1
|
Maier A, Teunissen AJP, Nauta SA, Lutgens E, Fayad ZA, van Leent MMT. Uncovering atherosclerotic cardiovascular disease by PET imaging. Nat Rev Cardiol 2024; 21:632-651. [PMID: 38575752 PMCID: PMC11324396 DOI: 10.1038/s41569-024-01009-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/06/2024]
Abstract
Assessing atherosclerosis severity is essential for precise patient stratification. Specifically, there is a need to identify patients with residual inflammation because these patients remain at high risk of cardiovascular events despite optimal management of cardiovascular risk factors. Molecular imaging techniques, such as PET, can have an essential role in this context. PET imaging can indicate tissue-based disease status, detect early molecular changes and provide whole-body information. Advances in molecular biology and bioinformatics continue to help to decipher the complex pathogenesis of atherosclerosis and inform the development of imaging tracers. Concomitant advances in tracer synthesis methods and PET imaging technology provide future possibilities for atherosclerosis imaging. In this Review, we summarize the latest developments in PET imaging techniques and technologies for assessment of atherosclerotic cardiovascular disease and discuss the relationship between imaging readouts and transcriptomics-based plaque phenotyping.
Collapse
Affiliation(s)
- Alexander Maier
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Abraham J P Teunissen
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Icahn Genomics Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sheqouia A Nauta
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Esther Lutgens
- Cardiovascular Medicine and Immunology, Experimental Cardiovascular Immunology Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mandy M T van Leent
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
2
|
Johnson D, Jamal S, Hung RW, Ye C. False-positive Findings of Large Vessel Vasculitis on FDG-PET in Patients Treated With Immune Checkpoint Inhibitors. J Immunother 2024; 47:275-278. [PMID: 38764383 DOI: 10.1097/cji.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 04/16/2024] [Indexed: 05/21/2024]
Abstract
Fluorine-18 fluorodeoxygluocose positron emission tomography (FDG-PET) is increasingly used in the evaluation of response to immune checkpoint inhibitor (ICI) therapy. Incidental findings of increased vessel wall uptake may prompt the concern for ICI-induced large vessel vasculitis (LVV). Precise radiographic and clinical evaluation is required to determine if this represents true vasculitis, as use of immune suppression and ICI discontinuation can have significant impacts on patient outcomes. We performed a retrospective case analysis of 4 consecutive patients referred to 2 rheumatology clinics treated with ICI with incidental findings of LVV on FDG-PET, reviewing their clinical course and radiographic findings. All 4 cases had FDG-PET scans for routine oncology indications and had no associated clinical features of LVV. One patient was treated with corticosteroids and no patients developed any clinical evidence of vasculitis during a mean follow-up period of 17 months (range: 7-33 mo). All FDG-PET images reporting LVV underwent a standardized analysis to identify any technical issues or concerns with interpretation. In review of imaging, 3 of the cases may have been due to delayed tracer to scan interval leading to misinterpretation of vascular uptake as suspected LVV. Recognition of technical pitfalls in FDG-PET interpretation is crucial to inform the need for immunosuppression and the safety of continued ICI therapy.
Collapse
Affiliation(s)
- Dylan Johnson
- Division of Rheumatology, University of Alberta, Edmonton, AB, Canada
| | - Shahin Jamal
- Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Ryan W Hung
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Carrie Ye
- Division of Rheumatology, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
3
|
Tocchetti CG, Farmakis D, Koop Y, Andres MS, Couch LS, Formisano L, Ciardiello F, Pane F, Au L, Emmerich M, Plummer C, Gulati G, Ramalingam S, Cardinale D, Brezden-Masley C, Iakobishvili Z, Thavendiranathan P, Santoro C, Bergler-Klein J, Keramida K, de Boer RA, Maack C, Lutgens E, Rassaf T, Fradley MG, Moslehi J, Yang EH, De Keulenaer G, Ameri P, Bax J, Neilan TG, Herrmann J, Mbakwem AC, Mirabel M, Skouri H, Hirsch E, Cohen-Solal A, Sverdlov AL, van der Meer P, Asteggiano R, Barac A, Ky B, Lenihan D, Dent S, Seferovic P, Coats AJS, Metra M, Rosano G, Suter T, Lopez-Fernandez T, Lyon AR. Cardiovascular toxicities of immune therapies for cancer - a scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Council of Cardio-Oncology. Eur J Heart Fail 2024. [PMID: 39087551 DOI: 10.1002/ejhf.3340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 05/22/2024] [Accepted: 06/03/2024] [Indexed: 08/02/2024] Open
Abstract
The advent of immunological therapies has revolutionized the treatment of solid and haematological cancers over the last decade. Licensed therapies which activate the immune system to target cancer cells can be broadly divided into two classes. The first class are antibodies that inhibit immune checkpoint signalling, known as immune checkpoint inhibitors (ICIs). The second class are cell-based immune therapies including chimeric antigen receptor T lymphocyte (CAR-T) cell therapies, natural killer (NK) cell therapies, and tumour infiltrating lymphocyte (TIL) therapies. The clinical efficacy of all these treatments generally outweighs the risks, but there is a high rate of immune-related adverse events (irAEs), which are often unpredictable in timing with clinical sequalae ranging from mild (e.g. rash) to severe or even fatal (e.g. myocarditis, cytokine release syndrome) and reversible to permanent (e.g. endocrinopathies).The mechanisms underpinning irAE pathology vary across different irAE complications and syndromes, reflecting the broad clinical phenotypes observed and the variability of different individual immune responses, and are poorly understood overall. Immune-related cardiovascular toxicities have emerged, and our understanding has evolved from focussing initially on rare but fatal ICI-related myocarditis with cardiogenic shock to more common complications including less severe ICI-related myocarditis, pericarditis, arrhythmias, including conduction system disease and heart block, non-inflammatory heart failure, takotsubo syndrome and coronary artery disease. In this scientific statement on the cardiovascular toxicities of immune therapies for cancer, we summarize the pathophysiology, epidemiology, diagnosis, and management of ICI, CAR-T, NK, and TIL therapies. We also highlight gaps in the literature and where future research should focus.
Collapse
Affiliation(s)
- Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Dimitrios Farmakis
- Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Yvonne Koop
- Department of Cardiovascular Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Dutch Heart Foundation, The Hague, The Netherlands
| | - Maria Sol Andres
- Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Liam S Couch
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Fortunato Ciardiello
- Department of Precision Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Fabrizio Pane
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Lewis Au
- Skin and Renal Unit, Royal Marsden NHS Foundation Trust, London, UK
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Max Emmerich
- The Francis Crick Institute, London, UK
- The Royal Marsden Hospital, London, UK
- St. John's Institute of Dermatology, Guy's and St Thomas' Hospital, London, UK
| | - Chris Plummer
- Department of Cardiology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Geeta Gulati
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Division of Medicine, Oslo University Hospital, Ullevål, Oslo, Norway
- Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway
| | - Sivatharshini Ramalingam
- Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- Oxted Health Centre, Oxted, UK
| | - Daniela Cardinale
- CardioOncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Zaza Iakobishvili
- Department of Community Cardiology, Tel Aviv Jaffa District, Clalit Health Services, Tel Aviv, Israel
- Department of Cardiology, Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Ciro Santoro
- Department of Advanced Biomedical Science, Federico II University Hospital, Naples, Italy
| | | | - Kalliopi Keramida
- Cardiology Department, General Anti-Cancer, Oncological Hospital, Agios Savvas, Athens, Greece
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
- Medical Clinic 1, University Clinic Würzburg, Würzburg, Germany
| | - Esther Lutgens
- Department of Cardiovascular Medicine and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Javid Moslehi
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Gilles De Keulenaer
- Department of Pharmaceutical Sciences, University of Antwerp, Antwerp, Belgium
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Jeroen Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joerg Herrmann
- Cardio-Oncology Clinic, Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amam C Mbakwem
- College of Medicine, University of Lagos/Lagos University Teaching Hospital Idi Araba, Lagos, Nigeria
| | | | - Hadi Skouri
- Cardiology Division, Sheikh Shakhbout Medical City, Khalifa University, Abu Dhabi, UAE
| | - Emilio Hirsch
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, Turin, Italy
| | - Alain Cohen-Solal
- Paris Cité University INSERM U 948 MASCOT Research Unit Cardiology, Lariboisere Universitaire Hospital, AP-HP, Paris, France
| | - Aaron L Sverdlov
- Newcastle Centre of Excellence in Cardio-Oncology, University of Newcastle, Hunter Medical Research Institute, Calvary Mater Newcastle, Hunter New England Health, Newcastle, NSW, Australia
- Cardiovascular Department, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Riccardo Asteggiano
- Internal Medicine, Department of Medicine and Surgery, University of Insubria, Varese, Italy
- LARC, Laboratorio Analisi e Ricerca Clinica, Turin, Italy
| | - Ana Barac
- Inova Schar Heart and Vascular Institute, Falls Church, VA, USA
| | - Bonnie Ky
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Lenihan
- Cape Cardiology, St Francis Healthcare, Cape Girardeau, MO, USA
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC, USA
| | - Petar Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Rosano
- Department of Human Sciences and Promotion of Quality of Life, San Raffaele Open University of Rome, Rome, Italy
- Cardiology, San Raffaele Cassino Hospital, Cassino, FR, Italy
| | - Thomas Suter
- Bern University Hospital, University of Bern, Bern, Switzerland
| | - Teresa Lopez-Fernandez
- Cardio-Oncology Unit, Cardiology Department, IdiPAZ Research Institute, La Paz University Hospital, Madrid, Spain
- Cardiology Department, Quironsalud Madrid University Hospital, Madrid, Spain
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
4
|
Buehning F, Lerchner T, Vogel J, Hendgen-Cotta UB, Totzeck M, Rassaf T, Michel L. Preclinical models of cardiotoxicity from immune checkpoint inhibitor therapy. Basic Res Cardiol 2024:10.1007/s00395-024-01070-0. [PMID: 39039301 DOI: 10.1007/s00395-024-01070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/30/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024]
Abstract
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.
Collapse
Affiliation(s)
- Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tobias Lerchner
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Ulrike B Hendgen-Cotta
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
| |
Collapse
|
5
|
Gergely TG, Drobni ZD, Sayour NV, Ferdinandy P, Varga ZV. Molecular fingerprints of cardiovascular toxicities of immune checkpoint inhibitors. Basic Res Cardiol 2024:10.1007/s00395-024-01068-8. [PMID: 39023770 DOI: 10.1007/s00395-024-01068-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy by unleashing the power of the immune system against malignant cells. However, their use is associated with a spectrum of adverse effects, including cardiovascular complications, which can pose significant clinical challenges. Several mechanisms contribute to cardiovascular toxicity associated with ICIs. First, the dysregulation of immune checkpoints, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein-1 (PD-1) and its ligand (PD-L1), and molecular mimicry with cardiac autoantigens, leads to immune-related adverse events, including myocarditis and vasculitis. These events result from the aberrant activation of T cells against self-antigens within the myocardium or vascular endothelium. Second, the disruption of immune homeostasis by ICIs can lead to autoimmune-mediated inflammation of cardiac tissues, manifesting as cardiac dysfunction and heart failure, arrhythmias, or pericarditis. Furthermore, the upregulation of inflammatory cytokines, particularly tumor necrosis factor-alpha, interferon-γ, interleukin-1β, interleukin-6, and interleukin-17 contributes to cardiac and endothelial dysfunction, plaque destabilization, and thrombosis, exacerbating cardiovascular risk on the long term. Understanding the intricate mechanisms of cardiovascular side effects induced by ICIs is crucial for optimizing patient care and to ensure the safe and effective integration of immunotherapy into a broader range of cancer treatment protocols. The clinical implications of these mechanisms underscore the importance of vigilant monitoring and early detection of cardiovascular toxicity in patients receiving ICIs. Future use of these key pathological mediators as biomarkers may aid in prompt diagnosis of cardiotoxicity and will allow timely interventions.
Collapse
Affiliation(s)
- Tamás G Gergely
- Center for Pharmacology and Drug Research & Development, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary
| | - Zsófia D Drobni
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Nabil V Sayour
- Center for Pharmacology and Drug Research & Development, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary
| | - Péter Ferdinandy
- Center for Pharmacology and Drug Research & Development, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Center for Pharmacology and Drug Research & Development, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary.
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary.
| |
Collapse
|
6
|
Gergely TG, Drobni ZD, Kallikourdis M, Zhu H, Meijers WC, Neilan TG, Rassaf T, Ferdinandy P, Varga ZV. Immune checkpoints in cardiac physiology and pathology: therapeutic targets for heart failure. Nat Rev Cardiol 2024; 21:443-462. [PMID: 38279046 DOI: 10.1038/s41569-023-00986-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/28/2024]
Abstract
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.
Collapse
Affiliation(s)
- Tamás G Gergely
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary
| | - Zsófia D Drobni
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marinos Kallikourdis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Adaptive Immunity Lab, Humanitas Research Hospital IRCCS, Milan, Italy
| | - Han Zhu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wouter C Meijers
- Erasmus MC, Cardiovascular Institute, Thorax Center, Department of Cardiology, Rotterdam, The Netherlands
| | - Tomas G Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.
- HCEMM-SU Cardiometabolic Immunology Research Group, Budapest, Hungary.
- MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Budapest, Hungary.
| |
Collapse
|
7
|
Chen J, Liu S, Ruan Z, Wang K, Xi X, Mao J. Thrombotic events associated with immune checkpoint inhibitors and novel antithrombotic strategies to mitigate bleeding risk. Blood Rev 2024:101220. [PMID: 38876840 DOI: 10.1016/j.blre.2024.101220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
Although immunotherapy is expanding treatment options for cancer patients, the prognosis of advanced cancer remains poor, and these patients must contend with both cancers and cancer-related thrombotic events. In particular, immune checkpoint inhibitors are associated with an increased risk of atherosclerotic thrombotic events. Given the fundamental role of platelets in atherothrombosis, co-administration of antiplatelet agents is always indicated. Platelets are also involved in all steps of cancer progression. Classical antithrombotic drugs can cause inevitable hemorrhagic side effects due to blocking integrin β3 bidirectional signaling, which regulates simultaneously thrombosis and hemostasis. Meanwhile, many promising new targets are emerging with minimal bleeding risk and desirable anti-tumor effects. This review will focus on the issue of thrombosis during immune checkpoint inhibitor treatment and the role of platelet activation in cancer progression as well as explore the mechanisms by which novel antiplatelet therapies may exert both antithrombotic and antitumor effects without excessive bleeding risk.
Collapse
Affiliation(s)
- Jiayi Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuang Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zheng Ruan
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Kankan Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Xiaodong Xi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Jianhua Mao
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| |
Collapse
|
8
|
Fan L, Liu J, Hu W, Chen Z, Lan J, Zhang T, Zhang Y, Wu X, Zhong Z, Zhang D, Zhang J, Qin R, Chen H, Zong Y, Zhang J, Chen B, Jiang J, Cheng J, Zhou J, Gao Z, Liu Z, Chai Y, Fan J, Wu P, Chen Y, Zhu Y, Wang K, Yuan Y, Huang P, Zhang Y, Feng H, Song K, Zeng X, Zhu W, Hu X, Yin W, Chen W, Wang J. Targeting pro-inflammatory T cells as a novel therapeutic approach to potentially resolve atherosclerosis in humans. Cell Res 2024; 34:407-427. [PMID: 38491170 PMCID: PMC11143203 DOI: 10.1038/s41422-024-00945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 02/24/2024] [Indexed: 03/18/2024] Open
Abstract
Atherosclerosis (AS), a leading cause of cardio-cerebrovascular disease worldwide, is driven by the accumulation of lipid contents and chronic inflammation. Traditional strategies primarily focus on lipid reduction to control AS progression, leaving residual inflammatory risks for major adverse cardiovascular events (MACEs). While anti-inflammatory therapies targeting innate immunity have reduced MACEs, many patients continue to face significant risks. Another key component in AS progression is adaptive immunity, but its potential role in preventing AS remains unclear. To investigate this, we conducted a retrospective cohort study on tumor patients with AS plaques. We found that anti-programmed cell death protein 1 (PD-1) monoclonal antibody (mAb) significantly reduces AS plaque size. With multi-omics single-cell analyses, we comprehensively characterized AS plaque-specific PD-1+ T cells, which are activated and pro-inflammatory. We demonstrated that anti-PD-1 mAb, when captured by myeloid-expressed Fc gamma receptors (FcγRs), interacts with PD-1 expressed on T cells. This interaction turns the anti-PD-1 mAb into a substitute PD-1 ligand, suppressing T-cell functions in the PD-1 ligands-deficient context of AS plaques. Further, we conducted a prospective cohort study on tumor patients treated with anti-PD-1 mAb with or without Fc-binding capability. Our analysis shows that anti-PD-1 mAb with Fc-binding capability effectively reduces AS plaque size, while anti-PD-1 mAb without Fc-binding capability does not. Our work suggests that T cell-targeting immunotherapy can be an effective strategy to resolve AS in humans.
Collapse
Affiliation(s)
- Lin Fan
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
- Research Center for Life Science and Human Health, Binjiang Institute of Zhejiang University, Hangzhou, Zhejiang, China
| | - Junwei Liu
- Department of Cell Biology, Zhejiang University School of Medicine, and Liangzhu Laboratory, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory for Biomedical Engineering of the Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, China
- Guangzhou National Laboratory, Guangzhou, Guangdong, China
| | - Wei Hu
- Department of Cell Biology, Zhejiang University School of Medicine, and Liangzhu Laboratory, Zhejiang University, Hangzhou, Zhejiang, China
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zexin Chen
- Center of Clinical Epidemiology and Biostatistics and Department of Scientific Research, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jie Lan
- National Laboratory of Biomacromolecules, Institute of Biophysics, University of Chinese Academy of Sciences, Beijing, China
- Department of Bioinformatics, The Basic Medical School of Chongqing Medical University, Chongqing, China
| | - Tongtong Zhang
- Department of Cell Biology, Zhejiang University School of Medicine, and Liangzhu Laboratory, Zhejiang University, Hangzhou, Zhejiang, China
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yang Zhang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xianpeng Wu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zhiwei Zhong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Danyang Zhang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Jinlong Zhang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Rui Qin
- Department of Cell Biology, Zhejiang University School of Medicine, and Liangzhu Laboratory, Zhejiang University, Hangzhou, Zhejiang, China
- The MOE Frontier Science Center for Brain Science & Brain-machine Integration, Zhejiang University, Hangzhou, Zhejiang, China
| | - Hui Chen
- National Laboratory of Biomacromolecules, Institute of Biophysics, University of Chinese Academy of Sciences, Beijing, China
| | - Yunfeng Zong
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Bing Chen
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Jifang Cheng
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingyi Zhou
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhiwei Gao
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhenjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Chai
- Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Junqiang Fan
- Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Pin Wu
- Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yinxuan Chen
- Department of Cell Biology, Zhejiang University School of Medicine, and Liangzhu Laboratory, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuefeng Zhu
- Department of Vascular Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kai Wang
- Department of Respiratory, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Yuan
- Department of Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Pintong Huang
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Zhang
- Department of Ultrasound in Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huiqin Feng
- Department of Clinical Research Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kaichen Song
- Key Laboratory for Biomedical Engineering of the Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xun Zeng
- National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Zhu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xinyang Hu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China.
- Research Center for Life Science and Human Health, Binjiang Institute of Zhejiang University, Hangzhou, Zhejiang, China.
| | - Weiwei Yin
- Key Laboratory for Biomedical Engineering of the Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Provincial Key Laboratory of Cardio-Cerebral Vascular Detection Technology and Medicinal Effectiveness Appraisal, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Wei Chen
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China.
- Department of Cell Biology, Zhejiang University School of Medicine, and Liangzhu Laboratory, Zhejiang University, Hangzhou, Zhejiang, China.
- Key Laboratory for Biomedical Engineering of the Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, China.
- The MOE Frontier Science Center for Brain Science & Brain-machine Integration, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Jian'an Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
- Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, China.
- Research Center for Life Science and Human Health, Binjiang Institute of Zhejiang University, Hangzhou, Zhejiang, China.
| |
Collapse
|
9
|
Michel L, Ferdinandy P, Rassaf T. Cellular Alterations in Immune Checkpoint Inhibitor Therapy-Related Cardiac Dysfunction. Curr Heart Fail Rep 2024; 21:214-223. [PMID: 38430308 PMCID: PMC11090976 DOI: 10.1007/s11897-024-00652-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) therapy has emerged as a pivotal advancement in cancer treatment, but the widespread adoption has given rise to a growing number of reports detailing significant cardiovascular toxicity. This review concentrates on elucidating the mechanisms behind ICI-related cardiovascular complications, emphasizing preclinical and mechanistic data. RECENT FINDINGS Accumulating evidence indicates a more significant role of immune checkpoints in maintaining cardiac integrity than previously understood, and new key scientific data are available to improve our understanding of ICI-related cardiovascular toxicity, including hidden cardiotoxicity. New avenues for innovative concepts are hypothesized, and opportunities to leverage the knowledge from ICI-therapy for pioneering approaches in related scientific domains can be derived from the latest scientific projects. Cardiotoxicity from ICI therapy is a paramount challenge for cardio-oncology. Understanding the underlying effects builds the foundation for tailored cardioprotective approaches in the growing collective at risk for severe cardiovascular complications.
Collapse
Affiliation(s)
- Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| |
Collapse
|
10
|
Suijkerbuijk KPM, van Eijs MJM, van Wijk F, Eggermont AMM. Clinical and translational attributes of immune-related adverse events. NATURE CANCER 2024; 5:557-571. [PMID: 38360861 DOI: 10.1038/s43018-024-00730-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/12/2024] [Indexed: 02/17/2024]
Abstract
With immune checkpoint inhibitors (ICIs) becoming the mainstay of treatment for many cancers, managing their immune-related adverse events (irAEs) has become an important part of oncological care. This Review covers the clinical presentation of irAEs and crucial aspects of reversibility, fatality and long-term sequelae, with special attention to irAEs in specific patient populations, such as those with autoimmune diseases. In addition, the genetic basis of irAEs, along with cellular and humoral responses to ICI therapy, are discussed. Detrimental effects of empirically used high-dose steroids and second-line immunosuppression, including impaired ICI effectiveness, call for more tailored irAE-treatment strategies. We discuss open therapeutic challenges and propose potential avenues to accelerate personalized management strategies and optimize outcomes.
Collapse
Affiliation(s)
- Karijn P M Suijkerbuijk
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Mick J M van Eijs
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Femke van Wijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alexander M M Eggermont
- University Medical Center Utrecht and Princess Máxima Center, Utrecht, the Netherlands
- Comprehensive Cancer Center Munich of the Technical University of Munich and the Ludwig Maximilian University, Munich, Germany
| |
Collapse
|
11
|
Zhang YL, Liu ZR, Liu Z, Bai Y, Chi H, Chen DP, Zhang YM, Cui ZL. Risk of cardiovascular death in patients with hepatocellular carcinoma based on the Fine-Gray model. World J Gastrointest Oncol 2024; 16:844-856. [PMID: 38577452 PMCID: PMC10989395 DOI: 10.4251/wjgo.v16.i3.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/15/2023] [Accepted: 01/17/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is one of the most common types of cancers worldwide, ranking fifth among men and seventh among women, resulting in more than 7 million deaths annually. With the development of medical technology, the 5-year survival rate of HCC patients can be increased to 70%. However, HCC patients are often at increased risk of cardiovascular disease (CVD) death due to exposure to potentially cardiotoxic treatments compared with non-HCC patients. Moreover, CVD and cancer have become major disease burdens worldwide. Thus, further research is needed to lessen the risk of CVD death in HCC patient survivors. AIM To determine the independent risk factors for CVD death in HCC patients and predict cardiovascular mortality (CVM) in HCC patients. METHODS This study was conducted on the basis of the Surveillance, Epidemiology, and End Results database and included HCC patients with a diagnosis period from 2010 to 2015. The independent risk factors were identified using the Fine-Gray model. A nomograph was constructed to predict the CVM in HCC patients. The nomograph performance was measured using Harrell's concordance index (C-index), calibration curve, receiver operating characteristic (ROC) curve, and area under the ROC curve (AUC) value. Moreover, the net benefit was estimated via decision curve analysis (DCA). RESULTS The study included 21545 HCC patients, of whom 619 died of CVD. Age (< 60) [1.981 (1.573-2.496), P < 0.001], marital status (married) [unmarried: 1.370 (1.076-1.745), P = 0.011], alpha fetoprotein (normal) [0.778 (0.640-0.946), P = 0.012], tumor size (≤ 2 cm) [(2, 5] cm: 1.420 (1.060-1.903), P = 0.019; > 5 cm: 2.090 (1.543-2.830), P < 0.001], surgery (no) [0.376 (0.297-0.476), P < 0.001], and chemotherapy(none/unknown) [0.578 (0.472-0.709), P < 0.001] were independent risk factors for CVD death in HCC patients. The discrimination and calibration of the nomograph were better. The C-index values for the training and validation sets were 0.736 and 0.665, respectively. The AUC values of the ROC curves at 2, 4, and 6 years were 0.702, 0.725, 0.740 in the training set and 0.697, 0.710, 0.744 in the validation set, respectively. The calibration curves showed that the predicted probabilities of the CVM prediction model in the training set vs the validation set were largely consistent with the actual probabilities. DCA demonstrated that the prediction model has a high net benefit. CONCLUSION Risk factors for CVD death in HCC patients were investigated for the first time. The nomograph served as an important reference tool for relevant clinical management decisions.
Collapse
Affiliation(s)
- Yu-Liang Zhang
- First Central Clinical College, Tianjin Medical University, Tianjin 300070, China
| | - Zi-Rong Liu
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Zhi Liu
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Yi Bai
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Hao Chi
- First Central Clinical College, Tianjin Medical University, Tianjin 300070, China
| | - Da-Peng Chen
- First Central Clinical College, Tianjin Medical University, Tianjin 300070, China
| | - Ya-Min Zhang
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| | - Zi-Lin Cui
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin 300192, China
| |
Collapse
|
12
|
Achim A, Liblik K, Gevaert S. Immune checkpoint inhibitors - the revolutionary cancer immunotherapy comes with a cardiotoxic price. Trends Cardiovasc Med 2024; 34:71-77. [PMID: 36152788 DOI: 10.1016/j.tcm.2022.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 12/17/2022]
Abstract
The development of immune checkpoint inhibitors (ICIs) has provided a novel and revolutionary treatment option for previously incurable cancers. However, this major advancement is accompanied by a spectrum of cardiotoxic adverse events that are uncommon but potentially fatal. The oncologic indications of ICIs are becoming increasingly complex, requiring robust clinical monitoring to assess for cardiovascular complications. This is reflected in the recent introduction of the first cardio-oncology guidelines, a sign of the cardiovascular community's recognition that seeks to match this dynamic. The aim of this review is to summarize the cardiac side effects of ICI, with an emphasis on prevalence, diagnosis, and treatment options.
