The spectrum of cardiovascular complications related to immune-checkpoint inhibitor treatment : Including myocarditis and the new entity of non inflammatory left ventricular dysfunction

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 Inhibitor-induced Myocarditis: A Case Report of Complete Heart Block and Challenges in a Patient on Pembrolizumab

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment by modulating immune responses, leading to enhanced anti-tumor activity. ICIs, including agents targeting cytotoxic T-lymphocyte antigen 4, programmed cell death 1, and programmed cell death ligand, are now widely used in various malignancies, either as monotherapy or in combination with chemotherapy, radiotherapy, or targeted therapies. However, ICIs are associated with immune-related adverse events, affecting multiple organ systems, with myocarditis emerging as a rare but potentially fatal complication. We present a 67-year-old man with a history of prostate and renal cell carcinoma treated with pembrolizumab and lenvatinib, who developed myocarditis secondary to ICI therapy. The patient initially presented with generalized fatigue and bradycardia, later progressing to more severe symptoms, including sinus bradycardia and elevated troponin levels. An electrocardiogram revealed a sinus rhythm with first-degree atrioventricular block, non-specific intraventricular conduction delay, and elevated high-sensitivity troponin levels progressively increasing to 50,000 pg/mL. A comprehensive diagnostic workup ruled out ischemic causes, leading to the diagnosis of ICI-induced myocarditis. The patient was treated with high-dose corticosteroids, intravenous immunoglobulin, and temporary pacemaker insertion, resulting in clinical improvement. This case highlights the need for vigilance and prompt intervention in patients receiving ICI therapy, as early recognition and treatment of myocarditis are crucial to optimizing patient outcomes in this high-risk population.

Preclinical models of cardiotoxicity from immune checkpoint inhibitor therapy

Immune checkpoint inhibitor (ICI) therapy represents a ground-breaking paradigm in cancer treatment, harnessing the immune system to combat malignancies by targeting checkpoints such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1). The use of ICI therapy generates distinctive immune-related adverse events (irAEs) including cardiovascular toxicity, necessitating targeted research efforts. This comprehensive review explores preclinical models dedicated to ICI-mediated cardiovascular complications including myocarditis. Tailored preclinical models of ICI-mediated myocardial toxicities highlight the key role of CD8+ T cells, emphasizing the profound impact of immune checkpoints on maintaining cardiac integrity. Cytokines and macrophages were identified as possible driving factors in disease progression, and at the same time, initial data on possible cardiac antigens responsible are emerging. The implications of contributing factors including thoracic radiation, autoimmune disorder, and the presence of cancer itself are increasingly understood. Besides myocarditis, mouse models unveiled an accelerated progression of atherosclerosis, adding another layer for a thorough understanding of the diverse processes involving cardiovascular immune checkpoint signalling. This review aims to discuss current preclinical models of ICI cardiotoxicity and their potential for improving enhanced risk assessment and diagnostics, offering potential targets for innovative cardioprotective strategies. Lessons from ICI therapy can drive novel approaches in cardiovascular research, extending insights to areas such as myocardial infarction and heart failure.

Early microvascular coronary endothelial dysfunction precedes pembrolizumab-induced cardiotoxicity. Preventive role of high dose of atorvastatin

Immune checkpoint inhibitors (ICIs) exhibit remarkable antitumor activity and immune-related cardiotoxicity of unknown pathomechanism. The aim of the study was to investigate the ICI class-dependent cardiotoxicity in vitro and pembrolizumab's (Pem's) cardiotoxicity in vivo, seeking for translational prevention means. Cytotoxicity was investigated in primary cardiomyocytes and splenocytes, incubated with ipilimumab, Pem and avelumab. Pem's cross-reactivity was assessed by circular dichroism (CD) on biotechnologically produced human and murine PD-1 and in silico. C57BL6/J male mice received IgG4 or Pem for 2 and 5 weeks. Echocardiography, histology, and molecular analyses were performed. Coronary blood flow velocity mapping and cardiac magnetic resonance imaging were conducted at 2 weeks. Human EA.hy926 endothelial cells were incubated with Pem-conditioned media from human mononuclear cells, in presence and absence of statins and viability and molecular signaling were assessed. Atorvastatin (20 mg/kg, daily) was administered in vivo, as prophylaxis. Only Pem exerted immune-related cytotoxicity in vitro. Pem's cross-reactivity with the murine PD-1 was confirmed by CD and docking. In vivo, Pem initiated coronary endothelial and diastolic dysfunction at 2 weeks and systolic dysfunction at 5 weeks. At 2 weeks, Pem induced ICAM-1 and iNOS expression and intracardiac leukocyte infiltration. At 5 weeks, Pem exacerbated endothelial activation and triggered cardiac inflammation. Pem led to immune-related cytotoxicity in EA.hy926 cells, which was prevented by atorvastatin. Atorvastatin mitigated functional deficits, by inhibiting endothelial dysfunction in vivo. We established for the first time an in vivo model of Pem-induced cardiotoxicity. Coronary endothelial dysfunction precedes Pem-induced cardiotoxicity, whereas atorvastatin emerges as a novel prophylactic therapy.

