Update on cardio-oncology: Novel cancer therapeutics and associated cardiotoxicities

Immune-Checkpoint Inhibitor-Related Myocarditis: Where We Are and Where We Will Go

Immune checkpoint inhibitors (ICIs) are specific monoclonal antibodies directed against inhibitory targets of the immune system, mainly represented by programmed death-1 (PD1) ligand-1 (PD-L1) and cytotoxic T-lymphocyte antigen-4 (CTLA-4), thus enabling an amplified T-cell-mediated immune response against cancer cells. These drugs have significantly improved prognosis in patients with advanced metastatic cancer (e.g., melanoma, non-small cell lung cancer, renal cell carcinoma). However, uncontrolled activation of anti-tumor T-cells could trigger an excessive immune response, possibly responsible for multi-organ damage, including, among others, lymphocytic myocarditis. The incidence of ICIs-induced myocarditis is underestimated and the patients affected are poorly characterized. The diagnosis and management of this condition are mainly based on expert opinion and case reports. EKG and ultrasound are tests that can help identify patients at risk of myocarditis during treatment by red flags, such as QRS complex enlargement and narrowing of global longitudinal strain (GLS). Therapy of ICI-related myocarditis is based on immunosuppressors, monoclonal antibodies and fusion proteins. A future strategy could involve the use of microRNAs. This review considers the current state of the art of immune-related adverse cardiovascular events, focusing on histological and clinical features, diagnosis and management, including current treatments and future pharmacological targets.

Cardio-Oncology and Heart Failure: A Scientific Statement from the Heart Failure Society of America

Heart failure and cancer remain two of the leading causes of morbidity and mortality and the two disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnosis and cancer survivors. Risk stratification, monitoring, and management of cardiotoxicity are presented across Stages A through D heart failure, with focused discussion on heart failure preserved ejection fraction and special populations such as survivors of childhood and young adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary team approach and critical collaboration between heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Discovery of Novel HDAC3 Inhibitors with PD-L1 Downregulating/Degrading and Antitumor Immune Effects

Targeting the programmed cell death-1/ligand 1 (PD-1/PD-L1) pathway is one of the most promising cancer treatment strategies. Studies have shown that HDAC inhibitors can enhance the antitumor immune response by modulating the expression of PD-L1. Herein, we designed and synthesized a series of novel hydrazide-based small molecule HDAC inhibitors; among them, compound HQ-30 showed selective HDAC3 inhibition (IC50 = 89 nM) and remarkable PD-L1-degrading activity (DC50 = 5.7 μM, Dmax = 80% at 10 μM). Further studies revealed that HQ-30 induced the degradation of PD-L1 by regulating cathepsin B (CTSB) in the lysosomes. Further, HQ-30 could enhance the infiltration of CD3+ CD4+ helper T and CD3+ CD8+ cytotoxic T cells in tumors, thus activating the tumor immune microenvironment. Moreover, HQ-30 possessed a benign toxicity profile (LD50 > 1000 mg/kg) and favorable pharmacokinetic properties (F = 57%). Taken together, HQ-30 is worthy of further investigation as a small molecule-based epigenetic modulator of tumor immunotherapy.

Complications and comorbidities associated with antineoplastic chemotherapy: Rethinking drug design and delivery for anticancer therapy

Despite the considerable advancements in chemotherapy as a cornerstone modality in cancer treatment, the prevalence of complications and pre-existing diseases is on the rise among cancer patients along with prolonged survival and aging population. The relationships between these disorders and cancer are intricate, bearing significant influence on the survival and quality of life of individuals with cancer and presenting challenges for the prognosis and outcomes of malignancies. Herein, we review the prevailing complications and comorbidities that often accompany chemotherapy and summarize the lessons to learn from inadequate research and management of this scenario, with an emphasis on possible strategies for reducing potential complications and alleviating comorbidities, as well as an overview of current preclinical cancer models and practical advice for establishing bio-faithful preclinical models in such complex context.

Treatment-related cardiovascular events in patients with non-small cell lung cancer: Evidence from real-world data with a competing risks approach

BACKGROUND

Understanding cancer treatment-related cardiovascular (CV) events is important for cancer care; however, comprehensive evaluation of CV events in patients with lung cancer is limited. This study aimed to assess the cumulative incidence and associated risks of various CV event types in patients with non-small cell lung cancer (NSCLC).

METHODS

A total of 7868 individuals aged 40 years and older, recently diagnosed with NSCLC (2007-2018), were assessed with data obtained from the National Cancer Center, Korea. This study included nine types of CV events. A 2-year cumulative incidence function (CIF) of CV events was estimated, with death as a competing event. The associated risks were assessed by subdistribution hazard ratio (sHR) in the Fine-Gray competing risks model.

RESULTS

CV events were observed in 7.8% of patients with NSCLC, with the most frequently observed types being atrial fibrillation and flutter (AF) (2.7%), venous thromboembolic disease (2.0%), and cerebrovascular disease (CeVD) (1.5%). Overall, all CV events were highest in the group treated with systemic therapy (CIF, 10.6%; 95% confidence interval [CI], 9.5%-11.8%), followed by those treated with surgery (CIF, 10.0%; 95% CI, 8.6%-11.6%); the incidence of AF (CIF, 5.7%; 95% CI, 4.6%-7.0%) was highest in patients treated with surgery. Individuals treated with systemic therapy were found to exhibit a higher CeVD risk than those treated with surgery (sHR, 4.12; 95% CI, 1.66-10.23). Among the patients who underwent surgery, those with lobectomy and pneumonectomy had a higher AF risk (vs. wedge resection/segmentectomy; sHR, 7.79; 95% CI, 1.87-32.42; sHR, 8.10; 95% CI, 1.60-40.89).

CONCLUSIONS

These findings revealed treatment-related CV event risks in patients with NSCLC, which suggests that the risk of AF in surgery and CeVD in systemic therapy should be paid more attention to achieve a better prognosis and improve cancer survivorship outcomes.

PLAIN LANGUAGE SUMMARY

Atrial fibrillation and flutter (AF) is the most common cardiovascular event, particularly at a high risk in patients with non-small cell lung cancer (NSCLC) undergoing surgery. Patients receiving surgery with poor performance status, diagnosed with regional stage, and undergoing lobectomy or pneumonectomy are at a high risk of AF. Systemic/radiotherapy is associated with cerebrovascular and ischemic heart disease in patients with NSCLC.