Collapse
Affiliation(s)
- Alexandru Achim
- Klinik für Kardiologie, Medizinische Universitätsklinik, Kantonsspital Baselland, Liestal, Switzerland; "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
| | - Kiera Liblik
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
13
|
Jiang C, Xu H, Wu Y. Effect of chemotherapy in tumor on coronary arteries: Mechanisms and management. Life Sci 2024; 338:122377. [PMID: 38135114 DOI: 10.1016/j.lfs.2023.122377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 12/24/2023]
Abstract
Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. The development of coronary ischemia events, myocardial infarction, and heart failure has been associated with many conventional chemotherapeutic agents, new targeted therapies, and immunotherapy. The most frequent pathological manifestations of chemotherapy-mediated coronary damage include acute vasospasm, acute thrombosis, accelerated atherosclerosis development, and microvascular dysfunction. Potential screening techniques for CAD patients include baseline risk factor evaluation, polygenic risk factors, and coronary artery calcium scores. Determining the risk requires consideration of both the type of chemotherapy and the type of cancer being treated. Cardiology-oncology guidelines offer some suggestions for the care of coronary artery disease, which might involve medication, lifestyle changes, and coronary revascularization.
Collapse
Affiliation(s)
- Chengqing Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haiyan Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| |
Collapse
|
14
|
Michel L, Rassaf T. [Update cardio-oncology : Immune checkpoint inhibitor therapy]. Herz 2024; 49:81-90. [PMID: 38175285 DOI: 10.1007/s00059-023-05228-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 01/05/2024]
Abstract
Cardiovascular diseases and cancer are the most common causes of death in Germany. Cancer treatment can lead to significant cardiovascular side effects and thus form a link between the two disease groups. The focus of cardio-oncology is on the best possible prevention, diagnostics and treatment of cardiovascular complications caused by cancer treatment. It is crucial for cardio-oncology to adapt to the continuous development of new forms of oncological treatment with previously unknown cardiovascular side effects. One such new form of treatment is immune checkpoint inhibitor (ICI) therapy, which is regarded as the most important oncological milestone of the last decade due to its excellent oncological efficacy; however, the growing use has revealed a high risk of diverse cardiovascular side effects with high morbidity and mortality, so that cardio-oncological care of affected patients is of particular importance. This review summarizes the current scientific and clinical state of the pathophysiology, incidence, diagnosis and treatment of cardiovascular side effects of ICI therapy.
Collapse
Affiliation(s)
- Lars Michel
- Klinik für Kardiologie und Angiologie, Westdeutsches Herz- und Gefäßzentrum, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Tienush Rassaf
- Klinik für Kardiologie und Angiologie, Westdeutsches Herz- und Gefäßzentrum, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| |
Collapse
|
15
|
Gong B, Guo Y, Li Y, Wang J, Zhou G, Chen YH, Nie T, Yang M, Luo K, Zheng C, Pan F, Liang B, Yang L. Immune checkpoint inhibitors in cancer: the increased risk of atherosclerotic cardiovascular disease events and progression of coronary artery calcium. BMC Med 2024; 22:44. [PMID: 38291431 PMCID: PMC10829401 DOI: 10.1186/s12916-024-03261-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have contributed to a significant advancement in the treatment of cancer, leading to improved clinical outcomes in many individuals with advanced disease. Both preclinical and clinical investigations have shown that ICIs are associated with atherosclerosis and other cardiovascular events; however, the exact mechanism underlying this relationship has not been clarified. METHODS Patients diagnosed with stages III or IV non-small cell lung cancer (NSCLC) at the Wuhan Union Hospital from March 1, 2020, to April 30, 2022, were included in this retrospective study. Coronary artery calcium (CAC) volume and score were assessed in a subset of patients during non-ECG-gated chest CT scans at baseline and 3, 6, and 12 months after treatment. Propensity score matching (PSM) was performed in a 1:1 ratio to balance the baseline characteristics between the two groups. RESULTS Overall, 1458 patients (487 with ICI therapy and 971 without ICI therapy) were enrolled in this cardiovascular cohort study. After PSM, 446 patients were included in each group. During the entire period of follow-up (median follow-up 23.1 months), 24 atherosclerotic cardiovascular disease (ASCVD) events (4.9%) occurred in the ICI group, and 14 ASCVD events (1.4%) in the non-ICI group, before PSM; 24 ASCVD events (5.4%) occurred in the ICI group and 5 ASCVD events (1.1%) in the non-ICI group after PSM. The CAC imaging study group comprised 113 patients with ICI therapy and 133 patients without ICI therapy. After PSM, each group consisted of 75 patients. In the ICI group, the CAC volume/score increased from 93.4 mm3/96.9 (baseline) to 125.1 mm3/132.8 (at 12 months). In the non-ICI group, the CAC volume/score was increased from 70.1 mm3/68.8 (baseline) to 84.4 mm3/87.9 (at 12 months). After PSM, the CAC volume/score was increased from 85.1 mm3/76.4 (baseline) to 111.8 mm3/121.1 (12 months) in the ICI group and was increased from 74.9 mm3/76.8 (baseline) to 109.3 mm3/98.7 (12 months) in the non-ICI group. Both cardiovascular events and CAC progression were increased after the initiation of ICIs. CONCLUSIONS Treatment with ICIs was associated with a higher rate of ASCVD events and a noticeable increase in CAC progression.
Collapse
Affiliation(s)
- Bingxin Gong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yusheng Guo
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yi Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Jing Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Guofeng Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yong-Hao Chen
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100005, China
| | - Tong Nie
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Ming Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Kun Luo
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Feng Pan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Bo Liang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| | - Lian Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Hubei Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
| |
Collapse
|
16
|
Calabretta R, Beer L, Prosch H, Kifjak D, Zisser L, Binder P, Grünert S, Langsteger W, Li X, Hacker M. Induction of Arterial Inflammation by Immune Checkpoint Inhibitor Therapy in Lung Cancer Patients as Measured by 2-[ 18F]FDG Positron Emission Tomography/Computed Tomography Depends on Pre-Existing Vascular Inflammation. Life (Basel) 2024; 14:146. [PMID: 38276275 PMCID: PMC10817655 DOI: 10.3390/life14010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/11/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are one of the most effective therapies in oncology, albeit associated with various immune-related adverse events also affecting the cardiovascular system. METHODS We aimed to investigate the effect of ICI on arterial 2-[18F]FDG uptake by using 2-[18F]FDG PET/CT imaging pre/post treatment in 47 patients with lung cancer. Maximum 2-[18F]FDG standardized uptake values (SUVmax) and target-to-background ratios (TBRs) were calculated along six arterial segments. We classified the arterial PET lesions by pre-existing active inflammation (cut-off: TBRpre ≥ 1.6). 2-[18F]FDG metabolic activity pre/post treatment was also quantified in bone marrow, spleen, and liver. Circulating blood biomarkers were additionally collected at baseline and after immunotherapy. RESULTS ICI treatment resulted in significantly increased arterial inflammatory activity, detected by increased TBRs, in all arterial PET lesions analyzed. In particular, a significant elevation of arterial 2-[18F]FDG uptake was only recorded in PET lesions without pre-existing inflammation, in calcified as well as in non-calcified lesions. Furthermore, a significant increase in arterial 2-[18F]FDG metabolic activity after immunotherapy was solely observed in patients not previously treated with chemotherapy or radiotherapy as well as in those without CV risk factors. No significant changes were recorded in either 2-[18F]FDG uptake of bone marrow, spleen and liver after treatment, or the blood biomarkers. CONCLUSIONS ICI induces vascular inflammation in lung cancer patients lacking pre-existing arterial inflammation.
Collapse
Affiliation(s)
- Raffaella Calabretta
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| | - Lucian Beer
- Division of Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Helmut Prosch
- Division of Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Daria Kifjak
- Division of Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
- Department of Radiology, UMass Memorial Medical Center and University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Lucia Zisser
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| | - Patrick Binder
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| | - Stefan Grünert
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| | - Werner Langsteger
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria (P.B.)
| |
Collapse
|
17
|
Zhang YJ, Huang C, Zu XG, Liu JM, Li YJ. Use of Machine Learning for the Identification and Validation of Immunogenic Cell Death Biomarkers and Immunophenotypes in Coronary Artery Disease. J Inflamm Res 2024; 17:223-249. [PMID: 38229693 PMCID: PMC10790656 DOI: 10.2147/jir.s439315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024] Open
Abstract
Objective Immunogenic cell death (ICD) is part of the immune system's response to coronary artery disease (CAD). In this study, we bioinformatically evaluated the diagnostic and therapeutic utility of immunogenic cell death-related genes (IRGs) and their relationship with immune infiltration features in CAD. Methods We acquired the CAD-related datasets GSE12288, GSE71226, and GSE120521 from the Gene Expression Omnibus (GEO) database and the IRGs from the GeneCards database. After identifying the immune cell death-related differentially expressed genes (IRDEGs), we developed a risk model and detected immune subtypes in CAD. IRDEGs were identified using least absolute shrinkage and selection operator (LASSO) analysis. Using a nomogram, we confirmed that both the LASSO model and ICD signature genes had good diagnostic performance. Results There was a high degree of coincidence and immune representativeness between two CAD groups based on characteristic genes and hub genes. Hub genes were associated with the interaction of neuroactive ligands with receptors and cell adhesion receptors. The two groups differed in terms of adipogenesis, allograft rejection, and apoptosis, as well as the ICD signature and hub gene expression levels. The two CAD-ICD subtypes differed in terms of immune infiltration. Conclusion Quantitative real-time PCR (qRT-PCR) correlated CAD with the expression of OAS3, ITGAV, and PIBF1. The ICD signature genes are candidate biomarkers and reference standards for immune grouping in CAD and can be beneficial in precise immune-targeted therapy.
Collapse
Affiliation(s)
- Yan-jiao Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, People’s Republic of China
| | - Chao Huang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, People’s Republic of China
| | - Xiu-guang Zu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, People’s Republic of China
| | - Jin-ming Liu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, People’s Republic of China
| | - Yong-jun Li
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, People’s Republic of China
| |
Collapse
|
18
|
Chen Z, Jia K, Zheng Y, Zhang N, Wang X, Tse G, Zhang Z, Hu H, Liu T. Electrocardiographic characteristics of bladder cancer patients receiving preoperative chemotherapy combined with immunotherapy. Ann Noninvasive Electrocardiol 2024; 29:e13107. [PMID: 38288514 PMCID: PMC10809286 DOI: 10.1111/anec.13107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/18/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024] Open
Abstract
OBJECTIVE Patients treated with preoperative chemotherapy and immunotherapy for bladder cancer may be at increased risk of cardiotoxicity and electrophysiological abnormalities. This study aimed to analyze their electrocardiographic (ECG) alterations. METHODS Patients with bladder cancer who were hospitalized and receiving tislelizumab plus nab-paclitaxel (TnP) were enrolled prospectively. ECG, cardiac biomarkers, and echocardiography were performed at baseline and the end of TnP. RESULTS A total of 60 patients (76.7% males), including 30 muscle-invasive and 30 non-muscle-invasive bladder cancer, received three or four cycles of TnP, respectively. Hypertension was the commonest comorbidity (41.7%), and 25 patients (41.7%) were prescribed cardiovascular drugs. In comparison with baseline characteristics, cardiac troponin I (cTnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were within normal ranges after TnP. However, echocardiographic parameter of left ventricular ejection fraction slightly decreased after TnP (62.81 ± 3.81% to 61.10 ± 4.37%, p = .011). The incidence of abnormal ECG increased from 65.0% at baseline to 76.7%, of which only a higher prevalence of fragmented QRS (fQRS) was observed (33.3% to 50.0%, p = .013; mainly in inferior leads). ECG parameters of QT dispersion (QTd) were prolonged significantly after the regimen (39.50 ± 11.37 to 44.20 ± 15.85 ms, p = .019). CONCLUSION In bladder cancer patients receiving preoperative chemotherapy combined with immunotherapy, the main ECG abnormality was fQRS and QTd, with relatively normal cardiac biomarkers and echocardiographic parameters. Regular ECG screening should be carried out carefully to detect potential cardiotoxicity in the long-term follow-up.
