerbated by cancer therapies. The leading cause of disability and death for many early-stage cancers is cardiovascular disease (CVD), which is often attributed to direct or indirect cardiac injury from cancer therapy. In this review, the authors propose that toxicities related to conventional and novel cancer therapeutics should be considered beyond the heart. The authors provide a framework using the oxygen pathway to understand the impact of cancer treatment on peak oxygen uptake, a marker of integrative cardiopulmonary function and CVD risk. Peripheral toxicities and the impact on oxygen transport are discussed. Consideration for the broad effects of cancer therapies will improve the prediction and identification of cancer survivors at risk for CVD, functional disability, and premature mortality and those who would benefit from therapeutic intervention, ultimately improving patient outcomes.

Risk of Venous Thromboembolism in Patients With Stage III and IV Non-Small-Cell Lung Cancer: Nationwide Descriptive Cohort Study

BACKGROUND

Venous thromboembolism (VTE) is a common complication in patients starting cancer therapies for non-small-cell lung cancer (NSCLC). We examined the risk and timing of VTE in patients with stage IIIA, IIIB to C, and stage IV NSCLC according to received cancer treatments.

MATERIALS AND METHODS

A nationwide registry-based cohort study of patients recorded in the Danish Lung Cancer Registry (2010-2021) followed for 1 year after entry into the registry to assess the incidence of VTE. The Aalen-Johansen estimator was used to calculate the risk of VTE after treatment commencement with chemotherapy, radiotherapy, chemoradiation, immunotherapy, and targeted therapy.

RESULTS

Among the 3475 patients with stage IIIA, 4047 with stage IIIB to C, and 18,082 patients with stage IV cancer, the 1-year risk of VTE was highest in the first 6 months and varied markedly by cancer stage and cancer treatment. In stage IIIA, VTE risk was highest with chemotherapy (3.9%) and chemoradiation (4.1%). In stage IIIB to C, risks increased with chemotherapy (5.2%), immunotherapy (9.4%), and targeted therapy (6.0%). Stage IV NSCLC showed high risk with targeted therapy (12.5%) and immunotherapy (12.2%). The risk was consistently higher for pulmonary embolism than deep vein thrombosis.

CONCLUSION

VTE risks vary substantially according to cancer treatments and cancer stages. The highest risk was observed in the initial 6 months of therapy initiation. These insights emphasize the need for tailored risk assessment and vigilance in managing VTE complications in patients with NSCLC. Further research is needed to optimize individual thromboprophylaxis strategies for patients with unresectable and metastatic NSCLC.

Incidental Extracardiac Findings of Technetium-99m Pyrophosphate Scintigraphy: A Pictorial Review

Technetium-99m pyrophosphate (Tc-99m PYP) cardiac imaging is a simple, widely available, noninvasive method to identify patients with transthyretin-type cardiac amyloidosis (ATTR), and it has remarkably high diagnostic accuracy with very high sensitivity and specificity. Visual scores of 0, 1, 2, and 3 indicate non-myocardial uptake, uptake less than rib, equal to rib, and greater than rib uptake, respectively. Semiquantitative assessment using the heart-to-contralateral lung ratio of more than 1.5 at 1 hour accurately distinguishes ATTR from the cardiac amyloid light chain subtype. However, there are several incidental non-cardiac findings that can be seen in planar images, rotating single-photon emission computed tomography (SPECT) images, maximum intensity projection images, or computed tomography images acquired for attenuation correction. These findings may lead to the early detection of a noncardiac condition that may require additional treatment. The intent of this review is to demonstrate several incidental noncardiac abnormalities that have an impact on patient management and follow-up.

Arterial Stiffness Changes in Adult Cancer Patients Receiving Anticancer Chemotherapy: A Real-World Bicentric Experience

Background Chemotherapy correlates to acute and long-term cardiotoxicity, is reflected clinically by myocardial and vascular endothelial dysfunction, and can cause cardiovascular complications. Thus, early diagnosis of cardiovascular disease in cancer patients undergoing anti-cancer treatment is necessary to enhance long-term survival. Our principal objective in this study was to discern the impact of specific anti-cancer chemotherapeutics and biologics on arterial stiffness alterations before and after the administration. Methods Conducted at Mustafa Bacha University Hospital, Algeria, the study focused on arterial stiffness in anti-cancer chemotherapy patients. Assessments included blood pressure, diabetes, and dyslipidemia, with precise measurements using validated systems, particularly pulse wave velocity (PWV). Various chemotherapy protocols were applied, and statistical analysis with R software (R Foundation for Statistical Computing, Vienna, Austria) maintained a significance level of p=0.05. Key outcomes centered on carotid-femoral PWV and secondary endpoints such as central and peripheral pressures and pulse pressure (PP). Univariate and bivariate analyses were conducted using appropriate statistical tests.  Results A comparative prospective observational study was completed on 58 patients (34 women and 24 men; mean age: 52.64 +/- 12.12 years) treated with anti-cancer chemotherapy agents. Our evaluation included a complete clinical exam, electrocardiogram, Doppler echocardiography, and applanation tonometry with arterial stiffness measurement using PWV. Patients presented significantly higher levels of carotid-femoral PWV, regardless of the chosen chemotherapy protocol, with no return to the initial level after one year of stopping treatment (p-value < 0.01). Moreover, this increase was more significant in patients with diabetes and hypertension and patients treated with monoclonal antibodies or intercalants.  Conclusion This prospective study shows that chemotherapy patients have elevated arterial stiffness, emphasizing the need to assess PWV and monitor cardiovascular risk factors. PP measurement with PWV could improve risk management.