Novel insights into cardiovascular toxicity of cancer targeted and immune therapies: Beyond ischemia with non-obstructive coronary arteries (INOCA)

Novel immune and targeted therapies approved over the past 2 decades have resulted in dramatic improvements in cancer-specific outcomes for many cancer patients. However, many of these agents can induce cardiovascular toxicity in a subset of patients. The field of cardio-oncology was established based on observations that anti-neoplastic chemotherapies and mantle radiation can lead to premature cardiomyopathy in cancer survivors. While conventional chemotherapy, targeted therapy, and immune therapies can all result in cardiovascular adverse events, the mechanisms, timing, and incidence of these events are inherently different. Many of these effects converge upon the coronary microvasculature to involve, through endocardial endothelial cells, a more direct effect through close proximity to cardiomyocyte with cellular communication and signaling pathways. In this review, we will provide an overview of emerging paradigms in the field of Cardio-Oncology, particularly the role of the coronary microvasculature in mediating cardiovascular toxicity of important cancer targeted and immune therapies. As the number of cancer patients treated with novel immune and targeted therapies grows exponentially and subsequently the number of long-term cancer survivors dramatically increases, it is critical that cardiologists and cardiology researchers recognize the unique potential cardiovascular toxicities of these agents.

Cardio-oncology: Shared Genetic, Metabolic, and Pharmacologic Mechanism

PURPOSE OF REVIEW

The article aims to investigate the complex relationship between cancer and cardiovascular disease (CVD), with a focus on the effects of cancer treatment on cardiac health.

RECENT FINDINGS

Advances in cancer treatment have improved long-term survival rates, but CVD has emerged as a leading cause of morbidity and mortality in cancer patients. The interplay between cancer itself, treatment methods, homeostatic changes, and lifestyle modifications contributes to this comorbidity. Recent research in the field of cardio-oncology has revealed common genetic mutations, risk factors, and metabolic features associated with the co-occurrence of cancer and CVD. This article provides a comprehensive review of the latest research in cardio-oncology, including common genetic mutations, risk factors, and metabolic features, and explores the interactions between cancer treatment and CVD drugs, proposing novel approaches for the management of cancer and CVD.

The Intersection of Prostate Cancer and Hypertension: a Call to Action

OPINION STATEMENT

With improvements in treatment and survival from prostate cancer, comorbid cardiac conditions will significantly impact overall morbidity and mortality from prostate cancer. Hypertension is a well-established cardiovascular risk factor that increases the risk of heart failure, myocardial infarction, and stroke. Therapies used in the treatment of prostate cancer, including GnRH agonists, GnRH antagonists, enzalutamide, abiraterone, and others, can directly or indirectly increase the risk of hypertension. In this paper, we review the evidence available on the incidence and mechanism of hypertension in prostate cancer patients. In addition, we provide recommendations on the assessment, treatment, and future directions for hypertension management in the prostate cancer population. We propose an individualized goal for blood pressure in prostate cancer patients, balancing the target goal of 130/80 mmHg with common comorbidities of frailty, orthostatic symptoms, and imbalance in this population. The presence of additional comorbidities (myocardial infarction, heart failure, renal disease, diabetes) can assist in preference of anti-hypertensive drugs.

Ventricular Arrhythmia in Cancer Patients: Mechanisms, Treatment Strategies and Future Avenues

Cardiovascular disease and cancer are the leading causes of morbidity and mortality in the US. Despite the significant progress made in cancer treatment leading to improved prognosis and survival, ventricular arrhythmias (VA) remain a known cardiovascular complication either exacerbated or induced by the direct and indirect effects of both traditional and novel cancer treatments. Although interruption of cancer treatment because of VA is rarely required, knowledge surrounding this issue is essential for optimising the overall care of patients with cancer. The mechanisms of cancer-therapeutic-induced VA are poorly understood. This review will discuss the ventricular conduction (QRS) and repolarisation abnormalities (QTc prolongation), and VAs associated with cancer therapies, as well as existing strategies for the identification, prevention and management of cancer-treatment-induced VAs.

A real-world study to assess the association of cardiovascular adverse events (CVAEs) with ibrutinib as first-line (1L) treatment for patients with chronic lymphocytic leukaemia (CLL) in the United States

Ibrutinib, a Bruton's tyrosine kinase inhibitor, is often used as first-line (1L) treatment of chronic lymphocytic leukaemia (CLL); however, it is associated with an increased risk for cardiovascular adverse events (CVAEs). This real-world study adds to existing literature by simultaneously investigating the correlation between pre-existing CV risk factors and the relative cardiotoxicity of ibrutinib vs other therapies in CLL/small lymphocytic lymphoma (SLL). Using a real-world database, the risk of subsequent CVAEs (any CVAE, atrial fibrillation [AF], or hypertension) were compared among patients who received 1L ibrutinib monotherapy or another type of non-ibrutinib therapy, grouped as intensive (IT) or non-intensive therapy (NIT). Each patient's baseline CV risk was estimated using the Framingham risk score. Inverse probability treatment weighting was incorporated into a logistic regression model to reduce baseline imbalance. Results showed ibrutinib was significantly associated with higher risk of CVAEs regardless of baseline CV risk. Compared with IT, odds ratios of any CVAE, hypertension, or AF were 2.61, 3.66, and 3.02, respectively vs 1.88, 2.13, and 2.46, respectively, with NIT. Sensitivity analyses confirmed the findings were robust. These results suggest clinical caution should be taken when selecting ibrutinib for patients with CLL/SLL, especially in those with high baseline CV risk.

Cardiac Biomarkers for the Detection and Management of Cancer Therapy-Related Cardiovascular Toxicity

Cardiotoxicity is one of the major side effects of anti-cancer therapy affecting the overall prognosis of patients and possibly leading to the discontinuation of chemotherapy. Traditional cardiovascular tests such as electrocardiography and transthoracic echocardiography have limited sensitivity and specificity for the early detection of myocardial injury. Cardiovascular imaging generally detects cancer therapy-related cardiac dysfunction (CTRCD) at advanced stages, whereas biomarkers are inexpensive, easily detected, reproducible, and capable of detecting even minimal cardiomyocyte damage or mild hemodynamic fluctuations. The presence of circulating cardiac biomarkers has been investigated as early indicators of cardiotoxicity and predictors of subsequent CTRCD. Currently, the most frequently used cardiac biomarkers are cardiac troponin (cTn) and natriuretic peptides (NPs). This review presents the evidence gathered so far regarding the usefulness and limitations of cardiac biomarkers in the field of cardio-oncology.