Collapse
Affiliation(s)
- Zi‐Liang Chen
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Kai‐Peng Jia
- Department of Urology, The Second Hospital of Tianjin Medical UniversityTianjin Institute of UrologyTianjinChina
| | - Yi Zheng
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Nan Zhang
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Xin Wang
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Gary Tse
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
- Kent and Medway Medical SchoolCanterburyKentUK
- School of Nursing and Health StudiesHong Kong Metropolitan UniversityHong KongChina
| | - Zhi‐Wei Zhang
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Hai‐Long Hu
- Department of Urology, The Second Hospital of Tianjin Medical UniversityTianjin Institute of UrologyTianjinChina
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of CardiologyThe Second Hospital of Tianjin Medical UniversityTianjinChina
| |
Collapse
|
19
|
Chan A, Torelli S, Cheng E, Batchelder R, Waliany S, Neal J, Witteles R, Nguyen P, Cheng P, Zhu H. Immunotherapy-Associated Atherosclerosis: A Comprehensive Review of Recent Findings and Implications for Future Research. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:715-735. [PMID: 38213548 PMCID: PMC10776491 DOI: 10.1007/s11936-023-01024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 01/13/2024]
Abstract
Purpose of the Review Even as immune checkpoint inhibitors (ICIs) have transformed the lifespan of many patients, they may also trigger acceleration of long-term cardiovascular disease. Our review aims to examine the current landscape of research on ICI-mediated atherosclerosis and address key questions regarding its pathogenesis and impact on patient management. Recent Findings Preclinical mouse models suggest that T cell dysregulation and proatherogenic cytokine production are key contributors to plaque development after checkpoint inhibition. Clinical data also highlight the significant burden of atherosclerotic cardiovascular disease (ASCVD) in patients on immunotherapy, although the value of proactively preventing and treating ASCVD in this population remains an open area of inquiry. Current treatment options include dietary/lifestyle modification and traditional medications to manage hypertension, hyperlipidemia, and diabetes risk factors; no current targeted therapies exist. Summary Early identification of high-risk patients is crucial for effective preventive strategies and timely intervention. Future research should focus on refining screening tools, elucidating targetable mechanisms driving ICI atherosclerosis, and evaluating long-term cardiovascular outcomes in cancer survivors who received immunotherapy. Moreover, close collaboration between oncologists and cardiologists is essential to optimize patient outcomes.
Collapse
Affiliation(s)
- Antonia Chan
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Stefan Torelli
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Evaline Cheng
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Ryan Batchelder
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Sarah Waliany
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Joel Neal
- Department of Medicine, Division of Oncology, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA USA
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Patricia Nguyen
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
- Stanford Cardiovascular Institute and Department of Medicine, Stanford University, 240 Pasteur Drive, Rm 3500, Biomedical Innovations Building, Stanford, CA 94304 USA
| | - Paul Cheng
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
- Stanford Cardiovascular Institute and Department of Medicine, Stanford University, 240 Pasteur Drive, Rm 3500, Biomedical Innovations Building, Stanford, CA 94304 USA
| | - Han Zhu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA USA
- Stanford Cardiovascular Institute and Department of Medicine, Stanford University, 240 Pasteur Drive, Rm 3500, Biomedical Innovations Building, Stanford, CA 94304 USA
| |
Collapse
|
20
|
Lessomo FYN, Mandizadza OO, Mukuka C, Wang ZQ. A comprehensive review on immune checkpoint inhibitors induced cardiotoxicity characteristics and associated factors. Eur J Med Res 2023; 28:495. [PMID: 37941006 PMCID: PMC10631013 DOI: 10.1186/s40001-023-01464-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023] Open
Abstract
Newly approved cancer drugs called ICIs have shown remarkable success in improving patient survival rates, but they also have the potential for inflammatory and immune-related side effects, including those affecting the cardiovascular system. Research has been conducted to understand the development of these toxicities and identify risk factors. This review focuses on the characteristics of ICI-induced cardiotoxicity and discusses the reported risk factors. It is important for cardio-oncologists to understand the basic concepts of these drugs to better understand how cardiotoxicities occur. It might be hard to find reports, where all patients treated with ICIs had developed cardiac toxicity, because there could be other existing and variable factors that influence the likelihood or risk of developing cardiotoxicity during treatment. Various clinical parameters have been explored as potential risk factors, and further investigation is needed through large-scale studies.
Collapse
Affiliation(s)
| | | | | | - Zhi-Quan Wang
- Cardiology Department, Zhongnan Hospital of Wuhan University, Wuhan, China.
| |
Collapse
|
21
|
Anastasiou M, Oikonomou E, Theofilis P, Papamikroulis GA, Gazouli M, Kalogeras K, Lygkoni S, Pesiridis T, Goliopoulou A, Papatheodoridi A, Psyrri A, Zagouri F, Siasos G, Tousoulis D. Prolonged impact of anti-cancer therapy on endothelial function and arterial stiffness in breast cancer patients. Vascul Pharmacol 2023; 152:107195. [PMID: 37455009 DOI: 10.1016/j.vph.2023.107195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Cardiotoxicity restricts anthracycline and trastuzumab treatment of Human Epidermal Growth Factor Receptor 2 positive early breast cancer. Endothelial dysfunction and arteriosclerosis are significant cardiovascular risk factors. OBJECTIVES We studied the effect of anthracycline-based chemotherapy, with or without trastuzumab, on endothelium and arteriosclerosis in patients with breast cancer. METHODS In this case-control study, 52 women with breast cancer and 104 women without breast cancer were examined longitudinally up to 15 months following (in the breast cancer group) initiation of chemotherapy. Arterial stiffness was evaluated through pulse wave velocity (PWV), while endothelial function via flow-mediated dilatation (FMD) at baseline (T0), 3 (T1), 6 (T2), and 15 (T3) months later. RESULTS There was no difference between subjects with breast cancer and control in PWV and FMD at baseline. Longitudinally, participants with breast cancer exhibited considerable impairment of PWV and FMD compared to the control group (p for interaction <0.001 for both parameters). In breast cancer patients, there was a significant increase from T0 to T3 in PWV (7.43 ± 1.68 m/s vs. 8.18 ± 2.00 m/s, p = 0.01) and decrease in FMD (6.95 ± 2.86% vs. 5.03 ± 2.83%, p = 0.006). The addition of trastuzumab in the treatment did not have any effect on PWV (p = 0.74) or FMD (p = 0.91). CONCLUSIONS In patients with breast cancer, there is progression of endothelial dysfunction and arteriosclerosis up to 15 months following initiation of anthracycline-based chemotherapy. Trastuzumab has no additive effect on endothelial function or arterial stiffness.
Collapse
Affiliation(s)
- Maria Anastasiou
- Section of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
| | - Panagiotis Theofilis
- 1st Cardiology Department, "Hippokration" General Hospital, Medical School, University of Athens, 11527 Athens, Greece
| | - George Angelos Papamikroulis
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Maria Gazouli
- Laboratory of Biology, Department of Basic Medical Sciences, Medical School, National and Kapodistrian University of Athens, Greece
| | - Konstantinos Kalogeras
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Stavroula Lygkoni
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Theodoros Pesiridis
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Athina Goliopoulou
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Alkistis Papatheodoridi
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, 11528 Athens, Greece
| | - Amanda Psyrri
- Section of Medical Oncology, Department of Internal Medicine, Faculty of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, 11528 Athens, Greece
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, "Hippokration" General Hospital, Medical School, University of Athens, 11527 Athens, Greece
| |
Collapse
|
22
|
Banerjee A, Narasimhulu CA, Singla DK. Immune interactions in pembrolizumab (PD-1 inhibitor) cancer therapy and cardiovascular complications. Am J Physiol Heart Circ Physiol 2023; 325:H751-H767. [PMID: 37594487 PMCID: PMC10659324 DOI: 10.1152/ajpheart.00378.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
The use of immunotherapies like pembrolizumab (PEM) is increasingly common for the management of numerous cancer types. The use of PEM to bolster T-cell response against tumor growth is well documented. However, the interactions PEM has on other immune cells to facilitate tumor regression and clearance is unknown and warrants further investigation. In this review, we present literature findings that have reported the interactions of PEM in stimulating innate and adaptive immune cells, which enhance cytotoxic phenotypes. This triggers secretion of cytokines and chemokines, which have both beneficial and detrimental effects. We also describe how this leads to the development of rare but underreported occurrence of PEM-induced immune-related cardiovascular complications that arise suddenly and progress rapidly to debilitating and fatal consequences. This review encourages further research and investigation of PEM-induced cardiovascular complications and other immune cell interactions in patients with cancer. As PEM therapy in treating cancer types is expanding, we expect that this review will inform health care professionals of diverse specializations of medicine like dermatology (melanoma skin cancers), ophthalmology (eye cancers), and pathology (hematological malignancies) about PEM-induced cardiac complications.
Collapse
Affiliation(s)
- Abha Banerjee
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| | - Chandrakala Aluganti Narasimhulu
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| | - Dinender K Singla
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| |
Collapse
|
23
|
Cina ML, Venegas J, Young A. Stocking the toolbox-Using preclinical models to understand the development and treatment of immune checkpoint inhibitor-induced immune-related adverse events. Immunol Rev 2023; 318:110-137. [PMID: 37565407 PMCID: PMC10529261 DOI: 10.1111/imr.13250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 08/12/2023]
Abstract
Cancer patients treated with immune checkpoint inhibitors (ICIs) are susceptible to a broad and variable array of immune-related adverse events (irAEs). With increasing clinical use of ICIs, defining the mechanism for irAE development is more critical than ever. However, it currently remains challenging to predict when these irAEs occur and which organ may be affected, and for many of the more severe irAEs, inaccessibility to the tissue site hampers mechanistic insight. This lack of understanding of irAE development in the clinical setting emphasizes the need for greater use of preclinical models that allow for improved prediction of biomarkers for ICI-initiated irAEs or that validate treatment options that inhibit irAEs without hampering the anti-tumor immune response. Here, we discuss the utility of preclinical models, ranging from exploring databases to in vivo animal models, focusing on where they are most useful and where they could be improved.
Collapse
Affiliation(s)
- Morgan L Cina
- Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jessica Venegas
- Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Arabella Young
- Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
24
|
Prousi GS, Joshi AM, Atti V, Addison D, Brown SA, Guha A, Patel B. Vascular Inflammation, Cancer, and Cardiovascular Diseases. Curr Oncol Rep 2023; 25:955-963. [PMID: 37261651 DOI: 10.1007/s11912-023-01426-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE OF REVIEW Cancer and cardiovascular disease are among the leading causes of morbidity and mortality in the USA. Cancer and cardiovascular disease have inflammatory underpinnings that have been associated with both the development and progression of these disease states. RECENT FINDINGS Inflammatory signaling has been found to be a critical event in both cardiovascular disease and cancer formation and progression. Further, many chemotherapeutic agents potentiate inflammation exacerbating existing cardiovascular disease or leading to its presence. The exact mechanisms of these interactions remain poorly understood. The proinflammatory milieu observed in both cancer and cardiovascular disease likely plays an important role in the development and potentiation of both conditions. Further evaluation of this relationship will be critical in the development of new diagnostic and therapeutic modalities.
Collapse
Affiliation(s)
| | - Amogh M Joshi
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Varun Atti
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26505, USA
| | - Daniel Addison
- Department of Cardiology, Ohio State University, Columbus, OH, USA
| | - Sherry-Ann Brown
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Avirup Guha
- Department of Cardiology, Medical College of Georgia, Augusta, GA, USA
| | - Brijesh Patel
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26505, USA.
| |
Collapse
|
25
|
Zhu J, Chen Y, Zhang Y, Wang W, Wang Y, Lu Z, Zhang Y, Lei H, Li D, Long B, Liu H. Association of immune checkpoint inhibitors therapy with arterial thromboembolic events in cancer patients: A retrospective cohort study. Cancer Med 2023; 12:18531-18541. [PMID: 37584246 PMCID: PMC10557854 DOI: 10.1002/cam4.6455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have emerged as a standard treatment for various malignancies. However, research indicates blocking the immune checkpoint pathway may exacerbate atherosclerotic lesions. OBJECTIVES We aimed to investigate whether ICI therapy increases the risk of arterial thromboembolic events (ATEs). METHODS A retrospective cohort study was conducted on patients with histologically confirmed cancer at our institution between 2018 and 2021, using the propensity score matching method. The primary endpoint was ATEs occurrence, comprising acute coronary syndrome, stroke/transient ischemic attack, and peripheral arterial thromboembolism. Subgroup analyses assessed whether the ICI treatment effect on ATEs varied over time by limiting the maximum follow-up duration. Logistic regression analysis identified ATE risk factors in ICI-treated patients. RESULTS Overall, the ICI group (n = 2877) demonstrated an ATEs risk 2.01 times higher than the non-ICI group (RR, 2.01 [95% CI (1.61-2.51)]; p < 0.001). Subgroup analysis revealed no significant increase in ATEs risk for ICI-treated patients within 1 year (Limited to a max 9-month follow-up, p = 0.075). However, ATEs risk in the ICI group rose by 41% at 1 year (p = 0.010) and 97% at 4 years (p ≤ 0.001). Age, diabetes, hypertension, peripheral atherosclerosis, atrial fibrillation, chronic ischemic heart disease, distant cancer metastasis, and ICI treatment cycles contributed to ATEs risk elevation in ICI-treated patients. CONCLUSION ICI-treated patients may exhibit a higher risk of ATEs, especially after 1 year of treatment.