Advancing the care of individuals with cancer through innovation & technology: Proceedings from the cardiology oncology innovation summit 2020 and 2021

As cancer therapies increase in effectiveness and patients' life expectancies improve, balancing oncologic efficacy while reducing acute and long-term cardiovascular toxicities has become of paramount importance. To address this pressing need, the Cardiology Oncology Innovation Network (COIN) was formed to bring together domain experts with the overarching goal of collaboratively investigating, applying, and educating widely on various forms of innovation to improve the quality of life and cardiovascular healthcare of patients undergoing and surviving cancer therapies. The COIN mission pillars of innovation, collaboration, and education have been implemented with cross-collaboration among academic institutions, private and public establishments, and industry and technology companies. In this report, we summarize proceedings from the first two annual COIN summits (inaugural in 2020 and subsequent in 2021) including educational sessions on technological innovations for establishing best practices and aligning resources. Herein, we highlight emerging areas for innovation and defining unmet needs to further improve the outcome for cancer patients and survivors of all ages. Additionally, we provide actionable suggestions for advancing innovation, collaboration, and education in cardio-oncology in the digital era.

Characteristics of patients with newly diagnosed hematological malignancies referred for echocardiography

Objective

The importance of cardio-hemato-oncology programs is increasing. The main aim of the study was to identify all coexisting cardiovascular disorders in patients with new hematological malignancies referred for echocardiography during baseline evaluation before anticancer therapy.

Material and methods

The study was based on 900 echocardiographic examinations performed within 12 months at the Institute of Hematology and Transfusion Medicine in Poland: 669 tests (74.3%) were dedicated to hemato-oncology patients at the different stages of cancer therapy, however almost a third of the tests (277, 30.8%) were part of a baseline evaluation before starting first line anticancer therapy due to newly diagnosed hematological malignancies.

Results

The group of 277 patients with new hematological malignancies (138 women, 49.82%) with a median age of 66 years (interquartile range: 53-72 years) was included in the main analyses. The three most frequent new histopathological diagnoses were: non-Hodgkin lymphoma (63 cases; 22.74%), acute myeloid leukaemia (47 cases; 16.97%), and multiple myeloma (45 cases; 16.25%). The three most common clinical cardiology disorders were arterial hypertension (in 133 patients, 48.01%), arrhythmias (48 patients, 17.33%), and heart failure (39 patients, 14.08%). Among 48 patients with arrhythmias there were 22 cases with atrial fibrillation. The most frequently detected echocardiographic abnormality was Left Atrial Volume Index >34 ml/m2 which was present in 108 of 277 patients (38.99%) and associated with a significantly greater chance of concomitant diagnosis of arrhythmias (OR=1.98; p=0.048) especially atrial fibrillation (OR=3.39; p=0.025). The second most common echocardiographic finding was diastolic dysfunction 2nd or 3rd degree revealed in 43 patients (15.52%) and associated with a greater chance of simultaneous diagnosis of heart failure (OR=8.32; p<0.0001) or arrhythmias (OR=4.44; p<0.0001) including atrial fibrillation (OR=5.40; p=0.0003).

Conclusions

In patients with newly diagnosed hematological malignancies left ventricular diastolic dysfunction is a common abnormality in echocardiography and may determine diagnoses of heart failure or arrhythmias.

Cardiovascular Toxicity of Angiogenesis Inhibitors Among Patients With Cancer in Taiwan: A Nested Case-Control Study

BACKGROUND

Research on the cardiovascular toxicity of angiogenesis inhibitors among patients with cancer in Taiwan is lacking. This observational study explored the risk of major adverse cardiovascular events (MACEs) associated with angiogenesis inhibitors in Taiwan.

METHODS AND RESULTS

We conducted a nested case-control study using the TCR (Taiwan Cancer Registry) linked with the Taiwan National Insurance Claim Database. We matched every case with 4 controls using risk-set sampling by index date, age, sex, cancer type, and cancer diagnosis date. Conditional logistic regression was used to evaluate the risks of MACEs and different cardiovascular events using propensity score adjustment or matching. Sensitivity analyses were used to evaluate the risks matched by cancer stages or exposure within 1 year. Among a cohort of 284 292 after the exclusion of prevalent cases, the incidences of MACEs among the overall cohort and those exposed to angiogenesis inhibitors were 22.5 and 32.5 events per 1000 person-years, respectively. We matched 17 817 cases with 70 740 controls, with a mean age of 74.9 years, and 56.8% of patients were men. After propensity score adjustment, angiogenesis inhibitors were associated with increased risks of MACEs (odds ratio, 4.56; 95% CI, 1.78-11.59). Significantly increased risks were noted for heart failure hospitalization, myocardial infarction, cerebrovascular accident, and venous thromboembolism, but not for new-onset atrial fibrillation. Similar results were observed after matching by cancer stage or restriction of 1-year exposure.

CONCLUSIONS

Angiogenesis inhibitors were associated with increased risks of MACEs among patients with various malignancies in Taiwan but were not associated with new-onset atrial fibrillation.

Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

Cardiovascular adverse events and prognosis in patients with haematologic malignancies and breast cancer receiving anticancer agents: Kurume-CREO Registry insights

AIMS

Cancer treatment-related cardiovascular toxicity (CTR-CVT) is a growing concern in patients undergoing anticancer therapy. The Heart Failure Association (HFA) and International Cardio-Oncology Society (ICOS) risk assessment tools have been proposed for the baseline cardiovascular (CV) risk stratification of patients with cancer. This study investigated the incidence of CV adverse events in clinical practice, also using the HFA-ICOS risk tool.