Immune checkpoints in cardiac physiology and pathology: therapeutic targets for heart failure

Immune checkpoint molecules are physiological regulators of the adaptive immune response. Immune checkpoint inhibitors (ICIs), such as monoclonal antibodies targeting programmed cell death protein 1 or cytotoxic T lymphocyte-associated protein 4, have revolutionized cancer treatment and their clinical use is increasing. However, ICIs can cause various immune-related adverse events, including acute and chronic cardiotoxicity. Of these cardiovascular complications, ICI-induced acute fulminant myocarditis is the most studied, although emerging clinical and preclinical data are uncovering the importance of other ICI-related chronic cardiovascular complications, such as accelerated atherosclerosis and non-myocarditis-related heart failure. These complications could be more difficult to diagnose, given that they might only be present alongside other comorbidities. The occurrence of these complications suggests a potential role of immune checkpoint molecules in maintaining cardiovascular homeostasis, and disruption of physiological immune checkpoint signalling might thus lead to cardiac pathologies, including heart failure. Although inflammation is a long-known contributor to the development of heart failure, the therapeutic targeting of pro-inflammatory pathways has not been successful thus far. The increasingly recognized role of immune checkpoint molecules in the failing heart highlights their potential use as immunotherapeutic targets for heart failure. In this Review, we summarize the available data on ICI-induced cardiac dysfunction and heart failure, and discuss how immune checkpoint signalling is altered in the failing heart. Furthermore, we describe how pharmacological targeting of immune checkpoints could be used to treat heart failure.

Immune checkpoint inhibitor-induced cardiotoxicity in patients with lung cancer: a systematic review and meta-analysis

BACKGROUND

The use of immune checkpoint inhibitors (ICIs) for the treatment of lung cancer may precipitate cardiotoxic events. We aimed to perform a meta-analysis to evaluate the cardiotoxicity associated with ICIs in patients with lung cancer.

METHODS

A literature search was conducted across four electronic databases (Cochrane CENTRAL, MEDLINE, OVID EMBASE and Google Scholar) from inception through 31st May 2023. Randomized controlled trials (RCTs) assessing the impact of ICIs on cardiac outcomes in lung cancer patients were considered for inclusion. Risk ratios (RR) with 95% confidence intervals (CIs) were pooled and analysis was performed using a random-effects model. The Grading of Recommendations Assessment, Development and Evaluation approach was followed to assess confidence in the estimates of effect (i.e., the quality of evidence).

RESULTS

A total of 30 studies including 16,331 patients, were included in the analysis. Pooled results showed that single ICI (RR: 2.15; 95% CI: 1.13-4.12; p = 0.02; I2 = 0%) or a combination of single ICI plus chemotherapy (RR: 1.38 [1.05-1.82]; p = 0.02) significantly increased the risk of cardiac adverse events when compared with chemotherapy alone. No significant difference was noted when a dual ICI (RR: 0.48 [0.13-1.80]; p = 0.27) was compared with single ICI. In addition, there was no significant association between the use of ICIs and incidence of cardiac failure (RR: 1.11 [0.48-2.58]; p = 0.80), or arrhythmia (RR: 1.87; [0.69-5.08]; p = 0.22).

CONCLUSION

Compared with chemotherapy alone, use of a single ICI or a combination of single ICI plus chemotherapy significantly increased the risk of cardiotoxicity. However, employing dual immunotherapy did not result in a significant increase in the risk of cardiotoxicity when compared to the use of a single ICI.

Immune Checkpoint Inhibitors and Cardiotoxicity: A Comparative Meta-Analysis of Observational Studies and Randomized Controlled Trials

BACKGROUND

Immune checkpoint inhibitors (ICIs) have uncommon associations with cardiotoxicity, yet these cardiotoxic effects are associated with high mortality. An accurate assessment of risk for cardiotoxicity is essential for clinical decision-making, but data from randomized controlled trials often differ from real-world observational studies.