Collapse
Affiliation(s)
- Jie Zhu
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| | - Yue Chen
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| | | | - Wei Wang
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| | - Yujue Wang
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| | - Zhuo Lu
- Medical Record Management DepartmentChongqing University Cancer HospitalChongqingChina
| | - Yulin Zhang
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| | - Haike Lei
- Chongqing Cancer Multi‐Omics Big Data Application Engineering Research CenterChongqing University Cancer HospitalChongqingChina
| | - Dairong Li
- Department of Medical OncologyChongqing University Cancer HospitalChongqingChina
| | - Bo Long
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| | - Haixia Liu
- Department of Cardio‐OncologyChongqing University Cancer HospitalChongqingChina
| |
Collapse
|
26
|
Ellison JM, Nohria A. An Increased Understanding of the Association Between Atherosclerosis and Immune Checkpoint Inhibitors. Curr Cardiol Rep 2023; 25:879-887. [PMID: 37395892 DOI: 10.1007/s11886-023-01908-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) therapy activates the host immune system to promote tumor cell death. This activation of the immune system can lead to off-target immune-related adverse events (irAEs). There is an established link between inflammation and atherosclerosis. The purpose of this manuscript is to review the existing body of literature discussing the potential association between ICI treatment and atherosclerosis. RECENT FINDINGS Pre-clinical studies suggest that ICI therapy may lead to T-cell-mediated progression of atherosclerosis. Recent retrospective clinical studies have shown higher rates of myocardial infarction and stroke with ICI therapy, particularly in patients with pre-existing cardiovascular risk factors. Additionally, small observational cohort studies have used imaging modalities to demonstrate higher rates of atherosclerotic progression with ICI treatment. Early pre-clinical and clinical evidence suggests an association between ICI treatment and the progression of atherosclerosis. However, these findings are preliminary, and adequately powered prospective studies are needed to demonstrate a conclusive association. As ICI therapy is increasingly used to treat a variety of solid tumors, it is important to evaluate and mitigate the potential adverse atherosclerotic effects of ICI treatment.
Collapse
Affiliation(s)
- Judah M Ellison
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Anju Nohria
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, 02115, USA.
| |
Collapse
|
27
|
Lee R, Mandala M, Long GV, Eggermont AMM, van Akkooi ACJ, Sandhu S, Garbe C, Lorigan P. Adjuvant therapy for stage II melanoma: the need for further studies. Eur J Cancer 2023; 189:112914. [PMID: 37301717 DOI: 10.1016/j.ejca.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 06/12/2023]
Abstract
Immunotherapy with checkpoint inhibitors has revolutionised the outcomes for melanoma patients. In the metastatic setting, patients treated with nivolumab and ipilimumab have an expected 5-year survival of> 50%. For patients with resected high-risk stage III disease, adjuvant pembrolizumab, nivolumab or dabrafenib and trametinib are associated with a significant improvement in both relapse-free survival (RFS) and distant metastasis-free survival (DMFS). More recently neoadjuvant immunotherapy has shown very promising outcomes in patients with clinically detectable nodal disease and is likely to become a new standard of care. For stage IIB/C disease, two pivotal adjuvant trials of pembrolizumab and nivolumab have also reported a significant improvement in both RFS and DMFS. However, the absolute benefit is low and there are concerns about the risk of severe toxicities as well as long-term morbidity from endocrine toxicity. Ongoing registration phase III trials are currently evaluating newer immunotherapy combinations and the role of BRAF/MEK-directed targeted therapy for stage II melanoma. However, our ability to personalise therapy based on molecular risk stratification has lagged behind the development of novel immune therapies. There is a critical need to evaluate the use of tissue and blood-based biomarkers, to better select patients that will recur and avoid unnecessary treatment for the majority of patients cured by surgery alone.
Collapse
Affiliation(s)
- Rebecca Lee
- The Christie NHS Foundation Trust, Department of Medical Oncology, Manchester, UK; The University of Manchester, Division of Cancer Sciences, Manchester, UK
| | - Mario Mandala
- University of Perugia, Perugia, Italy; Ospedale Papa Givoanni XXIII, Bergamo, Italy
| | - Georgina V Long
- Melanoma Institute Australia, Faculty of Medicine and Health, The University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - Alexander M M Eggermont
- University Medical Center Utrecht & Princess Maxima Center, Utrecht, the Netherlands; Comprehensive Cancer Center München, Technical University München & Ludwig Maximiliaan University, München, Germany
| | - Alexander C J van Akkooi
- Comprehensive Cancer Center München, Technical University München & Ludwig Maximiliaan University, München, Germany; Melanoma Institute Australia, Faculty of Medicine and Health, The University of Sydney, Royal Prince Alfred Hospital, Sydney, Australia
| | - Shahneen Sandhu
- Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Claus Garbe
- Centre for Dermatooncology, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - Paul Lorigan
- The Christie NHS Foundation Trust, Department of Medical Oncology, Manchester, UK; The University of Manchester, Division of Cancer Sciences, Manchester, UK.
| |
Collapse
|
28
|
Ibis B, Aliazis K, Cao C, Yenyuwadee S, Boussiotis VA. Immune-related adverse effects of checkpoint immunotherapy and implications for the treatment of patients with cancer and autoimmune diseases. Front Immunol 2023; 14:1197364. [PMID: 37342323 PMCID: PMC10277501 DOI: 10.3389/fimmu.2023.1197364] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/15/2023] [Indexed: 06/22/2023] Open
Abstract
During the past decade, there has been a revolution in cancer therapeutics by the emergence of antibody-based immunotherapies that modulate immune responses against tumors. These therapies have offered treatment options to patients who are no longer responding to classic anti-cancer therapies. By blocking inhibitory signals mediated by surface receptors that are naturally upregulated during activation of antigen-presenting cells (APC) and T cells, predominantly PD-1 and its ligand PD-L1, as well as CTLA-4, such blocking agents have revolutionized cancer treatment. However, breaking these inhibitory signals cannot be selectively targeted to the tumor microenvironment (TME). Since the physiologic role of these inhibitory receptors, known as immune checkpoints (IC) is to maintain peripheral tolerance by preventing the activation of autoreactive immune cells, IC inhibitors (ICI) induce multiple types of immune-related adverse effects (irAEs). These irAEs, together with the natural properties of ICs as gatekeepers of self-tolerance, have precluded the use of ICI in patients with pre-existing autoimmune diseases (ADs). However, currently accumulating data indicates that ICI might be safely administered to such patients. In this review, we discuss mechanisms of well established and newly recognized irAEs and evolving knowledge from the application of ICI therapies in patients with cancer and pre-existing ADs.
Collapse
Affiliation(s)
- Betul Ibis
- Division of Hematology-Oncology Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Konstantinos Aliazis
- Division of Hematology-Oncology Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Carol Cao
- Division of Hematology-Oncology Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard College, Cambridge, MA, United States
| | - Sasitorn Yenyuwadee
- Division of Hematology-Oncology Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Vassiliki A. Boussiotis
- Division of Hematology-Oncology Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Cancer Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
29
|
Chen M, Xue J, Wang M, Yang J, Chen T. Cardiovascular Complications of Pan-Cancer Therapies: The Need for Cardio-Oncology. Cancers (Basel) 2023; 15:cancers15113055. [PMID: 37297017 DOI: 10.3390/cancers15113055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/28/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
It is more likely that a long-term survivor will have both cardiovascular disease and cancer on account of the progress in cancer therapy. Cardiotoxicity is a well-recognized and highly concerning adverse effect of cancer therapies. This side effect can manifest in a proportion of cancer patients and may lead to the discontinuation of potentially life-saving anticancer treatment regimens. Consequently, this discontinuation may adversely affect the patient's survival prognosis. There are various underlying mechanisms by which each anticancer treatment affects the cardiovascular system. Similarly, the incidence of cardiovascular events varies with different protocols for malignant tumors. In the future, comprehensive cardiovascular risk assessment and clinical monitoring should be considered for cancer treatments. Baseline cardiovascular evaluation risk should be emphasized prior to initiating clinical therapy in patients. Additionally, we highlight that there is a need for cardio-oncology to avoid or prevent cardiovascular side effects. Cardio-oncology service is based on identifying cardiotoxicity, developing strategies to reduce these toxicities, and minimizing long-term cardiotoxic effects.
Collapse
Affiliation(s)
- Mengjia Chen
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Jianing Xue
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Maoling Wang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Junyao Yang
- Department of Laboratory Medicine, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Ting Chen
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
- Alibaba-Zhejiang University Joint Research Center of Future Digital Healthcare, Hangzhou 310058, China
| |
Collapse
|
30
|
Wang D, Bauersachs J, Berliner D. Immune Checkpoint Inhibitor Associated Myocarditis and Cardiomyopathy: A Translational Review. BIOLOGY 2023; 12:biology12030472. [PMID: 36979163 PMCID: PMC10045178 DOI: 10.3390/biology12030472] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized oncology and transformed the treatment of various malignancies. By unleashing the natural immunological brake of the immune system, ICIs were initially considered an effective, gentle therapy with few side effects. However, accumulated clinical knowledge reveals that ICIs are associated with inflammation and tissue damage in multiple organs, leading to immune-related adverse effects (irAEs). Most irAEs involve the skin and gastrointestinal tract; however, cardiovascular involvement is associated with very high mortality rates, and its underlying pathomechanisms are poorly understood. Ranging from acute myocarditis to chronic cardiomyopathies, ICI-induced cardiotoxicity can present in various forms and entities. Revealing the inciting factors, understanding the pathogenesis, and identifying effective treatment strategies are needed to improve the care of tumor patients and our understanding of the immune and cardiovascular systems.
Collapse
Affiliation(s)
- Dong Wang
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| |
Collapse
|
31
|
Waqas M, Halim SA, Alsalman A, Khan A, Elkord E, Al-Harrasi A. Structure-based small inhibitors search combined with molecular dynamics driven energies for human programmed cell death-1 (PD-1) protein. J Biomol Struct Dyn 2023; 41:14771-14785. [PMID: 36927289 DOI: 10.1080/07391102.2023.2188958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
Human immune system is specialized in distinguishing normal cells from foreign particles mainly through proteins expressed on immune cells called 'checkpoints'. Immune checkpoints work as a switch to activate and deactivate immune responses. T cells express one of the immune checkpoint, human programmed cell death-1 (PD-1), which normally operates as an off-switch function to protect the normal cell from T-cell attack. Binding of PD-1 to its ligand, the programmed cell death ligand (PD-L1/2) expressed on myeloid/cancer cells, induce downstream inhibitory signals, leading to tumor immune evasion. Targeting PD-1 or PD-L1 can boost the immune response against cancer cells. To design novel small molecule inhibitors for the PD-1, in silico structure-based screening on pharmacophoric points and molecular docking were performed. Based on the docking score and significant binding interaction with the crucial residues of PD-1 (Thr59, Glu61, Ser62, Glu84, Arg86 and Ala132), compounds were selected from the ZINC20 database, and their dynamic behavior and conformational stability were examined through molecular dynamic simulations. Besides, the Molecular Mechanics/Generalized Born Surface Area (MM/GBSA) method was used to calculate the binding strength of each selected inhibitor complexed with PD-1. The binding energy calculations revealed that these selected inhibitors show a considerable affinity for PD-1. The selected novel inhibitors exhibit excellent drug-like and pharmacokinetic properties (absorption, distribution, metabolism, excretion and toxicity). In conclusion, the identified novel compounds (ZINC1443480030, ZINC1002854123, ZINC988238128, ZINC1481242350, ZINC1001739421, ZINC1220816434 and ZINC1167786692) from the current study can be validated in-vitro as potential PD-1 inhibitors and for discovery of novel drugs against PD-1 in the future.Communicated by Ramaswamy H. Sarma.
Collapse
Affiliation(s)
- Muhammad Waqas
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Sultanate of Oman
- Department of Biotechnology and Genetic Engineering, Hazara University Mansehra, Dhodial, Pakistan
| | - Sobia Ahsan Halim
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Sultanate of Oman
| | - Alhasan Alsalman
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Sultanate of Oman
| | - Ajmal Khan
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Sultanate of Oman
| | - Eyad Elkord
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Sultanate of Oman
- Biomedical Research Center, School of Science, Engineering and Environment, University of Salford, Manchester, UK
| | - Ahmed Al-Harrasi
- Natural and Medical Sciences Research Center, University of Nizwa, Nizwa, Sultanate of Oman
| |
Collapse
|
32
|
Troncoso MF, Díaz-Vesga MC, Sanhueza-Olivares F, Riquelme JA, Müller M, Garrido L, Gabrielli L, Chiong M, Corbalan R, Castro PF, Lavandero S. Targeting VCAM-1: a therapeutic opportunity for vascular damage. Expert Opin Ther Targets 2023; 27:207-223. [PMID: 36880349 DOI: 10.1080/14728222.2023.2187778] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
INTRODUCTION The vascular cell adhesion molecule (VCAM-1) is a transmembrane sialoglycoprotein detected in activated endothelial and vascular smooth muscle cells involved in the adhesion and transmigration of inflammatory cells into damaged tissue. Widely used as a pro-inflammatory marker, its potential role as a targeting molecule has not been thoroughly explored. AREAS COVERED We discuss the current evidence supporting the potential targeting of VCAM-1 in atherosclerosis, diabetes, hypertension and ischemia/reperfusion injury. EXPERT OPINION There is emerging evidence that VCAM-1 is more than a biomarker and may be a promising therapeutic target for vascular diseases. While there are neutralizing antibodies that allow preclinical research, the development of pharmacological tools to activate or inhibit this protein are required to thoroughly assess its therapeutic potential.