METHODS AND RESULTS

This single-centre, prospective, observational study was conducted at Kurume University Hospital from October 2016 to August 2021, including patients aged ≥20 years with haematologic malignancies or breast cancer who were receiving anticancer agents. Cardiovascular assessments were performed at enrolment and every 6 months until August 2021, with additional assessments for suspected CV adverse events. The primary endpoint was common terminology criteria for adverse events v4.0 Grade ≥2, and the secondary endpoints were all-cause and CV deaths. Of the enrolled 486 patients, CV adverse events occurred in 24.5, 15.8, 38.1, and 18.0% of patients with leukaemia, malignant lymphoma, multiple myeloma, and breast cancer, respectively. Patients at high or very high risk had a significantly higher incidence of CV events, according to the HFA-ICOS risk tool. Cardiovascular death occurred in 4 (0.8%) patients during follow-up.

CONCLUSION

This study revealed that 16-38% of patients with haematologic malignancies and breast cancer developed CTR-CVT during follow-up, in which patients with high/very high risk were well predicted by the HFA-ICOS risk assessment tool. Monitoring and managing CV risk factors are essential for safe cancer therapy.

Endothelin-based markers for endothelial dysfunction in chemotherapy-induced cardiotoxicity

Current cardiac biomarkers, troponins and brain natriuretic peptide, are primarily used to assist in the diagnosis or exclusion of myocardial damage and congestive heart failure, respectively. The use of these biomarkers in chemotherapy-induced cardiotoxicity has been evaluated by various studies. However, neither biomarker provides early predictive value, leaving many cancer survivors with irreversible cardiac injury. Assessing endothelial dysfunction could be an effective measure of chemotherapy-induced cardiotoxicity at the vascular level. Risk profiling and detection of vascular toxicities may offer predictive biomarkers to prevent chronic manifestation of irreversible cardiotoxicities. Emerging interest has developed in finding biomarkers that could ideally provide earlier prognostic value. Thus, the aim of this review is to give an overview of current blood-based cardiac biomarkers and discuss the potential of endothelin-1 (ET-1) and more stable peptide fragments of ET-1 synthesis as biomarkers of endothelial dysfunction. For instance, endothelin-like domain peptide (ELDP) and C-terminal pro-endothelin-1 (CT-proET-1) demonstrated high-sensitivity and longer clearance rate than ET-1. Thus, investigating their biomarker role in chemotherapy-induced cardiotoxicity is important and could provide additional insights for identifying patients at risk. Also, additional research is required to fully understand ELDP-mediated vasoconstriction. This review will discuss the future development of ET-1, ELDP and CT-proET-1 as prospective predictive biomarkers.

Allied health professional's self-reported competences and confidence to deliver physical activity advice to cancer patients at a single Centre in England

PURPOSE

Allied Health Professionals (AHPs) are well placed to deliver physical activity advice but this is currently not routine clinical practice. Increasing evidence demonstrates physical activity can improve quality-of-life for people affected by cancer, enable behaviour change, improve survival and reduce long-term treatment effects. We aimed to understand AHPs' current knowledge and practice in advising about physical activity.

MATERIALS AND METHODS

AHPs' self-reported knowledge, competency and training needs in managing physical effects of cancer, and the merits of physical activity data were collected via an online survey. The survey link was cascaded electronically to all NHS and NHS-affiliated AHPs working across several generic and non-cancer-specific healthcare interfaces across one city in England.

RESULTS

Eighty AHPs responded. Forty-one percent of AHPs had patients with current or past diagnoses of cancer. Overall, AHPs reported low confidence in giving physical activity advice, with physiotherapists the most confident. 60% of respondents identified training needs concerning the impact of cancer.

CONCLUSIONS

Although the merits of physical activity for people affected by cancer is clearly evidenced, low levels of AHP confidence and competence in discussing this topic limit patients' awareness and access to services. Addressing this confidence and competence has potential to improve patient outcome.

Molecular Imaging Biomarkers in Cardiooncology: A View on Established Technologies and Future Perspectives

Novel therapeutic options have significantly improved survival and long-term outcomes in many cancer entities. Unfortunately, this improvement in outcome is often accompanied by new and increasingly relevant therapy-related cardiovascular toxicity. In this context, cardiooncology has emerged as a new field of interdisciplinary individual patient care. Important tasks are pretherapeutic risk stratification and early detection and treatment of cardiotoxicity, which comprises cardiac damage in relation to cardiovascular comorbidities, the tumor disease, and cancer treatment. Clinical manifestations can cover a broad spectrum, ranging from subtle and usually asymptomatic abnormalities to serious acute or chronic complications. Typical manifestations include acute and chronic heart failure, myo- and pericarditis, arrythmias, ischemia, and endothelial damage. They can be related to almost all current cancer treatments, including cytotoxic chemotherapy, targeted therapy, immunotherapy, hormonal therapy, and radiotherapy. Molecular imaging biomarkers can aid in pretherapeutic cardiooncologic assessment for primary prevention and personalized surveillance, detection, and differential diagnosis of cardiotoxic complications. Potential advantages over conventional diagnostics are the higher detection sensitivity for subtle changes in cardiac homeostasis, higher reproducibility, and better observer independence. Hybrid imaging with highly sensitive PET/MRI may be particularly suited for early diagnosis. Important technologies that are encouraged in current multidisciplinary guidelines are equilibrium radionuclide angiography for evaluation of ventricular function and chamber morphology, as well as myocardial perfusion imaging for additional detection of ischemia. Novel modalities that may detect even earlier signs of cardiotoxicity comprise 123I-metaiodobenzylguanidine SPECT to visualize sympathetic innervation, 18F-FDG and somatostatin receptor (68Ga-DOTATOC/DOTATATE) PET to indicate a metabolic shift and inflammation, and 68Ga-fibroblast activation protein inhibitor PET to monitor cardiac remodeling. In addition, PET imaging of mitochondrial function has recently been introduced in preclinical models and will potentially broaden the field of application through higher sensitivity and specificity and by enabling higher individualization of diagnostic concepts.