METHODS AND RESULTS

A systematic search of PubMed, Embase, Cochrane Library, and Scopus was performed, including phase II and III randomized controlled trials (RCTs) and observational studies (OSs) reporting myocarditis or pericardial disease, myocardial infarction, or stroke with an immunotherapy. Odds ratios (ORs) were used to pool results between ICIs and other cancer therapy in RCTs and OSs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. In total, 54 RCTs (N=38 264) and 24 OSs (N=12 561 455) were included. In RCTs, ICI use resulted in higher risk of myocarditis (OR, 3.55 [95% CI, 2.10-5.98]), pericardial disease (OR, 2.73 [95% CI, 1.57-4.77]), and myocardial infarction (OR, 1.83 [95% CI, 1.03-3.25]), compared with non-ICI (placebo or chemotherapy). In OSs, ICI use was not associated with myocarditis, pericardial disease, or myocardial infarction compared with controls; however, combination ICIs demonstrated higher risk of myocarditis compared with single ICI use (OR, 3.07 [95% CI, 1.28-7.39]). Stroke risk was not increased with use of ICIs in RCTs.

CONCLUSIONS

We demonstrated increased risk of ICI myocarditis, pericardial disease, and myocardial infarction in RCTs but not OSs. Results of this study suggest there are differences between ICI cardiotoxicity risk, possibly suggesting differences in diagnoses and management, in clinical trials versus the OSs.

Achilles' Heel of currently approved immune checkpoint inhibitors: immune related adverse events

Immunotherapy has revolutionized the cancer treatment landscape by opening up novel avenues for intervention. As the use of immune checkpoint inhibitors (ICIs) has exponentially increased, so have immune-related adverse events (irAEs). The mechanism of irAEs may involve the direct damage caused by monoclonal antibodies and a sequence of immune responses triggered by T cell activation. Common side effects include dermatologic toxicity, endocrine toxicity, gastrointestinal toxicity, and hepatic toxicity. While relatively rare, neurotoxicity, cardiotoxicity, and pulmonary toxicity can be fatal. These toxicities pose a clinical dilemma regarding treatment discontinuation since they can result in severe complications and necessitate frequent hospitalization. Vigilant monitoring of irAEs is vital in clinical practice, and the principal therapeutic strategy entails the administration of oral or intravenous glucocorticoids (GSCs). It may be necessary to temporarily or permanently discontinue the use of ICIs in severe cases. Given that irAEs can impact multiple organs and require diverse treatment approaches, the involvement of a multidisciplinary team of experts is imperative. This review aims to comprehensively examine the pathogenesis, clinical manifestations, incidence, and treatment options for various irAEs.

Immune-related cardiovascular toxicities of PD-1/PD-L1 inhibitors in solid tumors: an updated systematic review and meta-analysis

Purpose

The objective of this study was to investigate the risk of cardiovascular toxicities related to PD-1/PD-L1 inhibitors in solid tumors.

Methods

A literature search was performed following the participants, interventions, comparisons, outcomes, and study design (PICOS) principles, and the study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data analysis was conducted using Review Manager version 5.4.

Results

This meta-analysis included 69 randomized controlled trials (RCTs) divided into five groups based on the treatment regimens: PD-1/PD-L1 + chemotherapy versus chemotherapy, PD-1/PD-L1 versus chemotherapy, PD-1/PD-L1 versus placebo, PD-1/PD-L1 + CTLA-4 versus PD-1/PD-L1 and PD-1/PD-L1 + CTLA-4 versus chemotherapy. Compared to chemotherapy treatment alone, PD-1/PD-L1 +chemotherapy significantly increased the risk of hypertension [all-grade (OR = 1.27, 95% CI [1.05, 1.53], p = 0.01); grade 3-5 (OR = 1.36, 95% CI [1.04, 1.79], p = 0.03)], hypotension [all-grade (OR = 2.03, 95% CI [1.19, 3.45], p = 0.009); grade 3-5 (OR = 3.60, 95% CI [1.22, 10.60], p = 0.02)], arrhythmia [all-grade (OR = 1.53, 95% CI [1.02, 2.30], p = 0.04); grade 3-5 (OR = 2.91, 95% CI [1.33, 6.39], p = 0.008)] and myocarditis [all-grade (OR = 2.42, 95% CI [1.06, 5.54], p = 0.04)]. The risk of all-grade hypotension (OR = 2.87, 95% CI [1.26, 6.55], p = 0.01) and all-grade arrhythmia (OR = 2.03, 95% CI [1.13, 3.64], p = 0.02) significantly increased when treated with PD-1/PD-L1 inhibitors compared to the placebo. The risks of cardiovascular toxicities are significantly higher with PD-1+CTLA-4 compared to PD-1 alone (OR = 2.02, 95% CI [1.12, 3.66], p = 0.02).