Cardio-oncology in Austria: cardiotoxicity and surveillance of anti-cancer therapies : Position paper of the Heart Failure Working Group of the Austrian Society of Cardiology

Survival in cancer is continuously improving due to evolving oncological treatment. Therefore, cardiovascular short-term and long-term side effects gain crucial importance for overall outcome. Cardiotoxicity not only presents as heart failure, but also as treatment-resistant hypertension, acute coronary ischemia with plaque rupture or vasospasm, thromboembolism, arrhythmia, pulmonary hypertension, diastolic dysfunction, acute myocarditis and others. Recent recommendations have proposed baseline cardiac risk assessment and surveillance strategies. Major challenges are the availability of monitoring and imaging resources, including echocardiography with speckle tracking longitudinal strain (GLS), serum biomarkers such as natriuretic peptides (NT-proBNP) and highly sensitive cardiac troponins. This Austrian consensus encompasses cardiotoxicity occurrence in frequent antiproliferative cancer drugs, radiotherapy, immune checkpoint inhibitors and cardiac follow-up considerations in cancer survivors in the context of the Austrian healthcare setting. It is important to optimize cardiovascular risk factors and pre-existing cardiac diseases without delaying oncological treatment. If left ventricular ejection fraction (LVEF) deteriorates during cancer treatment (from >10% to <50%), or myocardial strain decreases (>15% change in GLS), early initiation of cardioprotective therapies (angiotensin-converting enzyme inhibitors, angiotensin or beta receptor blockers) is recommended, and LVEF should be reassessed before discontinuation. Lower LVEF cut-offs were recently shown to be feasible in breast cancer patients to enable optimal anticancer treatment. Interdisciplinary cardio-oncology cooperation is pivotal for optimal management of cancer patients.

Management of Acute Coronary Syndrome in Cancer Patients: It's High Time We Dealt with It

Cancer patients have an increased risk of cardiovascular disease and, notably, a significant prevalence of acute coronary syndrome (ACS). It has been shown that an elevated presence of cardiovascular risk factors in this setting leads to an interaction between these two conditions, influencing their therapeutic strategies and contributing to higher mortality. Nonetheless, cancer patients have generally not been evaluated in ACS trials, so that the treatment in these cases is still not fully known. We reviewed the current literature and discussed the best management for these very high-risk patients. The treatment strategy must be tailored based on the cancer type and stage, balancing thrombotic and bleeding risks. When the prognosis is longer than six months, especially if a clinical instability coexists, patients with ACS and cancer should be referred for percutaneous coronary intervention (PCI) as soon as possible. Moreover, an invasive strategy should be preferred in STEMI patients as well as in NSTEMI patients who are considered as high risk. On the contrary, in clinically stable NSTEMI patients, a conservative non-invasive strategy could be adopted, especially in cases of a poor life expectancy and/or of high risk of bleeding. Drug-Eluting-Stents (DES) should be the first choice if an invasive strategy is adopted. Conservative therapy could instead be considered in cancer patients with more stable CAD at an increased risk of major bleeding complications. However, the duration of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended, but it should be as short as possible, whereas triple antithrombotic therapy is non-advised because it significantly increases the risk of bleeding. ACS management among cancer patients should be based on an accurate evaluation of the risk of thrombosis and bleeding. Future studies focused on choosing optimal strategies in tumor patients with ACS should be performed to treat this subset of patients better.

Relationship Between Serum Concentration of Adrenomedullin and Myocardial Ischemic T Wave Changes in Patients With Lung Cancer

Background

Patients with lung cancer are at increased risk for the development of cardiovascular diseases. Molecular markers for early diagnosis of cardiac ischemia are of great significance for the early prevention of cardiovascular events in patients with lung cancer. By evaluating the relationship between adrenomedullin (ADM) and myocardial ischemic T wave changes, the clinical value of circulating ADM as a predictor of myocardial ischemia in patients with lung cancer is confirmed.

Methods

We enrolled patients with lung cancer and healthy people from 2019 to 2021 and extracted a detailed ECG parameter. After adjustment for potential confounders, logistic regression was used to assess the association of clinical data. We performed analyses on differences in T wave between patients with lung cancer and healthy people, and the relationship between T wave and ADM among patients with lung cancer. Receiver operator characteristic (ROC) curves were drawn to confirm the diagnostic value of biomarkers.

Results

After adjusting for potential confounders, the incidence of T wave inversion or flattening in patients with lung cancer was higher than in healthy people (OR: 3.3228, P = 0.02). Also, further analysis of the data of lung cancer patients revealed that the ADM in lung cancer patients with T wave inversion or flat was higher than those with normal T wave (189.8 ± 51.9 vs. 131.9 ± 38.4, p < 0.001). The area under the ROC curve was 0.8137.

Conclusion

Among the patients with lung cancer, serum ADM concentration is associated with the incidence of the abnormal T wave. ADM might be a potentially valuable predictor for heart ischemia in patients with lung cancer.

Discovery of Novel Histone Deacetylase 6 (HDAC6) Inhibitors with Enhanced Antitumor Immunity of Anti-PD-L1 Immunotherapy in Melanoma

A series of 2-phenylthiazole analogues were designed and synthesized as potential histone deacetylase 6 (HDAC6) inhibitors based on compound 12c (an HDAC6/tubulin dual inhibitor discovered by us recently) and CAY10603 (a known HDAC6 inhibitor). Among them, compound XP5 was the most potent HDAC6 inhibitor with an IC50 of 31 nM and excellent HDAC6 selectivity (SI = 338 for HDAC6 over HDAC3). XP5 also displayed high antiproliferative activity against various cancer cell lines including the HDACi-resistant YCC3/7 gastric cancer cells (IC50 = 0.16-2.31 μM), better than CAY10603. Further, XP5 (50 mg/kg) exhibited significant antitumor efficacy in a melanoma tumor model with a tumor growth inhibition (TGI) of 63% without apparent toxicity. Moreover, XP5 efficiently enhanced the in vivo antitumor immune response when combined with a small-molecule PD-L1 inhibitor, as demonstrated by the increased tumor-infiltrating lymphocytes and reduced PD-L1 expression levels. Taken together, the above results suggest that XP5 is a promising HDAC6 inhibitor deserving further investigation.

Incidence and Risk of Hypertension in Cancer Patients Treated With Atezolizumab and Bevacizumab: A Systematic Review and Meta-Analysis

PURPOSE

This study aims to inform previous clinical assessments to better understand the total risk of hypertension with atezolizumab and bevacizumab (hereafter referred to as "A-B") in cancer patients, and reduce future incidence of hypertension-related cardiovascular complications.

