A recent report highlighted evidence-based recommendations for the prevention, detection, and management of cancer therapy–related cardiovascular toxicity and cardiovascular events in patients with cancer, as well as knowledge gaps. Select considerations are summarized herein.
“The European Society of Cardiology has endorsed broad guidelines for cardio-oncology,” the authors remarked. “Although most of these guidelines are based on limited evidence and predominantly reflect expert opinion, the purpose of [our] paper is to offer expert consensus recommendations that are firmly supported by research.”
Cardioprotection
Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and statins may be used to prevent left ventricular ejection fraction declines in patients receiving anthracycline-containing chemotherapy, according to the panel. They further noted that it remains unclear whether the administration of such agents may reduce the risk of heart failure in those with preserved systolic left ventricular function.
For patients with a strong indication for anthracyclines and risk factors for heart failure (ie, > 300 mg/m2 of doxorubicin; left ventricular ejection fraction < 50%), the recommended cardioprotective strategy involves using dexrazoxane or liposomal doxorubicin. However, according to the panel, the specific populations that would benefit most from such interventions have not been clearly defined.
The panel advocated for the implementation of strategies to minimize cardiac exposure to radiation therapy, including the optimization of patient positioning, management of respiratory motion, and delineation of target volumes, as well as advanced planning techniques and/or proton therapy. They acknowledged that, although emerging data seem to support purposeful dosimetric sparing of specific cardiac substructures, the optimal dose limits have not been well established.
Surveillance
The panel recommended echocardiography at baseline for patients who will receive anthracyclines. Echocardiographic measurement of left ventricular ejection fraction should also be conducted every 3 months after adjuvant or neoadjuvant HER2-directed therapies, with a lower frequency of every 6 months being potentially acceptable in the metastatic setting.
For patients initiating immune checkpoint inhibitor therapy, a baseline troponin test and ECG were recommended. Those with suspected immune checkpoint inhibitor–associated myocarditis should be hospitalized and promptly treated with high-dose corticosteroids, according to the panel.
Blood pressure monitoring was recommended with the administration of vascular endothelial growth factor inhibitors, Bruton’s tyrosine kinase inhibitors, and anaplastic lymphoma kinase (ALK) inhibitors, with use of the ALK inhibitor lorlatinib also calling for lipid level checks.
The panel acknowledged several gaps in the evidence regarding surveillance, with many of the uncertainties pertaining to its yield and frequency.
Permissive Cardiotoxicity
Regarding permissive cardiotoxicity, according to the panel, angiotensin-converting enzyme inhibitor therapy may be reasonable in patients with elevated troponin values during chemotherapy with anthracyclines. They next noted that ongoing HER2-targeted therapies may feasibly be administered in patients with mild, minimally symptomatic left ventricular dysfunction, while acknowledging a poorly defined benefit-risk profile for this approach.
The panel recommended the consideration of nitrates and/or calcium channel blockers for patients who experienced a suspected fluorouracil- or capecitabine-induced coronary vasospasm. They emphasized that, if rechallenging is planned, it should be conducted in a closely monitored setting because of the unknown risk of recurrence of the condition.
“The identification, prevention, and management of cancer therapy–related cardiovascular toxicity should be driven by outcomes-based data,” the authors concluded. “In areas in which such data are lacking, management should be tailored to the individual needs of each patient.”
Darryl P. Leong, MBBS, MPH, MBiostat, PhD, of McMaster University, Hamilton, Ontario, is the corresponding author of the JACC: CardioOncology article.
Disclosure: For full disclosures of the study authors, visit jacc.org.