Cardiovascular Imaging in Contemporary Cardio-Oncology: A Scientific Statement From the American Heart Association

Advances in cancer therapeutics have led to dramatic improvements in survival, now inclusive of nearly 20 million patients and rising. However, cardiovascular toxicities associated with specific cancer therapeutics adversely affect the outcomes of patients with cancer. Advances in cardiovascular imaging have solidified the critical role for robust methods for detecting, monitoring, and prognosticating cardiac risk among patients with cancer. However, decentralized evaluations have led to a lack of consensus on the optimal uses of imaging in contemporary cancer treatment (eg, immunotherapy, targeted, or biological therapy) settings. Similarly, available isolated preclinical and clinical studies have provided incomplete insights into the effectiveness of multiple modalities for cardiovascular imaging in cancer care. The aims of this scientific statement are to define the current state of evidence for cardiovascular imaging in the cancer treatment and survivorship settings and to propose novel methodological approaches to inform the optimal application of cardiovascular imaging in future clinical trials and registries. We also propose an evidence-based integrated approach to the use of cardiovascular imaging in routine clinical settings. This scientific statement summarizes and clarifies available evidence while providing guidance on the optimal uses of multimodality cardiovascular imaging in the era of emerging anticancer therapies.

Prevalence and outcomes of type 2 myocardial infarction in patients with cancer: A retrospective analysis from the National Inpatient Sample dataset

BACKGROUND

This study aimed to investigate the prevalence, clinical characteristics and outcomes of type 2 myocardial infarction (T2AMI) in patients with versus without cancer.

METHODS

All hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to cancer status (secondary diagnosis of any-cancer vs cancer-free) using data from the US National Inpatient Sample (2016-2019). The primary outcome was in-hospital all-cause mortality while secondary outcomes were in-hospital major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Among 61,305 included hospitalizations with primary diagnosis of T2AMI, 3745 (6.1%) were associated with a diagnosis of cancer. Patients with T2AMI and cancer presented more frequently with acute respiratory failure (23.2% vs 18.1%), acute pulmonary embolism (3.7% v 1.3%), major bleeding (6.8% vs 4.1%) and renal failure (51.0% vs 46.8%), compared to patients without. On adjusted analysis, diagnosis of cancer was associated with lower odds of invasive coronary angiography (aOR 0.75, 95% CI 0.60 to 0.93, p = 0.009) but greater odds of mortality (aOR 1.95, 95% C.I. 1.26-2.99 p = 0.002). Among the different types of cancer, adjusted risk of all-cause mortality was higher in patients with colorectal (aOR 4.17 95% CI 1.68-10.32, p = 0.002), lung (aOR 3.63, 95% CI 1.83-7.18, p < 0.001) and haematologic (aOR 2.48, 95% CI 1.22-5.05, p = 0.001) cancer.

CONCLUSIONS

Patients with cancer presenting with T2AMI have lower odds of management with invasive diagnostic coronary angiography and have higher rates of in-hospital all-cause death. Further studies are warranted to improve overall care and outcomes of cancer patients and cardiovascular diseases.

Annual Increase of Acute Inpatients with Both Cancer and Cardiovascular Diseases in Japan 2011-2015: Analysis From National Database of Health Insurance Claims and Specific Health Checkups of Japan

BACKGROUND

Patients with cancer were able to live longer due to improvements in cancer treatment. Additionally, cardiovascular disease (CVD) is the second leading cause of mortality in cancer survivors. However, epidemiological data on onco-CVD have not been sufficiently provided. We aimed to investigate the clinical characteristics of cancer in CVD patients using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).

METHOD AND RESULTS

The NDB sampling dataset used in this study was randomly sampled 10% from the whole Diagnosis Procedure Combination (DPC) records from every January, April, July, and October from 2011 to 2015. The significance of the increase trend in the percentage of records in each disease group to the total number of all DPC records from 2011 to 2015 was checked with Chi-square test with a Bonferroni correction. The percentage of records in cancer with the CVD group to the total number of all DPC records significantly increased over time, and their average age also increased since 2011. Their proportion over 75 years was approximately 56 % in 2015. There was no difference in the cancer sites. However, the prevalence of heart failure dramatically elevated.

CONCLUSION

We were able to assess the increase in cancer among CVD patients using DPC inpatient records obtained from the NDB. Both cardiologists and oncologists should be more aware of this phenomenon.

Comparisons of drug-eluting balloon versus drug-eluting stent for the treatment of cancer patients presenting with acute myocardial infarction

BACKGROUND

Treatment for cancer patients presenting with acute myocardial infarction (AMI) remains challenging. The objective of the study was to investigate the safety and efficiency of drug eluting balloon (DEB) versus drug eluting stent (DES) in this high-risk group.

METHODS

Between 1st January 2017 and 1st January 2022, cancer patients admitted to Beijing Chaoyang Hospital with AMI were retrospectively enrolled. The primary endpoint was major adverse cardiovascular event (MACE). The secondary endpoints included major bleeding events, heart failure and cardiac complications.