Collapse
Affiliation(s)
- Mayarling F Troncoso
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Escuela de Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Magda C Díaz-Vesga
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana de Cali, Cali, Colombia
| | - Fernanda Sanhueza-Olivares
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Jaime A Riquelme
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Marioly Müller
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Departamento de Tecnología Médica, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Luis Garrido
- Division of Cardiovascular Diseases, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luigi Gabrielli
- Division Surgery, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Mario Chiong
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Ramon Corbalan
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo F Castro
- Division Surgery, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Lavandero
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas & Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Department of Internal Medicine (Cardiology Division), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
33
|
PCSK9 Inhibitors in Cancer Patients Treated with Immune-Checkpoint Inhibitors to Reduce Cardiovascular Events: New Frontiers in Cardioncology. Cancers (Basel) 2023; 15:cancers15051397. [PMID: 36900189 PMCID: PMC10000232 DOI: 10.3390/cancers15051397] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Cancer patients treated with immune checkpoint inhibitors (ICIs) are exposed to a high risk of atherosclerosis and cardiometabolic diseases due to systemic inflammatory conditions and immune-related atheroma destabilization. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key protein involved in metabolism of low-density lipoprotein (LDL) cholesterol. PCSK9 blocking agents are clinically available and involve monoclonal antibodies, and SiRNA reduces LDL levels in high-risk patients and atherosclerotic cardiovascular disease events in multiple patient cohorts. Moreover, PCSK9 induces peripheral immune tolerance (inhibition of cancer cell- immune recognition), reduces cardiac mitochondrial metabolism, and enhances cancer cell survival. The present review summarizes the potential benefits of PCSK9 inhibition through selective blocking antibodies and siRNA in patients with cancer, especially in those treated with ICIs therapies, in order to reduce atherosclerotic cardiovascular events and potentially improve ICIs-related anticancer functions.
Collapse
|
34
|
Chan JSK, Tang P, Lee TTL, Chou OHI, Lee YHA, Li G, Leung FP, Wong WT, Liu T, Tse G. Association between immune checkpoint inhibitors and myocardial infarction in Asians: A population-based self-controlled case series. Cancer Med 2023; 12:9541-9546. [PMID: 36808819 PMCID: PMC10166981 DOI: 10.1002/cam4.5729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND While immune checkpoint inhibitors (ICIs) are associated with elevated cardiovascular risks, evidence of any association between ICIs and myocardial infarction (MI) was scarce, especially in Asians. METHODS Using prospectively collected population-based data, this self-controlled case series included patients prescribed an ICI between 1/1/2014 and 31/12/2020 in Hong Kong who had MI within January 1, 2013 to December 31, 2021. Incidence rate ratios (IRRs) for MI during and after ICI exposure were estimated, compared to the year before ICI initiation. RESULTS Of 3684 identified ICI users, 24 had MI during the study period. MI incidence increased significantly in the first 90 days of exposure (IRR 3.59 [95% confidence interval: 1.31-9.83], p = 0.013), but not days 91-180 (p = 0.148) or ≥181 (p = 0.591) of exposure, nor postexposure (p = 0.923). Sensitivity analyses excluding patients with MI-related death and incorporating extended exposure periods produced consistent results separately. CONCLUSIONS ICIs were associated with increased MI incidence in Asian Chinese patients during the first 90 days of use, but not later.
Collapse
Affiliation(s)
- Jeffrey Shi Kai Chan
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, UK-China Collaboration, Hong Kong, China
| | - Pias Tang
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, UK-China Collaboration, Hong Kong, China
| | - Teddy Tai Loy Lee
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, UK-China Collaboration, Hong Kong, China.,Department of Emergency Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Oscar Hou In Chou
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, UK-China Collaboration, Hong Kong, China.,Division of Clinical Pharmacology, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Yan Hiu Athena Lee
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, UK-China Collaboration, Hong Kong, China
| | - Guoliang Li
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Fung Ping Leung
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, Canterbury, UK.,Department of Health Sciences, School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| |
Collapse
|
35
|
Zhou F, Zhu X, Liu Y, Sun Y, Zhang Y, Cheng D, Wang W. Coronary atherosclerosis and chemotherapy: From bench to bedside. Front Cardiovasc Med 2023; 10:1118002. [PMID: 36742069 PMCID: PMC9892653 DOI: 10.3389/fcvm.2023.1118002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023] Open
Abstract
Cardiovascular disease, particularly coronary artery disease, is the leading cause of death in humans worldwide. Coronary heart disease caused by chemotherapy affects the prognosis and survival of patients with tumors. The most effective chemotherapeutic drugs for cancer include proteasome inhibitors, tyrosine kinase inhibitors, immune checkpoint inhibitors, 5-fluorouracil, and anthracyclines. Animal models and clinical trials have consistently shown that chemotherapy is closely associated with coronary events and can cause serious adverse cardiovascular events. Adverse cardiovascular events after chemotherapy can affect the clinical outcome, treatment, and prognosis of patients with tumors. In recent years, with the development of new chemotherapeutic drugs, new discoveries have been made about the effects of drugs used for chemotherapy on cardiovascular disease and its related mechanisms, such as inflammation. This review article summarizes the effects of chemotherapeutic drugs on coronary artery disease and its related mechanisms to guide efforts in reducing cardiovascular adverse events during tumor chemotherapy, preventing the development of coronary heart disease, and designing new prevention and treatment strategies for cardiotoxicity caused by clinical tumor chemotherapy.
Collapse
Affiliation(s)
- Fanghui Zhou
- Department of Hematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xinxin Zhu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yao Liu
- Department of Hematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yue Sun
- Department of Blood and Endocrinology, The 962nd Hospital of the PLA Joint Logistic Support Force, Harbin, Heilongjiang, China
| | - Ying Zhang
- Key Laboratory of Preservation of Human Genetic Resources and Disease Control in China (Harbin Medical University), Ministry of Education, Harbin, China
| | | | - Wei Wang
- Department of Hematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China,*Correspondence: Wei Wang,
| |
Collapse
|
36
|
Totzeck M, Aide N, Bauersachs J, Bucerius J, Georgoulias P, Herrmann K, Hyafil F, Kunikowska J, Lubberink M, Nappi C, Rassaf T, Saraste A, Sciagra R, Slart RHJA, Verberne H, Rischpler C. Nuclear medicine in the assessment and prevention of cancer therapy-related cardiotoxicity: prospects and proposal of use by the European Association of Nuclear Medicine (EANM). Eur J Nucl Med Mol Imaging 2023; 50:792-812. [PMID: 36334105 PMCID: PMC9852191 DOI: 10.1007/s00259-022-05991-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
Cardiotoxicity may present as (pulmonary) hypertension, acute and chronic coronary syndromes, venous thromboembolism, cardiomyopathies/heart failure, arrhythmia, valvular heart disease, peripheral arterial disease, and myocarditis. Many of these disease entities can be diagnosed by established cardiovascular diagnostic pathways. Nuclear medicine, however, has proven promising in the diagnosis of cardiomyopathies/heart failure, and peri- and myocarditis as well as arterial inflammation. This article first outlines the spectrum of cardiotoxic cancer therapies and the potential side effects. This will be complemented by the definition of cardiotoxicity using non-nuclear cardiovascular imaging (echocardiography, CMR) and biomarkers. Available nuclear imaging techniques are then presented and specific suggestions are made for their application and potential role in the diagnosis of cardiotoxicity.
Collapse
Affiliation(s)
- Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicolas Aide
- Nuclear Medicine Department, University Hospital, Caen, France
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan Bucerius
- Department of Nuclear Medicine, University Medicine Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Panagiotis Georgoulias
- Department of Nuclear Medicine, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Ken Herrmann
- Clinic for Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Fabien Hyafil
- Department of Nuclear Medicine, DMU IMAGINA, Georges-Pompidou European Hospital, Assistance-Publique – Hôpitaux de Paris, University of Paris, Paris, France
| | - Jolanta Kunikowska
- Nuclear Medicine Department, Medical University of Warsaw, Warsaw, Poland
| | - Mark Lubberink
- Medical Physics, Uppsala University Hospital, Uppsala, Sweden
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Antti Saraste
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Roberto Sciagra
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Riemer H. J. A. Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands ,Department of Biomedical Photonic Imaging, Faculty of Science and Technology, Enschede, The Netherlands
| | - Hein Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christoph Rischpler
- Clinic for Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
37
|
Chiang CH, Chiang CH, Ma KSK, Hsia YP, Lee YW, Wu HR, Chiang CH, Peng CY, Wei JCC, Shiah HS, Peng CM, Neilan TG. The incidence and risk of cardiovascular events associated with immune checkpoint inhibitors in Asian populations. Jpn J Clin Oncol 2022; 52:1389-1398. [PMID: 36208180 PMCID: PMC9721460 DOI: 10.1093/jjco/hyac150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/30/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Immune checkpoint inhibitors are associated with adverse cardiovascular events. However, there are no data characterizing cardiovascular events among Asians on immune checkpoint inhibitors. We aim to determine the incidence and risk of cardiac events associated with immune checkpoint inhibitors in an Asian population. METHODS We performed a retrospective, propensity score-matched cohort study at two tertiary referral centers in Taiwan. Immune checkpoint inhibitor users were matched with non-immune checkpoint inhibitor users based on predetermined clinical variables. The primary outcome was major adverse cardiovascular events, defined as a composite of myocardial infarction, ischemic stroke, acute peripheral occlusive disease, pulmonary embolism, deep venous thrombosis, heart failure, pericardial disease, myocarditis, cardiac arrhythmias and conduction block. RESULTS Between January 2010 and November 2021, 868 immune checkpoint inhibitor users were matched 1:1 with non-immune checkpoint inhibitor users. Among immune checkpoint inhibitor users, 67 (7.7%) patients developed major adverse cardiovascular events. During a median follow-up period of 188 days, the incidence rate of major adverse cardiovascular events for immune checkpoint inhibitor and non-immune checkpoint inhibitor users was 94.8 and 46.2 per 1000 patient-years, respectively, resulting in an incidence rate ratio of 2.1 [95% confidence interval: 1.5-2.9]. In multivariate Cox proportional hazard models, immune checkpoint inhibitor users had a 60% increased risk for major adverse cardiovascular events [hazard ratio, 1.6 (95% confidence interval: 1.1-2.3)]. Immune checkpoint inhibitors use was independently associated with increased risk of ischemic stroke [hazard ratio, 3.0 (95% confidence interval: 1.0-9.0)] and pulmonary embolism [hazard ratio, 5.5 (95% confidence interval: 1.4-21.3)]. In multivariate logistic regression analysis, age > 65, metastatic disease, hypertension and baseline platelet-to-lymphocyte ratio < 180 were risk factors for major adverse cardiovascular events. CONCLUSIONS Among Asians, immune checkpoint inhibitors were associated with an increased risk of major adverse cardiovascular events, particularly ischemic stroke and pulmonary embolism.
Collapse
Affiliation(s)
- Cho-Han Chiang
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, MA, USA
| | - Cho-Hung Chiang
- Department of General Division, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and Computer Science, National Taiwan University, Taipei, Taiwan
| | - Yuan Ping Hsia
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan
| | - Yu-wen Lee
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Han-Ru Wu
- Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Cho-Hsien Chiang
- Department of Medical Education, Kuang Tien General Hospital, Taichung, Taiwan
- London School of Hygiene & Tropical Medicine, London, UK
| | - Chun-Yu Peng
- Department of Medicine, Danbury Hospital, Danbury, Connecticut, USA
- Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Her-Shyong Shiah
- Department of Hematology and Oncology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ming Peng
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Foundation, New Taipei City, Taiwan
- Da Vinci Minimally Invasive Surgery Center, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology and Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
38
|
Dong R, Jiang G, Tian Y, Shi X. Identification of immune-related biomarkers and construction of regulatory network in patients with atherosclerosis. BMC Med Genomics 2022; 15:245. [PMID: 36437453 PMCID: PMC9703734 DOI: 10.1186/s12920-022-01397-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND More and more evidence has established the crucial roles of the innate and adaptive immune systems in driving atherosclerosis-associated chronic inflammation in arterial blood vessels. Thus, the goal of this research was to determine immune-related biomarkers in atherosclerosis. METHODS In this study, we conducted analysis on the mRNA expression profile of atherosclerosis obtained from Gene Expression Omnibus. Differentially expressed genes (DEGs) between atherosclerosis and control samples and immune-related genes (IRGs) were intersected to obtain differentially expressed immune-related genes (DEIRGs). The protein-protein interaction (PPI) network was created by STRING database and hub genes were identified by the MCODE plug-in. Furthermore, the receiver operating characteristic (ROC) curve was executed to verify the diagnostic value of the hub genes, and microRNA (miRNA)-gene-transcription factor (TF) regulatory networks were used to explain the regulatory mechanism of hub genes in atherosclerosis. Finally, qRT-PCR was performed to identify the mRNA levels of the target genes. RESULTS A total of 199 overlapping genes were screened out as DEIRGs by intersecting the DEGs and IRGs. Then, 6 hub genes with high diagnostic value (IFIH1, IFIT1, IFIT2, IFIT3, ISG15 and OAS3) were identified via PPI network and ROC curve. Finally, miRNA-gene-TF networks revealed the regulatory mechanism of diagnostic genes.We used the carotid artery of AS patients and normal human carotid artery plaque samples for qRT-PCR verification, and the results showed that the hub gene had the same trend. CONCLUSION Our study identified IFIH1, IFIT1, IFIT2, IFIT3, ISG15 and OAS3 as immune-related hub genes of atherosclerosis. These genes may serve as potential therapeutic targets for atherosclerosis patients.