METHODS

Databases, including PubMed, Embase, Cochrane, and Web of Science were searched to identify relevant studies, which were retrieved from inception to March 6, 2021. Studies focused on cancer patients treated with A-B that provided data on hypertension were included. Statistical analyses were conducted to calculate hypertension incidence and relative risk (RR) with a random-effects or fixed-effects model, hinging on heterogeneity status.

RESULTS

Ten studies including 2106 patients with renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), ovarian cancer, anal cancer, neuroendocrine tumors (NETs), and cervical cancer were selected for this meta-analysis. For patients treated with A-B, the all-grade and high-grade (grade 3) hypertension incidence were 31.1% (95% CI: 25.5-37.3) and 14.1% (95% CI: 10.9-18.1), respectively. No significant difference was observed in all-grade hypertension incidence between RCC and a non-RCC patients (32.9% [95% CI: 25.3-42.6] v.s. 29.2% [95% CI: 19.7-39.6)]). However, the number of high-grade hypertension incidence in RCC patients (9.4% [95% CI: 4.1-21.3]) was lower than that of non-RCC patients (15.6% [95% CI: 12.8-19.1]). RCC or HCC patients who received the A-B treatment were associated with significantly increased risk of all-grade hypertension with a RR of 7.22 (95% CI: 3.3-15.7; p = 0.6) compared with patients treated with atezolizumab.

CONCLUSIONS

Cancer Patients treated with atezolizumab and bevacizumab have a significantly increased risk of hypertension. Sufficient monitoring is highly recommended to prevent the consequences of treatment-induced hypertension and other cardiovascular complications.

A quantitative systems pharmacology approach to predict the safe-equivalent dose of doxorubicin in patients with cardiovascular comorbidity

Patients with cardiovascular comorbidity are less tolerant to cardiotoxic drugs and should be treated with reduced doses to prevent cardiotoxicity. However, the safe‐equivalent dose of antitumor drugs in patients with cardiovascular disease/risk is difficult to predict because they are usually excluded from clinical trials as a result of ethical considerations. In this study, a translational quantitative system pharmacology‐pharmacokinetic‐pharmacodynamic (QSP‐PK‐PD) model was developed based on preclinical study to predict the safe‐equivalence dose of doxorubicin in patients with or without cardiovascular disease. Virtual clinical trials were conducted to validate the translational QSP‐PK‐PD model. The model replicated several experimental and clinical observations: the left ventricular ejection fraction (LVEF) was reduced and the left ventricular end‐diastolic volume (LVEDV) was elevated in systolic dysfunction rats, the LVEF was preserved and LVEDV reduced in diastolic dysfunction rats, and patients with preexisting cardiovascular disease were more vulnerable to doxorubicin‐induced cardiac dysfunction than cardiovascular healthy patients. A parameter sensitivity analysis showed that doxorubicin‐induced cardiovascular dysfunction was mainly determined by the sensitivity of cardiomyocytes to cardiotoxic drugs and the baseline value of LVEDV, reflected in LVEF change percentage from the baseline. Blood pressure was the least sensitive factor affecting doxorubicin‐induced cardiotoxicity.

Efficient Synthesis and Bioevaluation of Novel Dual Tubulin/Histone Deacetylase 3 Inhibitors as Potential Anticancer Agents

Novel dual HDAC3/tubulin inhibitors were designed and efficiently synthesized by combining the pharmacophores of SMART (tubulin inhibitor) and MS-275 (HDAC inhibitor), among which compound 15c was found to be the most potent and balanced HDAC3/tubulin dual inhibitor with high HDAC3 activity (IC50 = 30 nM) and selectivity (SI > 1000) as well as excellent antiproliferative potency against various cancer cell lines, including an HDAC-resistant gastric cancer cell line (YCC3/7) with IC50 values in the range of 30-144 nM. Compound 15c inhibited B16-F10 cancer cell migration and colony formation. In addition, 15c demonstrated significant in vivo antitumor efficacy in a B16-F10 melanoma tumor model with a better TGI (70.00%, 10 mg/kg) than that of the combination of MS-275 and SMART. Finally, 15c presented a safe cardiotoxicity profile and did not cause nephro-/hepatotoxicity. Collectively, this work shows that compound 15c represents a novel tubulin/HDAC3 dual-targeting agent deserving further investigation as a potential anticancer agent.

Cardiovascular Complications Associated with Contemporary Lung Cancer Treatments

OPINION STATEMENT

Lung cancer is the most common form of cancer in humans and the leading cause of cancer-related death worldwide. Traditionally, lung cancer has been diagnosed as either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC). However, recent developments in molecular pathology have revolutionized the diagnosis and treatment of the disease, thus improving patient prognosis and increasing the number of survivors. In advanced NSCLC cases, molecularly targeted drugs for patients with positive driver gene mutation/rearrangement, and immune checkpoint inhibitors for those with a positive biomarker, have changed the standard of care. SCLC is a highly malignant entity. In addition to the chemotherapy and radiotherapy, immune checkpoint inhibitors have recently provided some hope for extended-stage SCLC. Smoking cessation is related to decreased morbidity. However, early metastasis remains a significant challenge. Recently, cancer therapy-related cardiovascular disease (CTRCD) has emerged as diverse pathophysiology, including fulminant myocarditis, fatal arrhythmia, pericarditis, hypertension, and thrombosis, that emerged with modern lung cancer therapies. Cardio-oncology is a new interdisciplinary collaboration to develop methodologies to manage cardiovascular risk factors and CTRCDs with the common goal of minimizing unnecessary interruption of cancer treatment and maximizing outcomes of lung cancer survivors.

Cancer treatment-related cardiovascular disease: Current status and future research priorities

With the development of new drugs, such as molecular-targeted drugs, and multidisciplinary therapies, cancer treatment outcomes have improved, and the number of cancer survivors is increasing every year. However, some chemotherapeutic agents cause cardiovascular complications (cancer treatment-related cardiovascular disease, CTRCVD), which affect the life prognosis and quality of life (QOL) of cancer patients. Therefore, it is necessary to select treatment methods that take into account the prognosis and QOL of cancer patients, and to take measures against CTRCVD. The mechanism of cardiotoxicity of high-risk drugs, such as doxorubicin and HER2 inhibitors, are still unclear; genetic factors, and cardiovascular disease risk factors (e.g., hypertension, dyslipidemia, and diabetes) are associated with CTRCVD progression. The establishment of methods for prevention, early diagnosis, and treatment of CTRCVD and the generation of evidence for these methods are needed. It is also necessary to develop screening methods for chemotherapy cardiotoxicity. In this review, we discuss the current status of CTRCVD, its complications, and expected countermeasures.