RESULTS

A total of 164 cancer patients presenting with AMI were included in the final analysis. Patients treated with DEB had a numerically lower rate of MACE than those treated with DES during a median follow-up of 21.8 months (22.9% vs. 37.1%, p = 0.23). Patients treated with DEB had a trend towards lower rate of major bleeding events than patients treated with DES (6.3% vs. 18.1%, HR 2.96, 95% CI [0.88, 9.92], p = 0.08). There were no significant differences between the two groups with regards to the rate of heart failure (4.2% vs. 9.5%, p = 0.32) and cardiac complications (0.0% vs. 2.6%, p = 0.56).

CONCLUSIONS

The present study demonstrated that in cancer patients with AMI, DEB had a trend towards lower rate of major bleeding events and a numerically lower rate of MACE compared with DES.

Doxorubicin-Loaded Platelet Decoys for Enhanced Chemoimmunotherapy Against Triple-Negative Breast Cancer in Mice Model

Introduction

Triple-negative breast cancer (TNBC) is a highly aggressive subtype with a poor prognosis. Current single-agent checkpoint therapy has limited effectiveness in TNBC patients. In this study, we developed doxorubicin-loaded platelet decoys (PD@Dox) for chemotherapy and induction of tumor immunogenic cell death (ICD). By combining PD-1 antibody, PD@Dox has the potential to enhance tumor therapy through chemoimmunotherapy in vivo.

Methods

Platelet decoys were prepared using 0.1% Triton X-100 and co-incubated with doxorubicin to obtain PD@Dox. Characterization of PDs and PD@Dox was performed using electron microscopy and flow cytometry. We evaluated the properties of PD@Dox to retain platelets through sodium dodecyl sulfate-polyacrylamide gel electrophoresis, flow cytometry, and thromboelastometry. In vitro experiments assessed drug-loading capacity, release kinetics, and the enhanced antitumor activity of PD@Dox. The mechanism of PD@Dox was investigated through cell viability assays, apoptosis assays, Western blot analysis, and immunofluorescence staining. In vivo studies were performed using a TNBC tumor-bearing mouse model to assess the anticancer effects.

Results

Electron microscopic observations confirmed that platelet decoys and PD@Dox exhibited a round shape similar to normal platelets. Platelet decoys demonstrated superior drug uptake and loading capacity compared to platelets. Importantly, PD@Dox retained the ability to recognize and bind tumor cells. The released doxorubicin induced ICD, resulting in the release of tumor antigens and damage-related molecular patterns that recruit dendritic cells and activate antitumor immunity. Notably, the combination of PD@Dox and immune checkpoint blockade therapy using PD-1 antibody achieved significant therapeutic efficacy by blocking tumor immune escape and promoting ICD-induced T cell activation.

Conclusion

Our results suggest that PD@Dox, in combination with immune checkpoint blockade therapy, holds promise as a potential strategy for TNBC treatment.

Long-term risks of cardiovascular death in a population-based cohort of 1,141,675 older patients with cancer

BACKGROUND

previous studies have focused on the risk of cardiovascular disease (CVD)-related death in individual cancers, adolescents or all cancers.

OBJECTIVE

to evaluate the risk of CVD-related death in older patients with cancer.

METHODS

older patients with cancer (over 65 years) of 16 cancers diagnosed between 1975 and 2018 were screened out from the Surveillance, Epidemiology and End Results program. The proportion of deaths, competing risk regression models, standardized mortality ratios (SMRs) and absolute excess risks (AERs) were used to assess the risk of CVD-related death.

RESULTS

this study included 1,141,675 older patients (median follow-up: 13.5 years). Of the 16 individual cancers, the risk of CVD death exceeded primary neoplasm death in older patients with cancers of the breast, endometrium, vulva, prostate gland, penis and melanoma of the skin over time (high competing risk group). Compared to the general older population, older patients with cancer had higher SMR and AER of CVD-related death (SMR: 1.58-4.23; AER: 21.16-365.89), heart disease-related death (SMR: 1.14-4.16; AER: 16.29-301.68) and cerebrovascular disease-related death (SMR: 1.11-4.66; AER: 3.02-72.43), with the SMR trend varying with CVD-related death competing risk classifications. The risk of CVD-related death in the high-competing risk group was higher than in the low-competing risk group.

CONCLUSIONS

for older patients with cancer, six of 16 individual cancers, including breast, endometrium, vulva, prostate gland, penis and melanoma of the skin was at high risk of CVD-related death. Management for long-term cardiovascular risk in older patients with cancer is needed.

Cardiovascular Risks in Testicular Cancer: Assessment, Prevention, and Treatment

PURPOSE OF REVIEW

Testicular cancer (TC) is the leading cancer in men between 18 and 39 years of age. Current treatment involves tumor resection followed by surveillance and/or one or more lines of cisplatin-based chemotherapy (CBCT) and/or bone marrow transplant (BMT). Ten years after treatment, CBCT has been associated with significant atherosclerotic cardiovascular disease (CVD) including myocardial infarction (MI), stroke, and heightened rates of hypertension, dyslipidemia, diabetes mellitus, and metabolic syndrome (MetS). Additionally, low testosterone levels and hypogonadism contribute to MetS and may further drive CVD.

RECENT FINDINGS

CVD in TCS has been associated with worse physical functioning accompanied by role limitations, decreased energy, and decreased overall health. Exercise may play a role in ameliorating these effects. Systematic CVD screening practices are needed at TC diagnosis and in survivorship. We encourage a multidisciplinary partnership between primary care physicians, cardiologists, cardio-oncologists, medical oncologists, and survivorship providers to address these needs.

