Management of Cardiac Function in Cancer Patients

Management of Cardiac Function in Cancer Patients

With the aggravation of population ageing, the global cancer burden will intensify annually. According to the global burden of cancer data released by the International Agency for Research on Cancer (IARC) in 2020, 19.3 million new cancer cases and 10.0 million cancer deaths worldwide (Sung et al., 2021). Classical chemotherapy is still the first-line treatment for most cancers, while targeted therapy and immunotherapy have become the focus of current cancer treatment.

However, these therapies are closely associated with cardiovascular and metabolic sequelae, and studies have demonstrated an increased risk of cardiovascular disease in patients with long-term survival of malignant tumours. The guideline issued by the European Society of Cardiology (ESC) in 2016 classified the cardiovascular complications caused during cancer treatment into nine categories. Including cardiac insufficiency and heart failure, coronary artery disease, valvular disease etc. (Zamorano et al., 2016), covering almost all types of cardiovascular diseases.

With the help of myocardial marker detection, improving the level of cardiovascular disease risk management in cancer patients has become a new interdisciplinary research focus of Cardio-Oncology.

Cardiotoxicity induced by anthracyclines is most common

A variety of chemotherapy drugs can cause cardiac toxicity in cancer treatment. Among which anthracycline drugs represented by doxorubicin and epirubicin are the most common, mainly due to the fact that anthracyclines can induce lipid peroxidation of the myocardial cell membrane and mitochondrial DNA damage, resulting in permanent myocardial cell damage and death. For example, in breast cancer treatment, a study has shown an adjusted heart failure hazard ratio of 1.26 in older breast cancer patients treated with anthracyclines and non-anthracene (Pinder et al., 2007).

Cardiotoxicity induced by anthracyclines can be classified as acute, chronic, and delayed types. Acute cardiotoxicity usually occurs within a few hours or days after administration. It is usually characterised by intracardiac conduction disorder and arrhythmia, rarely by pericarditis and acute left heart failure.  Chronic cardiotoxicity generally occurs within one year of chemotherapy, manifested as left ventricular dysfunction, leading to heart failure. Delayed cardiotoxicity may occur several years after chemotherapy and may present as heart failure, cardiomyopathy, arrhythmia, etc.

Immune checkpoint inhibitors associated myocarditis tends to critical condition

Immune checkpoint inhibitors (ICI) are considered to be one of the most successful cancer therapies. Although the incidence of ICI-related cardiotoxicity is low, it is easy to progress to a particularly critical type(Moslehi et al., 2018). Which is characterised by relatively early onset and high mortality and is easily ignored at the early stage.

There have been case reports of myocarditis and fatal heart failure in ICI patients. A retrospective study reported that 6.2% of ICI-related adverse events were cardiotoxic, 35% of which were fatal, and up to half of patients with myocarditis died (Martins et al., 2019). The Lancet published a report on ICI-related myocarditis in 2018, which showed that among 101 severe myocarditis cases caused by ICI after treatment, the median onset time was 27 days, and the mortality caused by cardiovascular complications reached 46% (Moslehi et al., 2018b). It warned that patients treated with immune checkpoint inhibitors to be on high alert for the development of myocarditis.

Standardised management of cardiac function in cancer patients

The clinical manifestations of ICI-associated cardiotoxicity were atypical in the past review studies, and there were no universally accepted criteria for diagnosing ICI-associated myocarditis (Neilan et al., 2018). For example, the dominant histopathological feature of ICI-associated myocarditis is T-lymphocyte infiltration in necrotic areas and surrounding tissues, which is similar to the patients with cardiac transplant rejection (Läubli et al., 2015). Due to the lack of sensitivity and specificity for diagnosing ICI myocarditis, the criteria for assessing and diagnosing ICI-associated myocarditis should be comprehensive.

In clinical practice guidelines (Sinagra et al., 2016), clinicians can use several noninvasive diagnostic tests with varying diagnostic potential and accuracy to identify suspected myocarditis and grade the severity of the condition. The commonly used cardiac function monitoring methods are mainly the combination of biomarker, cardiac imaging and endomyocardial biopsy.

Cardiac imaging supports the assessm