Hypertension and Prohypertensive Antineoplastic Therapies in Cancer Patients

The development of a wide range of novel antineoplastic therapies has improved the prognosis for patients with a wide range of malignancies, which has increased the number of cancer survivors substantially. Despite the oncological benefit, cancer survivors are exposed to short- and long-term adverse cardiovascular toxicities associated with anticancer therapies. Systemic hypertension, the most common comorbidity among cancer patients, is a major contributor to the increased risk for developing these adverse cardiovascular events. Cancer and hypertension have common risk factors, have overlapping pathophysiological mechanisms and hypertension may also be a risk factor for some tumor types. Many cancer therapies have prohypertensive effects. Although some of the mechanisms by which these antineoplastic agents lead to hypertension have been characterized, further preclinical and clinical studies are required to investigate the exact pathophysiology and the optimal management of hypertension associated with anticancer therapy. In this way, monitoring and management of hypertension before, during, and after cancer treatment can be improved to minimize cardiovascular risks. This is vital to optimize cardiovascular health in patients with cancer and survivors, and to ensure that advances in terms of cancer survivorship do not come at the expense of increased cardiovascular toxicities.

Concepts in cardiac oncology

Cardiac oncology is a subspecialty of cardiology engaging cardiologists and oncologists alike, in order to provide the best possible oncologic treatment for patients at high cardiovascular risk or developing cardio-toxicity during the course of their treatment, thus avoiding discontinuing it, and aiming at improving survival and quality of life. Early diagnosis and the effectiveness of the newer cancer treatments delivered an increasing number of long-term survivors (presently almost 30 million worldwide), at high risk of developing cardiovascular diseases. This predisposition has been correlated not only to the toxic side effects of the oncologic treatment but also to a real vulnerability to the risk factors in this patients population. For decades, the concept of cardio-toxicity in cardiac oncology has been restricted to ventricular dysfunction, but during the last few years the Food and Drug Administration has approved hundreds of new molecules and cardiac oncology has escalated its complexity. The introduction of new target therapy, proteasome inhibitors, immuno-modulators, and inhibitors of the immunitary checkpoint, magnified the concept of cardio-toxicity to a wider definition of ‘cardiovascular toxicity’ incorporating arterial hypertension, ischaemia, cardiomyopathy, myocarditis, arrhythmic complications, long QT, and arterial and venous thrombosis. We are still lacking guidelines on the new and varied forms of toxicity, as well as monitoring strategies in the short- and long-term follow-up.

Toxicities Associated with Immunotherapy and Approach to Cardiotoxicity with Novel Cancer Therapies

In recent years, major advances in oncology especially the advent of targeted agents and immunotherapies (immune checkpoint inhibitors [ICIs] and chimeric antigen receptor [CAR] T-cell therapy) have led to improved quality of life and survival rates in patients with cancer. This article focuses on the clinical features, and grading and management of toxicities associated with ICIs and CAR T-cell therapy. In addition, because cardiotoxicity is one of the most harmful effects of anticancer therapeutics, we describe the risk factors and mechanisms of cardiovascular injury associated with newer agents, screening technologies for at-risk patients, and preventive and treatment strategies.

Hypertensive Cardiotoxicity in Cancer Treatment-Systematic Analysis of Adjunct, Conventional Chemotherapy, and Novel Therapies-Epidemiology, Incidence, and Pathophysiology

Cardiotoxicity is the umbrella term for cardiovascular side effects of cancer therapies. The most widely recognized phenotype is left ventricular dysfunction, but cardiotoxicity can manifest as arrhythmogenic, vascular, myocarditic and hypertensive toxicities. Hypertension has long been regarded as one of the most prevalent and modifiable cardiovascular risk factors in the general population, but its relevance during the cancer treatment journey may be underestimated. Hypertensive cardiotoxicity occurs de novo in a substantial proportion of treated cancer patients. The pathology is incompletely characterized—natriuresis and renin angiotensin system interactions play a role particularly in conventional treatments, but in novel therapies endothelial dysfunction and the interaction between the cancer and cardiac kinome are implicated. There exists a treatment paradox in that a significant hypertensive response not only mandates anti-hypertensive treatment, but in fact, in certain cancer treatment scenarios, hypertension is a predictor of cancer treatment efficacy and response. In this comprehensive review of over 80,000 patients, we explored the epidemiology, incidence, and mechanistic pathophysiology of hypertensive cardiotoxicity in adjunct, conventional chemotherapy, and novel cancer treatments. Conventional chemotherapy, adjunct treatments, and novel targeted therapies collectively caused new onset hypertension in 33–68% of treated patients. The incidence of hypertensive cardiotoxicity across twenty common novel therapies for any grade hypertension ranged from 4% (imatinib) to 68% (lenvatinib), and high grade 3 or 4 hypertension in <1% (imatinib) to 42% (lenvatinib). The weighted average effect was all-grade hypertension in 24% and grade 3 or 4 hypertension in 8%.

Impact of cytokine release syndrome on cardiac function following CD19 CAR-T cell therapy in children and young adults with hematological malignancies

Background

Chimeric antigen receptor (CAR) T-cell-associated cytokine release syndrome (CRS) may present with tachycardia, hemodynamic instability and reduced cardiac function. Pediatric CAR studies examining cardiac toxicity are limited.

Methods

We report on cardiac toxicity observed in children and young adults with hematologic malignancies enrolled in a CD19-28ζ CAR T-cell phase I trial (NCT01593696). All patients had a formal baseline echocardiogram. Real-time studies included echocardiograms on intensive care unit (ICU) transfer, and serial troponin and pro-B-type natriuretic peptide (pro-BNP) in the select patients.

Results

From July 2012 to March 2016, 52 patients, with a median age of 13.4 years (range 4.2–30.3) were treated. CRS developed in 37/52 (71%), which was grade 3–4 CRS in nine patients (17%). The median prior anthracycline exposure was 205 mg/m² (range 70–620 mg/m²) in doxorubicin equivalents. The median baseline left ventricle ejection fraction (LVEF) and baseline LV global longitudinal strain (GLS) were 60% (range 50%–70%) and 16.8% (range 14.1%–23.5%, n=37) respectively. The majority, 78% (29/37), of patients had a reduced GLS <19% at baseline, and 6% (3/52) of patients had baseline LVEF <53%. ICU transfers occurred in 21 patients, with nine requiring vasoactive hemodynamic support and three necessitating >1 vasopressor. Six (12%) patients developed cardiac dysfunction (defined by >10% absolute decrease in LVEF or new-onset grade 2 or higher LV dysfunction, per CTCAE v4), among whom 4 had grade 3–4 CRS. Troponin elevations were seen in 4 of 13 patients, all of whom had low LVEF. Pro-BNP was elevated from baseline in 6/7 patients at the onset of CRS, with higher levels correlating with more severe CRS. Cardiac dysfunction fully resolved in all but two patients by day 28 post-CAR.