Established and Emerging Cancer Therapies and Cardiovascular System: Focus on Hypertension-Mechanisms and Mitigation

Cardiovascular disease and cancer are 2 of the leading causes of death worldwide. Although improvements in outcomes have been noted for both disease entities, the success of cancer therapies has come at the cost of at times very impactful adverse events such as cardiovascular events. Hypertension has been noted as both, a side effect as well as a risk factor for the cardiotoxicity of cancer therapies. Some of these dynamics are in keeping with the role of hypertension as a cardiovascular risk factor not only for heart failure, but also for the development of coronary and cerebrovascular disease, and kidney disease and its association with a higher morbidity and mortality overall. Other aspects such as the molecular mechanisms underlying the amplification of acute and long-term cardiotoxicity risk of anthracyclines and increase in blood pressure with various cancer therapeutics remain to be elucidated. In this review, we cover the latest clinical data regarding the risk of hypertension across a spectrum of novel anticancer therapies as well as the underlying known or postulated pathophysiological mechanisms. Furthermore, we review the acute and long-term implications for the amplification of the development of cardiotoxicity with drugs not commonly associated with hypertension such as anthracyclines. An outline of management strategies, including pharmacological and lifestyle interventions as well as models of care aimed to facilitate early detection and more timely management of hypertension in patients with cancer and survivors concludes this review, which overall aims to improve both cardiovascular and cancer-specific outcomes.

Exploring Vessel Wall Biology In Vivo by Ultrasensitive Total-Body PET

Ultrasensitive, high-resolution, extended-field-of-view total-body (TB) PET using the first-of-its-kind 194-cm axial-field-of-view uEXPLORER may facilitate the interrogation of biologic hallmarks of hitherto difficult-to-evaluate low-signal vessel wall pathology in cardiovascular disease. Methods: Healthy volunteers were imaged serially for up to 12 h after a standard dose of 18F-FDG (n = 15) or for up to 3 h after injection of a very low dose (about 5% of a standard dose; n = 15). A cohort undergoing standard 18F-FDG PET (n = 15) on a conventional scanner with a 22-cm axial field of view served as a comparison group. Arterial wall signal, crosstalk with hematopoietic and lymphoid organs, and image quality were analyzed using standardized techniques. Results: TB PET depicted the large vessel walls with excellent quality. The arterial wall could be imaged with high contrast up to 12 h after tracer injection. Ultralow-dose TB 18F-FDG images yielded a vessel wall signal and target-to-background ratio comparable to those of conventional-dose, short-axial-field-of-view PET. Crosstalk between vessel wall and lymphoid organs was identified with better accuracy in both TB PET cohorts than in conventional PET. Conclusion: TB PET enables detailed assessment of in vivo vessel wall biology and its crosstalk with other organs over an extended time window after tracer injection or at an ultralow tracer dose. These initial observations support the feasibility of serial imaging in low-risk populations and will stimulate future mechanistic studies or therapy monitoring in atherosclerosis and other vessel wall pathologies.

Impact of sodium-glucose cotransporter-2 inhibitors on heart failure and mortality in patients with cancer

OBJECTIVES

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce heart failure (HF) in at-risk patients and may possess antitumour effects. We examined the effect of SGLT2i on HF and mortality among patients with cancer and diabetes.

METHODS

This was a retrospective propensity score-matched cohort study involving adult patients with type 2 diabetes mellitus diagnosed with cancer between January 2010 and December 2021. The primary outcomes were hospitalisation for incident HF and all-cause mortality. The secondary outcomes were serious adverse events associated with SGLT2i.

RESULTS

From a total of 8640 patients, 878 SGLT2i recipients were matched to non-recipients. During a median follow-up of 18.8 months, SGLT2i recipients had a threefold lower rate of hospitalisation for incident HF compared with non-SGLT2i recipients (2.92 vs 8.95 per 1000 patient-years, p=0.018). In Cox regression and competing regression models, SGLT2i were associated with a 72% reduction in the risk of hospitalisation for HF (HR 0.28 (95% CI: 0.11 to 0.77), p=0.013; subdistribution HR 0.32 (95% CI: 0.12 to 0.84), p=0.021). The use of SGLT2i was also associated with a higher overall survival (85.3% vs 63.0% at 2 years, p<0.001). The risk of serious adverse events such as hypoglycaemia and sepsis was similar between the two groups.

CONCLUSIONS

The use of SGLT2i was associated with a lower rate of incident HF and prolonged overall survival in patients with cancer with diabetes mellitus.

Ponatinib Drives Cardiotoxicity by S100A8/A9-NLRP3-IL-1β Mediated Inflammation

BACKGROUND

The tyrosine kinase inhibitor ponatinib is the only treatment option for chronic myelogenous leukemia patients with T315I (gatekeeper) mutation. Pharmacovigilance analysis of Food and Drug Administration and World Health Organization datasets has revealed that ponatinib is the most cardiotoxic agent among all Food and Drug Administration-approved tyrosine kinase inhibitors in a real-world scenario. However, the mechanism of ponatinib-induced cardiotoxicity is unknown.

METHODS

The lack of well-optimized mouse models has hampered the in vivo cardio-oncology studies. Here, we show that cardiovascular comorbidity mouse models evidence a robust cardiac pathological phenotype upon ponatinib treatment. A combination of multiple in vitro and in vivo models was employed to delineate the underlying molecular mechanisms.