Collapse
Affiliation(s)
- Ruoyu Dong
- Department of Vascular Surgery, Hebei Provincial People's Hospital, Shijiazhuang, 050000, China
| | - Guangwei Jiang
- Department of Vascular Surgery, Hebei Provincial People's Hospital, Shijiazhuang, 050000, China
| | - Yunjie Tian
- The Fourth Hospital of Hebei Medical University Gynecology, Shijiazhuang, 050000, China
| | - Xiaoming Shi
- Department of Vascular Surgery, Hebei Provincial People's Hospital, Shijiazhuang, 050000, China.
| |
Collapse
|
39
|
Efentakis P, Andreadou I, Iliodromitis KE, Triposkiadis F, Ferdinandy P, Schulz R, Iliodromitis EK. Myocardial Protection and Current Cancer Therapy: Two Opposite Targets with Inevitable Cost. Int J Mol Sci 2022; 23:ijms232214121. [PMID: 36430599 PMCID: PMC9696420 DOI: 10.3390/ijms232214121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022] Open
Abstract
Myocardial protection against ischemia/reperfusion injury (IRI) is mediated by various ligands, activating different cellular signaling cascades. These include classical cytosolic mediators such as cyclic-GMP (c-GMP), various kinases such as Phosphatydilinositol-3- (PI3K), Protein Kinase B (Akt), Mitogen-Activated-Protein- (MAPK) and AMP-activated (AMPK) kinases, transcription factors such as signal transducer and activator of transcription 3 (STAT3) and bioactive molecules such as vascular endothelial growth factor (VEGF). Most of the aforementioned signaling molecules constitute targets of anticancer therapy; as they are also involved in carcinogenesis, most of the current anti-neoplastic drugs lead to concomitant weakening or even complete abrogation of myocardial cell tolerance to ischemic or oxidative stress. Furthermore, many anti-neoplastic drugs may directly induce cardiotoxicity via their pharmacological effects, or indirectly via their cardiovascular side effects. The combination of direct drug cardiotoxicity, indirect cardiovascular side effects and neutralization of the cardioprotective defense mechanisms of the heart by prolonged cancer treatment may induce long-term ventricular dysfunction, or even clinically manifested heart failure. We present a narrative review of three therapeutic interventions, namely VEGF, proteasome and Immune Checkpoint inhibitors, having opposing effects on the same intracellular signal cascades thereby affecting the heart. Moreover, we herein comment on the current guidelines for managing cardiotoxicity in the clinical setting and on the role of cardiovascular confounders in cardiotoxicity.
Collapse
Affiliation(s)
- Panagiotis Efentakis
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 15771 Athens, Greece
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 15771 Athens, Greece
- Correspondence: ; Tel.: +30-210-727-4827; Fax: +30-210-727-4747
| | | | | | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, 1089 Budapest, Hungary
- Pharmahungary Group, 6722 Szeged, Hungary
| | - Rainer Schulz
- Institute of Physiology, Justus Liebig University Giessen, 35390 Giessen, Germany
| | | |
Collapse
|
40
|
CHENG X, ZHAO C, JIN Z, HU J, ZHANG Z, ZHANG C. Natural products: potential therapeutic agents for atherosclerosis. Chin J Nat Med 2022; 20:830-845. [DOI: 10.1016/s1875-5364(22)60219-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Indexed: 11/24/2022]
|
41
|
Evans PC, Davidson SM, Wojta J, Bäck M, Bollini S, Brittan M, Catapano AL, Chaudhry B, Cluitmans M, Gnecchi M, Guzik TJ, Hoefer I, Madonna R, Monteiro JP, Morawietz H, Osto E, Padró T, Sluimer JC, Tocchetti CG, Van der Heiden K, Vilahur G, Waltenberger J, Weber C. From novel discovery tools and biomarkers to precision medicine-basic cardiovascular science highlights of 2021/22. Cardiovasc Res 2022; 118:2754-2767. [PMID: 35899362 PMCID: PMC9384606 DOI: 10.1093/cvr/cvac114] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Here, we review the highlights of cardiovascular basic science published in 2021 and early 2022 on behalf of the European Society of Cardiology Council for Basic Cardiovascular Science. We begin with non-coding RNAs which have emerged as central regulators cardiovascular biology, and then discuss how technological developments in single-cell 'omics are providing new insights into cardiovascular development, inflammation, and disease. We also review recent discoveries on the biology of extracellular vesicles in driving either protective or pathogenic responses. The Nobel Prize in Physiology or Medicine 2021 recognized the importance of the molecular basis of mechanosensing and here we review breakthroughs in cardiovascular sensing of mechanical force. We also summarize discoveries in the field of atherosclerosis including the role of clonal haematopoiesis of indeterminate potential, and new mechanisms of crosstalk between hyperglycaemia, lipid mediators, and inflammation. The past 12 months also witnessed major advances in the field of cardiac arrhythmia including new mechanisms of fibrillation. We also focus on inducible pluripotent stem cell technology which has demonstrated disease causality for several genetic polymorphisms in long-QT syndrome and aortic valve disease, paving the way for personalized medicine approaches. Finally, the cardiovascular community has continued to better understand COVID-19 with significant advancement in our knowledge of cardiovascular tropism, molecular markers, the mechanism of vaccine-induced thrombotic complications and new anti-viral therapies that protect the cardiovascular system.
Collapse
Affiliation(s)
| | | | | | | | - Sveva Bollini
- Department of Experimental Medicine (DIMES), University of Genova, L.go R. Benzi 10, 16132 Genova, Italy
| | - Mairi Brittan
- Queens Medical Research Institute, BHF Centre for Cardiovascular Sciences, University of Edinburgh, Scotland
| | | | - Bill Chaudhry
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Matthijs Cluitmans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Philips Research, Eindhoven, Netherlands
| | - Massimiliano Gnecchi
- Department of Molecular Medicine, Unit of Cardiology, University of Pavia Division of Cardiology, Unit of Translational Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Medicine, University of Cape Town, South Africa
| | - Tomasz J Guzik
- Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Imo Hoefer
- Central Diagnostic Laboratory, UMC Utrecht, the Netherlands
| | - Rosalinda Madonna
- Institute of Cardiology, Department of Surgical, Medical, Molecular and Critical Care Area, University of Pisa, Pisa, 56124 Italy
- Department of Internal Medicine, Cardiology Division, University of Texas Medical School, Houston, TX, USA
| | - João P Monteiro
- Queens Medical Research Institute, BHF Centre for Cardiovascular Sciences, University of Edinburgh, Scotland
| | - Henning Morawietz
- Division of Vascular Endothelium and Microcirculation, Department of Medicine III, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Elena Osto
- Institute of Clinical Chemistry and Department of Cardiology, Heart Center, University Hospital & University of Zurich, Switzerland
| | - Teresa Padró
- Cardiovascular Program-ICCC, IR-Hospital Santa Creu i Sant Pau, IIB-Sant Pau, and CIBERCV-Instituto de Salud Carlos III, Barcelona, Spain
| | - Judith C Sluimer
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherland
- University/BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Carlo Gabriele Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Center for Basic and Clinical Immunology (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, 80131 Napoli, Italy
| | - Kim Van der Heiden
- Biomedical Engineering, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Program-ICCC, IR-Hospital Santa Creu i Sant Pau, IIB-Sant Pau, and CIBERCV-Instituto de Salud Carlos III, Barcelona, Spain
| | - Johannes Waltenberger
- Cardiovascular Medicine, Medical Faculty, University of Muenster, Muenster, Germany
- Diagnostic and Therapeutic Heart Center, Zurich, Switzerland
| | | |
Collapse
|
42
|
Yang Y, Ding X, Chen F, Wu X, Chen Y, Zhang Q, Cao J, Wang J, Dai Y. Inhibition Effects of Nippostrongylus brasiliensis and Its Derivatives against Atherosclerosis in ApoE-/- Mice through Anti-Inflammatory Response. Pathogens 2022; 11:pathogens11101208. [PMID: 36297265 PMCID: PMC9610917 DOI: 10.3390/pathogens11101208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Atherosclerosis (AS) is a dominant and growing cause of death and disability worldwide that involves inflammation from its inception to the emergence of complications. Studies have demonstrated that intervention with helminth infections or derived products could modulate the host immune response and effectively prevent or mitigate the onset and progression of inflammation-related diseases. Therefore, to understand the molecular mechanisms underlying the development of atherosclerosis, we intervened in ApoE-/- mice maintained on a high-fat diet with Nippostrongylus brasiliensis (N. brasiliensis) infection and immunized with its derived products. We found that N. brasiliensis infection and its derived proteins had suitable protective effects both in the initial and progressive stages of atherosclerosis, effectively reducing aortic arch plaque areas and liver lipid contents and downregulating serum LDL levels, which may be associated with the significant upregulation of serum anti-inflammatory cytokines (IL-10 and IL-4) and the down-regulation of proinflammatory cytokines (TNF-α and IFN-γ) in the serum. In conclusion, these data highlighted the effective regulatory role of N. brasiliensis and its derived proteins in the development and progression of atherosclerosis. This could provide a promising new avenue for the prevention and treatment of atherosclerosis.
Collapse
Affiliation(s)
- Yougui Yang
- School of Public Health, Nanjing Medical University, Nanjing 211166, China
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
| | - Xin Ding
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
| | - Fuzhong Chen
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xiaomin Wu
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
- Microbiological Laboratory, Anhui Provincial Center for Disease Control and Prevention, Hefei 230601, China
| | - Yuying Chen
- School of Public Health, Nanjing Medical University, Nanjing 211166, China
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
| | - Qiang Zhang
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
| | - Jun Cao
- School of Public Health, Nanjing Medical University, Nanjing 211166, China
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
| | - Junhong Wang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Correspondence: (J.W.); (Y.D.)
| | - Yang Dai
- School of Public Health, Nanjing Medical University, Nanjing 211166, China
- Key Laboratory of National Health Commission on Parasitic Disease Control and Prevention, Key Laboratory of Jiangsu Province on Parasite and Vector Control Technology, Jiangsu Institute of Parasitic Diseases, Wuxi 214064, China
- Correspondence: (J.W.); (Y.D.)
| |
Collapse
|
43
|
Ganesh S, Zhong P, Zhou X. Cardiotoxicity induced by immune checkpoint inhibitor: The complete insight into mechanisms, monitoring, diagnosis, and treatment. Front Cardiovasc Med 2022; 9:997660. [PMID: 36204564 PMCID: PMC9530557 DOI: 10.3389/fcvm.2022.997660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have been taking cancer research by storm as they provide valuable therapeutic benefits to cancer patients in terms of immunotherapy. Melanoma and non-small cell lung cancer (NSCLC) are among the most prevalent cancer varieties that were utilized in ICI trials with many other cancer types being involved too. Despite impressive clinical benefits of overall response rate (ORR), progression-free survival (PFS), etc., ICIs are also accompanied by various immune-related adverse events (irAEs). Amongst the irAEs, cardiotoxicity bags a crucial role. It is of paramount importance that ICI-induced cardiotoxicity should be studied in detail due to its high mortality rate although the prevalence rate is low. Patients with ICI cardiotoxicity can have a greatly enhanced life quality despite adverse reactions from ICI therapy if diagnosed early and treated in time. As such, this review serves to provide a complete insight into the predisposing factors, mechanism, diagnostic methods and treatment plans revolving around ICI-induced cardiotoxicity.
Collapse
|
44
|
Quagliariello V, Passariello M, Di Mauro A, Cipullo C, Paccone A, Barbieri A, Palma G, Luciano A, Buccolo S, Bisceglia I, Canale ML, Gallucci G, Inno A, De Lorenzo C, Maurea N. Immune checkpoint inhibitor therapy increases systemic SDF-1, cardiac DAMPs Fibronectin-EDA, S100/Calgranulin, galectine-3, and NLRP3-MyD88-chemokine pathways. Front Cardiovasc Med 2022; 9:930797. [PMID: 36158826 PMCID: PMC9505026 DOI: 10.3389/fcvm.2022.930797] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/03/2022] [Indexed: 11/15/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) have significantly changed the oncology clinic in recent years, improving survival expectations in cancer patients. ICI therapy have a broad spectrum of side effects from endocrinopathies to cardiovascular diseases. In this study, pro-inflammatory and pro-fibrotic effects of short-term ICIs therapy in preclinical models were analyzed. Methods Firstly, in a human in vitro model, human cardiomyocytes co-cultured with hPBMC were exposed to ICIs (with CTLA-4 or PD-1 blocking agents, at 200 nM) for 72 h. After treatment, production of DAMPs and 12 cytokines were analyzed in the supernatant through colorimetric and enzymatic assays. C57/Bl6 mice were treated with CTLA-4 or PD-1 blocking agents (15 mg/kg) for 10 days. Before (T0), after three days (T3) and after treatments (T10), ejection fraction, fractional shortening, radial and longitudinal strain were calculated by using bidimensional echocardiography (Vevo 2100, Fujfilm). Fibrosis, necrosis, hypertrophy and vascular NF-kB expression were analyzed through Immunohistochemistry. Myocardial expression of DAMPs (S100- Calgranulin, Fibronectin and Galectine-3), MyD88, NLRP3 and twelve cytokines have been analyzed. Systemic levels of SDF-1, IL-1β, and IL-6 were analyzed before, during and after ICIs therapy. Results Radial and longitudinal strain were decreased after 10 days of ICIs therapy. Histological analysis of NF-kB expression shows that short-term anti-CTLA-4 or anti-PD-1 treatment increased vascular and myocardial inflammation. No myocardial hypertrophy was seen with the exception of the pembrolizumab group. Myocardial fibrosis and expression of galectin-3, pro-collagen 1-α and MMP-9 were increased after treatment with all ICIs. Both anti-CTLA-4 or anti-PD-1 treatments increased the expression of DAMPs, NLRP3 inflammasome and MyD88 and induced both in vitro and in vivo the secretion of IL-1β, TNF-α and IL-6. Systemic levels of SDF-1, IL-1β and IL-6 were increased during and after treatment with ICIs. Conclusions Short therapy with PD-1 and CTLA-4 blocking agents increases vascular expression of NF-kB, systemic SDF-1, IL-1β, IL-6 levels and myocardial NLRP3, MyD88 and DAMPs expression in preclinical models. A pro-inflammatory cytokine storm was induced in myocardial tissues and in cultured cardiac cells after ICIs therapy. The overall picture of the study suggests new putative biomarkers of ICIs-mediated systemic and myocardial damages potentially useful in clinical cardioncology.