Conclusion

Cardiac toxicity related to CD19-28ζ CAR T-cell-associated CRS was generally reversible by day 28 postinfusion. Implementation of more frequent monitoring with formal echocardiograms incorporating systemic analysis of changes in GLS, and cardiac biomarkers (troponin and proBNP) may help to earlier identify those patients at highest risk of severe cardiac systolic dysfunction, facilitating earlier interventions for CRS to potentially mitigate acute cardiac toxicity.

The Role of Biomarkers in Cardio-Oncology

In the field of cardio-oncology, it is well recognised that despite the benefits of chemotherapy in treating and possibly curing cancer, it can cause catastrophic damage to bystander tissues resulting in a range of potentially of life-threatening cardiovascular toxicities, and leading to a number of damaging side effects including heart failure and myocardial infarction. Cardiotoxicity is responsible for significant morbidity and mortality in the long-term in oncology patients, specifically due to left ventricular dysfunction. There is increasing emphasis on the early use of biomarkers in order to detect the cardiotoxicity at a stage before it becomes irreversible. The most important markers of cardiac injury are cardiac troponin and natriuretic peptides, whilst markers of inflammation such as interleukin-6, C-reactive protein, myeloperoxidase, Galectin-3, growth differentiation factor-15 are under investigation for their use in detecting cardiotoxicity early. In addition, microRNAs, genome-wide association studies and proteomics are being studied as novel markers of cardiovascular injury or inflammation. The aim of this literature review is to discuss the evidence base behind the use of these biomarkers for the detection of cardiotoxicity.

A Series of Novel HDAC Inhibitors with Anthraquinone as a Cap Group

Although anthraquinone derivatives possess significant antitumor activity, most of them also displayed those side effects like cardiotoxicity, mainly owing to their inhibition of topoisomerase II of DNA repair mechanisms. Our raised design strategy by switching therapeutic target from topoisomerase II to histone deacetylase (HDAC) has been applied to the design of anthraquinone derivatives in current study. Consequently, a series of novel HDAC inhibitors with a tricylic diketone of anthraquinone as a cap group have been synthesized. After screening and evaluation, compounds 4b, 4d, 7b and 7d have displayed the comparable inhibition in enzymatic activity and cell proliferation than that of Vorinostat (SAHA). Notably, compound 4b showed certain selectivity of antiproliferative effects on cancer cell lines over non-cancer cell lines.

Clinical Practice and Research in Cardio-Oncology: Finding the "Rosetta Stone" for Establishing Program Excellence in Cardio-oncology

The burgeoning field of cardio-oncology (C-O) is now necessary for the delivery of excellent care for patients with cancer. Many factors have contributed to this increasing population of cancer survivors or those being treated with novel and targeted cancer therapies. There is a tremendous need to provide outstanding cardiovascular (CV) care for these patients; however, current medical literature actually provides a paucity of guidance. C-O therefore provides a novel opportunity for clinical, translational, and basic research to advance patient care. This review aims to be a primer for cardio-oncologists on how to develop a vibrant and comprehensive C-O program, use practical tools to assist in the construction of C-O services, and to proactively incorporate translational and clinical research into the training of future leaders as well as enhance clinical care.

Bibliometric Analysis of the Results of Cardio-Oncology Research

Objective

To analyze the development of cardio-oncology, summarize the research achievements, and provide proposals for its future research.

Methods

The web of science database was used to search for “cardio-oncology” and “oncocardiology” related articles from the beginning of the database (1970) to April 5, 2019. Excel 2016 and Cytoscape were used to analyze the trend of cardio-oncology research.

Results

A total of 356 articles were obtained. The number of articles has grown rapidly in recent years. Cardiac injury caused by tumor therapy was a research hotspot (n = 107). Researchers paid more attention to the prevention and treatment of cardiotoxicity (n = 54). Experimental researches were a small part of all studies (n = 72), mainly focusing on the study of cancer drugs' cardiac injury, test indicators of cardiotoxicity, and preventive drugs. The United States (n = 156.25), Italy (n = 48.5), and Canada (n = 23.5) published the most articles, making a great contribution to the development of cardio-oncology.

Conclusions

Cardio-oncology has been developing rapidly and receiving a large amount of research efforts in recent years. Most articles on cardio-oncology were published by the authors from the United States (44%) and Italy (17%), while other countries need to pay more attention to cardio-oncology. As an independent discipline, cardio-oncology is certainly in need of significant progress, but it has formed a basic framework, which has obtained many leading theories and meaningful achievements in diagnostic criteria, diagnostic methods, prevention and treatment, mechanism research, and influencing factor. Cardiac injury of tumor drugs has always been a research hotspot in this discipline, and there is still a lot of research space. The research about detection methods of cardiotoxicity and preventive drugs is gradually increasing. Basic research lags behind, and many mechanisms are still unclear.

[Clinical pharmacology of cardio-oncology: a novel interdisciplinary platform for basic and translational research]

Advances in cancer treatment have led to dramatic increase in cancer survivors. In addition to cardiotoxicity resulting from anthracyclines and radiation therapy, the emergence of novel cancer treatment-related cardiovascular disease (CTRCD) with molecularly targeted therapies and immune checkpoint inhibitors has been recognized as an unmet medical need. Cardio-oncology is a new interdisciplinary research opportunity at the intersection of cardiovascular disease and cancer. Research priorities need to be identified for diagnosis, treatment, and prevention of previously unknown CTRCD(s), including (a) cardiac dysfunction and heart failure, (b) coronary artery disease, (c) valvular disease, (d) arrhythmias and QT-prolongation, (e) arterial hypertension, (f) thromboembolic disease, and (g) other cardiovascular disorders. In particular, understanding the fundamental mechanisms underlying CTRCD is essential for developing new methods. Applying more appropriate disease models and more effective methods for toxicity screening will help to better understand CTRCD. Although animal models have been used to predict potential problems, more advanced predictive models are also needed. Biobanks and other specimens with patient registries are expected to facilitate the validation of new biomarkers, genomic analysis, and imaging methods.