RESULTS

An unbiased RNA sequencing analysis identified the enrichment of dysregulated inflammatory genes, including a multifold upregulation of alarmins S100A8/A9, as a top hit in ponatinib-treated hearts. Mechanistically, we demonstrate that ponatinib activates the S100A8/A9-TLR4 (Toll-like receptor 4)-NLRP3 (NLR family pyrin domain-containing 3)-IL (interleukin)-1β signaling pathway in cardiac and systemic myeloid cells, in vitro and in vivo, thereby leading to excessive myocardial and systemic inflammation. Excessive inflammation was central to the cardiac pathology because interventions with broad-spectrum immunosuppressive glucocorticoid dexamethasone or specific inhibitors of NLRP3 (CY-09) or S100A9 (paquinimod) nearly abolished the ponatinib-induced cardiac dysfunction.

CONCLUSIONS

Taken together, these findings uncover a novel mechanism of ponatinib-induced cardiac inflammation leading to cardiac dysfunction. From a translational perspective, our results provide critical preclinical data and rationale for a clinical investigation into immunosuppressive interventions for managing ponatinib-induced cardiotoxicity.

Patient similarity and other artificial intelligence machine learning algorithms in clinical decision aid for shared decision-making in the Prevention of Cardiovascular Toxicity (PACT): a feasibility trial design

BACKGROUND

The many improvements in cancer therapies have led to an increased number of survivors, which comes with a greater risk of consequent/subsequent cardiovascular disease. Identifying effective management strategies that can mitigate this risk of cardiovascular complications is vital. Therefore, developing computer-driven and personalized clinical decision aid interventions that can provide early detection of patients at risk, stratify that risk, and recommend specific cardio-oncology management guidelines and expert consensus recommendations is critically important.

OBJECTIVES

To assess the feasibility, acceptability, and utility of the use of an artificial intelligence (AI)-powered clinical decision aid tool in shared decision making between the cancer survivor patient and the cardiologist regarding prevention of cardiovascular disease.

DESIGN

This is a single-center, double-arm, open-label, randomized interventional feasibility study. Our cardio-oncology cohort of > 4000 individuals from our Clinical Research Data Warehouse will be queried to identify at least 200 adult cancer survivors who meet the eligibility criteria. Study participants will be randomized into either the Clinical Decision Aid Group (where patients will use the clinical decision aid in addition to current practice) or the Control Group (current practice). The primary endpoint of this study is to assess for each patient encounter whether cardiovascular medications and imaging pursued were consistent with current medical society recommendations. Additionally, the perceptions of using the clinical decision tool will be evaluated based on patient and physician feedback through surveys and focus groups. This trial will determine whether a clinical decision aid tool improves cancer survivors' medication use and imaging surveillance recommendations aligned with current medical guidelines.

TRIAL REGISTRATION

ClinicalTrials.Gov Identifier: NCT05377320.

Essentials of cardio-oncology

Cardio-oncology is a subspecialty that provides cardiac care for patients with cancer. Newer oncological agents have not only increased survivorship, but also sprouted novel cardiovascular toxicity (CVT) involving any component of the cardiovascular system, albeit with some preferential targets. Patients with cancer should undergo a baseline cardiovascular risk assessment and have individualised surveillance planned during cancer therapy and post treatment. The early diagnosis of CVT, by clinical history and examination along with imaging and laboratory analysis, is paramount. Management includes cardioprotective strategies and multidisciplinary decision-making regarding the risk-benefit ratio of oncological treatment based on CVT.

Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS)

Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.

Iodine-123 β-methyl-P-iodophenyl-pentadecanoic Acid (123I-BMIPP) Myocardial Scintigraphy for Breast Cancer Patients and Possible Early Signs of Cancer-Therapeutics-Related Cardiac Dysfunction (CTRCD)

(1) Background: The mortality of breast cancer has decreased due to the advancement of cancer therapies. However, more patients are suffering from cancer-therapeutics-related cardiac dysfunction (CTRCD). Diagnostic and treatment guidelines for CTRCD have not been fully established yet. Ultrasound cardiogram (UCG) is the gold standard for diagnosis of CTRCD, but many breast cancer patients cannot undergo UCG due to the surgery wounds or anatomical reasons. The purpose of the study is to evaluate the usefulness of myocardial scintigraphy using Iodine-123 β-methyl-P-iodophenyl-pentadecanoic acid (123I-BMIPP) in comparison with UCG. (2) Methods: 100 breast cancer patients who received chemotherapy within 3 years underwent Thallium (201Tl) and 23I-BMIPP myocardial perfusion and metabolism scintigraphy. The images were visually evaluated by doctors and radiological technologists, and the grade of uptake reduction was scored by Heart Risk View-S software (Nihon Medi-Physics). The scores were deployed in a 17-segment model of the heart. The distribution of the scores were analyzed. (3) Results: Nine patients (9%) could not undergo UCG. No correlation was found between left ventricular ejection fraction (LVEF) and Heart Risk View-S scores of 201Tl myocardial perfusion scintigraphy nor those of BMIPP myocardial metabolism scintigraphy. In a 17-segment model of the heart, the scores of the middle rings were higher than for the basal ring. (4) Conclusions: Evaluation by UCG is not possible for some patients. Myocardial scintigraphy cannot serve as a perfect alternative to UCG. However, it will become the preferable second-choice screening test, as it could point out the early stage of CTRCD.