Collapse
Affiliation(s)
- Vincenzo Quagliariello
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy,*Correspondence: Vincenzo Quagliariello
| | - Margherita Passariello
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy,Ceinge-Biotecnologie Avanzate s.c.a.r.l., Naples, Italy
| | - Annabella Di Mauro
- Pathology Unit, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Ciro Cipullo
- Pathology Unit, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Andrea Paccone
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Antonio Barbieri
- Animal Facility, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Giuseppe Palma
- Animal Facility, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Antonio Luciano
- Animal Facility, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Simona Buccolo
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy
| | - Irma Bisceglia
- Servizi Cardiologici Integrati, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Maria Laura Canale
- U.O.C. Cardiologia, Ospedale Versilia, Lido di Camaiore (LU), Camaiore, Italy
| | - Giuseppina Gallucci
- Cardiologia, Centro di Riferimento Oncologico della Basilicata (CROB) - Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rionero in Vulture, Italy
| | - Alessandro Inno
- Medical Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Sacro Cuore Don Calabria, Negrar, Italy
| | - Claudia De Lorenzo
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, Naples, Italy,Ceinge-Biotecnologie Avanzate s.c.a.r.l., Naples, Italy
| | - Nicola Maurea
- Division of Cardiology, Istituto Nazionale Tumori- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)- Fondazione G. Pascale, Naples, Italy,Nicola Maurea
| |
Collapse
|
45
|
Michel L, Korste S, Spomer A, Hendgen-Cotta UB, Rassaf T, Totzeck M. PD1 Deficiency Modifies Cardiac Immunity during Baseline Conditions and in Reperfused Acute Myocardial Infarction. Int J Mol Sci 2022; 23:ijms23147533. [PMID: 35886878 PMCID: PMC9321105 DOI: 10.3390/ijms23147533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
The programmed cell death protein 1 (PD1) immune checkpoint prevents inflammatory tissue damage by inhibiting immune reactions. Understanding the relevance of cardiac PD1 signaling may provide new insights into the inflammatory events under baseline conditions and disease. Here, we demonstrate distinct immunological changes upon PD1 deficiency in healthy hearts and during reperfused acute myocardial infarction (repAMI). In PD1-deficient mice, upregulated inflammatory cytokines were identified under baseline conditions including cardiac interleukins and extracellular signal-related kinase 1/2 (ERK1/2). A murine in vivo repAMI model to determine inflammatory changes in the early phase showed downregulation of the ligand PDL1, paralleled by an endothelial injury, indicated by loss of the CD31 signal. Immunofluorescence imaging showed decreased PDL1 expression specifically in the infarct zone, highlighting an involvement in PDL1 in myocardial injury response. Pharmacological depletion of PD1 prior to repAMI did not alter the area of infarction but led to increased numbers of CD8+ T cells in treated mice. We conclude that PD1/PDL1 signaling plays a significant role in healthy hearts and repAMI, emphasizing the relevance of adaptive immunity during myocardial injury. The findings highlight the risk for adverse outcomes from acute myocardial infarction in the growing group of patients receiving immune checkpoint inhibitor therapy.
Collapse
|
46
|
Reeves DJ, Rao VU. Update on cancer therapy-induced atherosclerosis. Curr Opin Cardiol 2022; 37:372-379. [PMID: 35731682 DOI: 10.1097/hco.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Recent advances in oncologic therapies have significantly improved overall survival for patients with malignancy. However, cardiovascular complications have not only increased in this population due to shared risk factors and pathophysiology, but also due to the therapies themselves. One key mechanism that warrants further attention is accelerated atherosclerosis due to these agents. RECENT FINDINGS Here we review recent studies focusing on four classes of anticancer agents with the potential to accelerate atherosclerosis, including breakpoint cluster region-Ableson (BCR-ABL) tyrosine kinase inhibitors, immunotherapies, androgen deprivation therapies, and vascular endothelial growth factor inhibitors. In addition to drug therapy, radiation therapy may also accelerate atherosclerosis. SUMMARY In order to optimize outcomes for patients with malignancy, enhanced efforts need to focus on mitigating common risk factors, but also recognizing enhanced atherosclerotic risk with certain oncologic therapies. For patients exposed to these agents, risk reduction with agents such as aspirin and/or statins prior to, during, and after cancer treatment may provide opportunities to improve overall outcomes.
Collapse
Affiliation(s)
- David J Reeves
- Division of Oncology, Franciscan Health and Butler University College of Pharmacy and Health Sciences
| | - Vijay U Rao
- Franciscan CardioOncology Center, IC-OS Center of Excellence, Indiana Heart Physicians, Franciscan Health, Indianapolis, Indiana, USA
| |
Collapse
|
47
|
Zhao S, Wu Y, Wei Y, Xu X, Zheng J. Identification of Biomarkers Associated With CD8+ T Cells in Coronary Artery Disease and Their Pan-Cancer Analysis. Front Immunol 2022; 13:876616. [PMID: 35799780 PMCID: PMC9254733 DOI: 10.3389/fimmu.2022.876616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo identify biomarkers associated with CD8+ T cells in coronary artery disease (CAD) and initially explore their potential role in the tumor immune microenvironment.Materials and MethodsCAD-related datasets GSE12288, GSE34198, and GSE66360, were downloaded from the GEO database. First, GSVA was performed based on the GSE12288 dataset. Then WGCNA analysis was performed to identify the most relevant module and candidate hub gene for CD8+ T cells, followed by GO and KEGG analysis of this module. Secondly, the relationship between candidate hub genes and CD8+ T cells was verified using GSE34198 and GSE66360, which led to the identification of hub genes. The relationship of hub genes with CD8+ T cells in cancer was analyzed using the TIMER database. Methylation analysis of hub genes was performed using the DiseaseMeth database. CAD, pan-cancer, pan-cell lines, and pan-normal tissues, correlations between hub genes. In addition, potential drugs and TFs associated with hub genes were predicted, and the ceRNA network was constructed. Finally, GSEA was performed separately for hub genes.ResultsCAD was shown to be associated with immune response by GSVA analysis. WGCNA identified the blue module as most related to CD8+ T cells and identified nine candidate hub genes. The relevance of CAD to immunity was further confirmed by GO and KEGG analysis of the module. Two additional datasets validated and identified three hub genes (FBXO7, RAD23A, and MKRN1) that significantly correlated with CD8+ T cells. In addition, we found that hub genes were positively associated with CD8+ T cells in TGCT, THCA, and KICH cancers by our analysis. Moreover, the hub gene was differentially methylated. We also analyzed the correlation between hub genes in CAD, different cancers, different cell lines, and different normal tissues. The results of all the analyses showed a positive correlation between them. Finally, we successfully constructed hub gene-associated TF-gene and ceRNA networks and predicted 11 drugs associated with hub genes. GSEA suggests that hub genes are related to multiple immune response processes.ConclusionFBXO7, RAD23A, and MKRN1 are significantly associated with CD8+ T cells in CAD and multiple cancers and may act through immune responses in CAD and cancer.
Collapse
Affiliation(s)
- Shijian Zhao
- Department of Cardiology, the Affiliated Cardiovascular Hospital of Kunming Medical University (Fuwai Yunnan Cardiovascular Hospital), Kunming, China
| | - Yinteng Wu
- Department of Orthopedic and Trauma Surgery, the First Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Yantao Wei
- Department of Cardiology, the Affiliated Cardiovascular Hospital of Kunming Medical University (Fuwai Yunnan Cardiovascular Hospital), Kunming, China
| | - Xiaoyu Xu
- Department of Cardiology, the Affiliated Cardiovascular Hospital of Kunming Medical University (Fuwai Yunnan Cardiovascular Hospital), Kunming, China
| | - Jialin Zheng
- Department of Cardiology, the Affiliated Cardiovascular Hospital of Kunming Medical University (Fuwai Yunnan Cardiovascular Hospital), Kunming, China
- *Correspondence: Jialin Zheng,
| |
Collapse
|
48
|
Poto R, Troiani T, Criscuolo G, Marone G, Ciardiello F, Tocchetti CG, Varricchi G. Holistic Approach to Immune Checkpoint Inhibitor-Related Adverse Events. Front Immunol 2022; 13:804597. [PMID: 35432346 PMCID: PMC9005797 DOI: 10.3389/fimmu.2022.804597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) block inhibitory molecules, such as cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death protein 1 (PD-1), or its ligand, programmed cell death protein ligand 1 (PD-L1) and enhance antitumor T-cell activity. ICIs provide clinical benefits in a percentage of patients with advanced cancers, but they are usually associated with a remarkable spectrum of immune-related adverse events (irAEs) (e.g., rash, colitis, hepatitis, pneumonitis, endocrine, cardiac and musculoskeletal dysfunctions). Particularly patients on combination therapy (e.g., anti-CTLA-4 plus anti-PD-1/PD-L1) experience some form of irAEs. Different mechanisms have been postulated to explain these adverse events. Host factors such as genotype, gut microbiome and pre-existing autoimmune disorders may affect the risk of adverse events. Fatal ICI-related irAEs are due to myocarditis, colitis or pneumonitis. irAEs usually occur within the first months after ICI initiation but can develop as early as after the first dose to years after ICI initiation. Most irAEs resolve pharmacologically, but some appear to be persistent. Glucocorticoids represent the mainstay of management of irAEs, but other immunosuppressive drugs can be used to mitigate refractory irAEs. In the absence of specific trials, several guidelines, based on data from retrospective studies and expert consensus, have been published to guide the management of ICI-related irAEs.
Collapse
Affiliation(s)
- Remo Poto
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gjada Criscuolo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | | | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,World Allergy Organization (WAO) Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| |
Collapse
|
49
|
Yaros K, Eksi B, Chandra A, Agusala K, Lehmann LH, Zaha Vlad G. Cardio-oncology imaging tools at the translational interface. J Mol Cell Cardiol 2022; 168:24-32. [DOI: 10.1016/j.yjmcc.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/03/2022] [Accepted: 03/27/2022] [Indexed: 10/18/2022]
|
50
|
Ronen D, Bsoul A, Lotem M, Abedat S, Yarkoni M, Amir O, Asleh R. Exploring the Mechanisms Underlying the Cardiotoxic Effects of Immune Checkpoint Inhibitor Therapies. Vaccines (Basel) 2022; 10:vaccines10040540. [PMID: 35455289 PMCID: PMC9031363 DOI: 10.3390/vaccines10040540] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/15/2022] [Accepted: 03/24/2022] [Indexed: 02/01/2023] Open
Abstract
Adaptive immune response modulation has taken a central position in cancer therapy in recent decades. Treatment with immune checkpoint inhibitors (ICIs) is now indicated in many cancer types with exceptional results. The two major inhibitory pathways involved are cytotoxic T-lymphocyte-associated protein 4 (CTLA4) and programmed cell death protein 1 (PD-1). Unfortunately, immune activation is not tumor-specific, and as a result, most patients will experience some form of adverse reaction. Most immune-related adverse events (IRAEs) involve the skin and gastrointestinal (GI) tract; however, any organ can be involved. Cardiotoxicity ranges from arrhythmias to life-threatening myocarditis with very high mortality rates. To date, most treatments of ICI cardiotoxicity include immune suppression, which is also not cardiac-specific and may result in hampering of tumor clearance. Understanding the mechanisms behind immune activation in the heart is crucial for the development of specific treatments. Histological data and other models have shown mainly CD4 and CD8 infiltration during ICI-induced cardiotoxicity. Inhibition of CTLA4 seems to result in the proliferation of more diverse T0cell populations, some of which with autoantigen recognition. Inhibition of PD-1 interaction with PD ligand 1/2 (PD-L1/PD-L2) results in release from inhibition of exhausted self-recognizing T cells. However, CTLA4, PD-1, and their ligands are expressed on a wide range of cells, indicating a much more intricate mechanism. This is further complicated by the identification of multiple co-stimulatory and co-inhibitory signals, as well as the association of myocarditis with antibody-driven myasthenia gravis and myositis IRAEs. In this review, we focus on the recent advances in unraveling the complexity of the mechanisms driving ICI cardiotoxicity and discuss novel therapeutic strategies for directly targeting specific underlying mechanisms to reduce IRAEs and improve outcomes.
Collapse
Affiliation(s)
- Daniel Ronen
- Department of Internal Medicine D, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Aseel Bsoul
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
| | - Michal Lotem
- Department of Oncology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Suzan Abedat
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
| | - Merav Yarkoni
- Department of Cardiology, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Offer Amir
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
- Department of Cardiology, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
| | - Rabea Asleh
- Cardiovascular Research Center, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel; (A.B.); (S.A.); (O.A.)
- Department of Cardiology, Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
- Correspondence: ; Tel.: +972-2-6776564; Fax: +972-2-6411028
| |
Collapse
|