Risk Profiling of Cancer Treatment-Related Cardiovascular Disorders in Breast Cancer Patients Who Received Adjuvant Chemotherapy With Trastuzumab

Background: The prognosis of cancer survivors has dramatically improved, but effective strategies for cancer treatment-related cardiovascular disorders (CTRCD) remain to be elucidated in the emerging field of cardio-oncology. In this study, we investigated risk factors for CTRCD in breast cancer patients treated with trastuzumab. Methods and Results: We performed a retrospective analysis of 141 consecutive women who received adjuvant trastuzumab, and underwent baseline (BL) and follow-up (FU) echocardiography at Juntendo University between April 2010 and December 2016. The major concomitant treatment was anthracyclines in 94% and radiotherapy in 53%. During the median treatment period of 11 months, there were 22 (15.6%) cardiology consultations, 3 (2.1%) treatment interruptions with irreversible CTRCD, and no deaths. Left ventricular ejection fraction (LVEF) was decreased from a median 67.5% (BL) to 63.4% (FU; P<0.0001), with reduced LVEF noted in 26.2% at FU<90%BL, in 13.5% at FU Collapse

Key Words

• Breast cancer
• Cancer treatment-related cardiovascular disorder
• Cardio-oncology
• Cardiovascular risk factor
• Trastuzumab

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Affiliation(s)

Hiromi Shinano Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University Tokyo Japan
Sakiko Miyazaki Department of Cardiovascular Medicine, Graduate School of Medicine, Juntendo University Tokyo Japan
Kayo Miura Department of Breast and Endocrine Surgery, Graduate School of Medicine, Juntendo University Tokyo Japan
Hiroshi Ohtsu Leading Center for the Development and Research of Cancer Medicine, Juntendo University Tokyo Japan Center for Clinical Sciences, Department of Data Science, National Center for Global Health and Medicine Tokyo Japan Institute for Medical Regulatory Science, Organization for University Research Initiatives, Waseda University Tokyo Japan
Naohiro Yonemoto Innovative Medical Technology Research & Development Center, Juntendo University Tokyo Japan Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry Tokyo Japan
Kiyoshi Matsuoka Innovative Medical Technology Research & Development Center, Juntendo University Tokyo Japan Center for Clinical Sciences, Department of Data Science, National Center for Global Health and Medicine Tokyo Japan
Hakuou Konishi Department of Cardiovascular Medicine, Graduate School of Medicine, Juntendo University Tokyo Japan
Hiroyuki Daida Department of Cardiovascular Medicine, Graduate School of Medicine, Juntendo University Tokyo Japan Innovative Medical Technology Research & Development Center, Juntendo University Tokyo Japan
Mitsue Saito Department of Breast and Endocrine Surgery, Graduate School of Medicine, Juntendo University Tokyo Japan
Kazuhiro Sase Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University Tokyo Japan Institute for Medical Regulatory Science, Organization for University Research Initiatives, Waseda University Tokyo Japan

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Emerging Challenges of Radiation-Associated Cardiovascular Dysfunction (RACVD) in Modern Radiation Oncology: Clinical Practice, Bench Investigation, and Multidisciplinary Care

Radiotherapy (RT) is a crucial treatment modality in managing cancer patients. However, irradiation dose sprinkling to tumor-adjacent normal tissues is unavoidable, generating treatment toxicities, such as radiation-associated cardiovascular dysfunction (RACVD), particularly for those patients with combined therapies or pre-existing adverse features/comorbidities. Radiation oncologists implement several efforts to decrease heart dose for reducing the risk of RACVD. Even applying the deep-inspiration breath-hold (DIBH) technique, the risk of RACVD is though reduced but still substantial. Besides, available clinical methods are limited for early detecting and managing RACVD. The present study reviewed emerging challenges of RACVD in modern radiation oncology, in terms of clinical practice, bench investigation, and multidisciplinary care. Several molecules are potential for serving as biomarkers and therapeutic targets. Of these, miRNAs, endogenous small non-coding RNAs that function in regulating gene expression, are of particular interest because low-dose irradiation, i.e., 200 mGy (one-tenth of conventional RT daily dose) induces early changes of pro-RACVD miRNA expression. Moreover, several miRNAs, e.g., miR-15b and miR21, involve in the development of RACVD, further demonstrating the potential bio-application in RACVD. Remarkably, many RACVDs are late RT sequelae, characterizing highly irreversible and progressively worse. Thus, multidisciplinary care from oncologists and cardiologists is crucial. Combined managements with commodities control (such as hypertension, hypercholesterolemia, and diabetes), smoking cessation, and close monitoring are recommended. Some agents show abilities for preventing and managing RACVD, such as statins and angiotensin-converting enzyme inhibitors (ACEIs); however, their real roles should be confirmed by further prospective trials.

Contemporary Trends and Outcomes of Percutaneous and Surgical Aortic Valve Replacement in Patients With Cancer

Background

Patients with cancer and severe aortic stenosis are often ineligible for surgical aortic valve replacement (SAVR). Patients with cancer may likely benefit from emerging transcatheter aortic valve replacement (TAVR), given its minimally invasive nature.

Methods and Results

The US‐based National Inpatient Sample was queried between 2012 and 2015 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM), codes to identify all hospitalized adults (aged ≥50 years), who had a primary diagnosis of aortic stenosis. We examined the effect modification of cancer on the relative use rate, outcomes, and dispositions associated with propensity‐matched cohort TAVR versus SAVR. Overall, 47 295 TAVRs (22.6% comorbid cancer) and 113 405 SAVRs (15.2% comorbid cancer) were performed among admissions with aortic stenosis between 2012 and 2015. In the year 2015, patients with cancer saw relatively higher rates of TAVR use compared with SAVR (relative use rate_TAVR versus relative use rate_SAVR, 67.8% versus 57.2%; P<0.0001). Among patients with cancer, TAVR was associated with lower odds of acute kidney injury (odds ratio, 0.64; 95% CI, 0.54–0.75) and major bleeding (odds ratio, 0.44; 95% CI, 0.38–0.51]), with no differences in in‐hospital mortality and stroke compared with SAVR. In addition, TAVR was associated with higher odds of home discharge (odds ratio, 1.92; 95% CI, 1.68–2.19) compared with SAVR among patients with cancer. Lower risk of acute kidney injury was noted in cancer versus noncancer (P<0.001) undergoing TAVR versus SAVR in effect modification analysis.

Conclusions

TAVR use has increased irrespective of cancer status, with a greater increase in cancer versus noncancer. In patients with cancer, there was an association of TAVR with lower periprocedural complications and better disposition when compared with patients undergoing SAVR.