Conclusion

PD-1/PD-L1 inhibitor leads to an increased risk of cardiovascular toxicities, especially hypertension, hypotension, arrhythmia, and myocarditis.

Cardiovascular health: an important component of cancer survivorship

Advances in the detection and treatment of cancer have translated into improved cancer survival rates and a growing population of cancer survivors. These include those living with cancer and individuals free of the disease following treatment. Epidemiological studies demonstrate that cancer survivors are at an increased risk of cardiovascular disease (CVD), with cardiovascular (CV) mortality overtaking cancer mortality in some tumour types. Cancer and CVD share common aetiological risk factors, for example, age, tobacco use and obesity, as well as a shared inflammatory pathogenesis. The CV risks of mediastinal radiotherapy and chemotherapy, first observed in the 1970s with anthracyclines, have long been appreciated. More recently, targeted anticancer therapeutics (human epidermal growth factor receptor-2 targeted therpies, vascular endothelial growth factor inhibitors, second/third-generation BCR-ABL inhibitors, multiple myeloma therapies and combination RAF and MEK inhibitors in particular) as well as immunotherapies have added to the burden of treatment-related CV toxicity. Additionally, cancer therapy may indirectly impact on CV health by decreasing physical activity, increasing weight gain and accelerating the ageing process. Improving overall health outcomes by considering cardiological prevention and management in cancer survivorship is an area of increasing interest. CV risk factor assessment and management are recommended post-cancer treatment in accordance with primary prevention guidelines. The European Society of Cardiology 2022 guidelines also recommend enhanced surveillance after cancer treatments with a moderate to high risk of CV consequences. The aim of this article is to provide an overview of the interconnections between cancer and CVD, review current survivorship recommendations, and highlight key areas of ongoing and future research.

Role of Biomarkers in the Management of Immune-Checkpoint Inhibitor-Related Myocarditis

PURPOSE OF REVIEW

Immune checkpoint inhibitor (ICI)-related myocarditis poses a major clinical challenge given its non-specific presentation, rapid progression, and high mortality rate. Here, we review the role of blood-based biomarkers in the clinical management of patients with ICI-related myocarditis.

RECENT FINDINGS

Myocardial injury, its unique pattern, and the co-occurrence with myositis are defining features of ICI-related myocarditis. Non-cardiac biomarkers, specifically creatinine phosphokinase, precedes the symptomatic presentation and is highly sensitive for diagnosing ICI-related myocarditis, making them useful screening biomarkers. Combined elevations in cardiac troponins and non-cardiac biomarkers improve the confidence of an ICI myocarditis diagnosis. High troponin and creatinine phosphokinase levels are strongly associated with severe outcomes. We propose biomarker-based algorithms for the monitoring and diagnosis of ICI-related myocarditis. Biomarkers, such as cardiac troponins and creatine phosphokinase, can be used in combination in the monitoring, diagnosis, and prognostication of patients with ICI-related myocarditis.

The TSP1-CD47-SIRPα interactome: an immune triangle for the checkpoint era

The use of treatments, such as programmed death protein 1 (PD1) or cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) antibodies, that loosen the natural checks upon immune cell activity to enhance cancer killing have shifted clinical practice and outcomes for the better. Accordingly, the number of antibodies and engineered proteins that interact with the ligand-receptor components of immune checkpoints continue to increase along with their use. It is tempting to view these molecular pathways simply from an immune inhibitory perspective. But this should be resisted. Checkpoint molecules can have other cardinal functions relevant to the development and use of blocking moieties. Cell receptor CD47 is an example of this. CD47 is found on the surface of all human cells. Within the checkpoint paradigm, non-immune cell CD47 signals through immune cell surface signal regulatory protein alpha (SIRPα) to limit the activity of the latter, the so-called trans signal. Even so, CD47 interacts with other cell surface and soluble molecules to regulate biogas and redox signaling, mitochondria and metabolism, self-renewal factors and multipotency, and blood flow. Further, the pedigree of checkpoint CD47 is more intricate than supposed. High-affinity interaction with soluble thrombospondin-1 (TSP1) and low-affinity interaction with same-cell SIRPα, the so-called cis signal, and non-SIRPα ectodomains on the cell membrane suggests that multiple immune checkpoints converge at and through CD47. Appreciation of this may provide latitude for pathway-specific targeting and intelligent therapeutic effect.

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

Background

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

Objectives

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

Materials and methods

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

Results

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

Conclusion

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