Advances in Multimodality Imaging in Cardio-Oncology: JACC State-of-the-Art Review

The population of patients with cancer is rapidly expanding, and the diagnosis and monitoring of cardiovascular complications greatly rely on imaging. Numerous advances in the field of cardio-oncology and imaging have occurred in recent years. This review presents updated and practical approaches for multimodality cardiovascular imaging in the cardio-oncology patient and provides recommendations for imaging to detect the myriad of adverse cardiovascular effects associated with antineoplastic therapy, such as cardiomyopathy, atherosclerosis, vascular toxicity, myocarditis, valve disease, and cardiac masses. Uniquely, we address the role of cardiovascular imaging in patients with pre-existing cardiomyopathy, pregnant patients, long-term survivors, and populations with limited resources. We also address future avenues of investigation and opportunities for artificial intelligence applications in cardio-oncology imaging. This review provides a uniform practical approach to cardiovascular imaging for patients with cancer.

Hypertension in Cancer Survivors: A Review of the Literature and Suggested Approach to Diagnosis and Treatment

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among cancer survivors. Hypertension, which is common among cancer survivors with a prevalence of greater than 70% by age 50, potentiates the risk for CVD in a more than additive fashion. For example, childhood cancer survivors who develop hypertension may have up to a 12 times higher risk for heart failure than survivors who remain normotensive. Studies have shown that mild valvular disease (28% incidence), cardiomyopathy (7.4%), arrhythmias (4.6%), and coronary artery disease (3.8%) are among the most common CVDs in childhood cancer survivors. Among adolescent and young adult cancer survivors, the most common reasons for cardiovascular-related hospital admission are venous/lymphatic disease (absolute excess risk 19%), cardiomyopathy and arrhythmia (15%), hypertension (13%), and ischemic heart disease (12%). In addition, cancer therapies can increase the risk for hypertension and CVD. Therefore, early detection and treatment of hypertension is essential to reducing cardiovascular morbidity and mortality among survivors.

METHODS

We present a literature review, which identified over 20 clinical trials, systemic reviews, and meta-analyses (13 clinical trials, 8 systemic reviews or meta-analyses) by searching PubMed, Google Scholar, and the Cochrane Library for relevant articles addressing hypertension in cancer survivors.

RESULTS

Although our understanding of the complex relationship between cancer therapies and CVD has grown significantly over the past 2 decades, there remain several gaps in knowledge when specifically addressing CVD in the survivor population. This review provides an up-to-date survivor-centered approach to the screening and treatment of hypertension, which considers survivor-specific cardiovascular risk, applies guideline directed therapies when appropriate, screens for survivor-specific factors that may influence antihypertensive medication selection, and finally considers the prohypertensive mechanisms of antineoplastic agents as a potential target for antihypertensive medications.

CONCLUSIONS

Screening for and treating hypertension among survivors can promote cardiovascular health in this vulnerable population.

Contributions of the Women's Health Initiative to Cardiovascular Research: JACC State-of-the-Art Review

The WHI (Women's Health Initiative) enrolled 161,808 racially and ethnically diverse postmenopausal women, ages 50-79 years, from 1993 to 1998 at 40 clinical centers across the United States. In its clinical trial component, WHI evaluated 3 randomized interventions (menopausal hormone therapy; diet modification; and calcium/vitamin D supplementation) for the primary prevention of major chronic diseases, including cardiovascular disease, in older women. In the WHI observational study, numerous clinical, behavioral, and social factors have been evaluated as predictors of incident chronic disease and mortality. Although the original interventions have been completed, the WHI data and biomarker resources continue to be leveraged and expanded through ancillary studies to yield novel insights regarding cardiovascular disease prevention and healthy aging in women.

Application of Carotid Duplex Ultrasonography in the Surveillance of Carotid Artery Stenosis after Neck Irradiation

Head and neck cancer (HNC) shares some risk factors with cardiovascular disease. Neck radiotherapy (RT) causes carotid artery injury and stenosis. In HNC patients treated with RT, the prevalence rate of severe ( > 70%) carotid artery stenosis is > 10%, and the cumulative incidence continuously increases over time. There is at least a two-fold risk of cerebrovascular events in these patients compared with the normal population. Carotid artery stenosis is mainly assessed and diagnosed via duplex ultrasonography. Angioplasty and stenting may be recommended to patients who developed severe post-irradiation carotid artery stenosis. This review assessed Taiwanese data that provided some recommendations for HNC patients treated with RT. With consideration of the high prevalence rate of carotid artery stenosis after neck irradiation, duplex ultrasonography should be included in the follow-up workup.

Cardiovascular Imaging in Cardio-Oncology: The Role of Echocardiography and Cardiac MRI in Modern Cardio-Oncology

Cardiovascular (CV) events are an increasingly common limitation of effective anticancer therapy. Over the last decade imaging has become essential to patients receiving contemporary cancer therapy. Herein we discuss the current state of CV imaging in cardio-oncology. We also provide a practical apparatus for the use of imaging in everyday cardiovascular care of oncology patients to improve outcomes for those at risk for cardiotoxicity, or with established cardiovascular disease. Finally, we consider future directions in the field given the wave of new anticancer therapies.

Training and Career Development in Cardio-Oncology Translational and Implementation Science

Cardiovascular disease is a leading cause of death in cancer survivors, after recurrence of the primary tumor or occurrence of a secondary malignancy. Consequently, the interdisciplinary field of cardio-oncology has grown rapidly in recent years to address the cardiovascular care needs of this unique population through clinical care and research initiatives. Here, the authors discuss the ideal infrastructure for training and career development in cardio-oncology translational and implementation science and emphasize the importance of the multidisciplinary cardiovascular team for both research and patient care. Cardio-oncology training opportunities in general cardiology, hematology/oncology, and specialized cardio-oncology clinical and research fellowships are also considered.