Clinical manifestation and management of immune checkpoint inhibitor-associated cardiotoxicity

Immune checkpoint inhibitors (ICIs) targeting programmed death-1 (PD-1), its ligand (PD-L1), and cytotoxic T-lymphocyte-associated antigen 4 (CTLA4) have revolutionized cancer treatment by recovering the attack of T lymphocytes on the malignant cells. They have improved clinical outcomes dramatically in multiple types of advanced-stage malignancies. Even though the tolerance and safety profiles are generally good, it has been widely reported that ICIs can cause severe or fatal immune-related adverse events (irAEs), since the activated T lymphocytes are not specific for tumor cells. Cardiac irAEs appear to occur less frequently than irAEs in other organ systems but are notorious for high mortality. Here, we aim to identify and characterize the ICI-associated cardiotoxicity and summarize the optional diagnosis and treatment strategies.

Cardiovascular Disease Risk in Survivors of Breast Cancer

PURPOSE OF REVIEW

Early detection and improved treatment in breast cancer have resulted in an increased number of survivors. Cardiovascular disease now remains an important cause for morbidity and mortality in this population. There is a growing gap in the knowledge about the optimal long-term cardiovascular management of this population.

FINDINGS

Breast cancer and cardiovascular disease share a number of common risk factors. Different breast cancer treatment modalities, including anthracyclines, radiation, and hormonal therapy, can act in synergy with preexisting and/or new cardiovascular risk factors to result in significant cardiovascular disease. We summarize the recent evidence about cardiovascular effects of breast cancer therapy and recommendations for their diagnosis and management during the cancer treatment continuum into survivorship. We also present current research initiatives and how they inform clinical care.

Proceedings From the Global Cardio-Oncology Summit: The Top 10 Priorities to Actualize for CardioOncology

The discipline of cardio-oncology has expanded at a remarkable pace. Recent developments and challenges to clinicians who practice cardio-oncology were presented at the Global Cardio-Oncology Summit on October 3 to 4, 2019, in São Paulo, Brazil. Here, we present the top 10 priorities for our field that were discussed at the meeting, and also detail a potential path forward to address these challenges. Defining robust predictors of cardiotoxicity, clarifying the role of cardioprotection, managing and preventing thromboembolism, improving hematopoietic stem cell transplant outcomes, personalizing cardiac interventions, building the cardio-oncology community, detecting and treating cardiovascular events associated with immunotherapy, understanding tyrosine kinase inhibitor cardiotoxicity, and enhancing survivorship care are all priorities for the field. The path forward requires a commitment to research, education, and excellence in clinical care to improve our patients' lives.

Health care utilization and mortality associated with heart failure-related admissions among cancer patients

AIMS

Heart failure (HF) outcomes continue to improve with widespread use of new therapies. Concurrently, cancer survival has dramatically improved. Yet whether cancer patients share similar strategies and outcomes of inpatient HF treatment to those without HF is unknown. We sought to assess the contemporary impacts of cancer on inpatient HF outcomes over time.

METHODS AND RESULTS

The retrospective National Inpatient Sample (2003-15) and National Readmissions Database (2013-14) registries were queried for adults admitted for HF and stratified for cancer status, excluding cases of metastatic disease. Temporal trends in HF admissions, hospital charge rates, length of hospitalization, HF-related procedure utilization, in-hospital mortality, and hospital readmissions were analysed. Over 13 years of follow-up, there were 12 769 077 HF admissions (mean age 73 years, 50.8% female, 30.8% non-White), among which 1 413 287 (11%) had a co-morbid cancer diagnosis. Cancer patients were older, were predominantly male, and tended to be smokers. Over time, HF admission rates among cancer patients increased, despite a concurrent decrease among patients without cancer (P < 0.0001). After propensity matching, in-hospital mortality was significantly higher among cancer HF patients (5.1% vs. 2.9%, P < 0.0001). Additionally, HF-related procedure utilization was disproportionately lower among cancer patients (0.30 vs. 0.35 procedures/HF hospitalization, P < 0.001); the presence of cancer was associated with increased costs, length of hospitalizations, and all-cause readmissions, but fewer HF readmissions (P < 0.0001, each).

CONCLUSIONS

While the incidence of HF hospitalizations has increased among cancer patients, they do not appear to share the same rates of advanced HF care, readmissions trends, or reductions in in-hospital mortality. Future studies targeting modifiable factors related to these differences are needed.

Heart Failure and Cancer: Mechanisms of Old and New Cardiotoxic Drugs in Cancer Patients

Although there have been many improvements in prognosis for patients with cancer, anticancer therapies are burdened by the risk of cardiovascular toxicity. Heart failure is one of the most dramatic clinical expressions of cardiotoxicity, and it may occur acutely or appear years after treatment. This article reviews the main mechanisms and clinical presentations of left ventricular dysfunction induced by some old and new cardiotoxic drugs in cancer patients, referring to the most recent advances in the field. The authors describe the mechanisms of cardiotoxicity induced by anthracyclines, which can lead to cardiovascular problems in up to 48% of patients who take them. The authors also describe mechanisms of cardiotoxicity induced by biological drugs that produce left ventricular dysfunction through secondary mechanisms. They outline the recent advances in immunotherapies, which have revolutionised anticancer therapies.

Cardio-Oncology Fellowship Training and Education

PURPOSE OF REVIEW

With the rapid development of novel cancer therapeutics and the growing number of cancer survivors, there is significant demand for cardio-oncology experts to care for these patients. As such, it has become increasingly necessary to develop formalized training in the field of cardio-oncology. This review will focus on the current state of cardio-oncology education, with recommendations for the development of dedicated cardio-oncology fellowships.

RECENT FINDINGS

Cardio-oncology fellowships should be affiliated with high-volume centers that have established cardio-oncology clinical and research programs with dedicated cardio-oncology faculty. Several recent publications have proposed recommendations to develop uniform cardio-oncology training standards, core curricula, and evaluation metrics. With the rapid evolution of the field and the support of various profession organizations, the number and quality of dedicated cardio-oncology fellowship programs is expected to increase significantly. The adoption of defined training requirements and evaluation standards to measure competency will be essential to ensure the legitimacy and success of the field.

Emergence of cardio-oncology

Cardio-oncology is a new discipline that focuses on understanding, detection, monitoring and treating cardiovascular disease during and after cancer treatment. The development of this emerging field is based on an interdisciplinary collaboration between cardiology and oncology researchers and clinicians. Cardio-oncology aims at identifying how cancer therapies impact cardiovascular homeostasis, particular risk factors, diagnostic biomarkers and novel therapeutic approaches to help to effectively detect, prevent and cure the cardiotoxicity.