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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.
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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.
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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.
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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
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3
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Li Z, Zhao R, Wang C, Wang Y, Lin J, Zhao S, Chen J, Zhou Y, Liu T, Wang F, Shu X, Zeng M, Cheng L. Cardiac magnetic resonance-based layer-specific strain in immune checkpoint inhibitor-associated myocarditis. ESC Heart Fail 2024; 11:1061-1075. [PMID: 38243390 DOI: 10.1002/ehf2.14664] [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: 08/24/2023] [Revised: 11/10/2023] [Accepted: 12/18/2023] [Indexed: 01/21/2024] Open
Abstract
AIMS To assess the different imaging characteristics between corticosteroid-sensitive (CS) and corticosteroid-refractory (CR) immune checkpoint inhibitor-associated myocarditis (ICIaM) with cardiac magnetic resonance (CMR) and the potential CMR parameters in the early detection of CR ICIaM. METHODS AND RESULTS Thirty-five patients diagnosed with ICIaM and 30 age and gender-matched cancer patients without a history of ICI treatment were enrolled. CMR with contrast was performed within 2 days of clinical suspicion. Left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) were assessed by CMR. LV sub-endocardial (GLSendo) and sub-epicardial (GLSepi) global longitudinal strains were quantified by offline feature tracking analysis. CS and CR ICIaM were defined based on the trend of Troponin I and clinical course during corticosteroid treatment. All 35 patients presented with non-fulminant symptoms upon initial assessment. Twenty patients (57.14%) were sensitive, and 15 (42.86%) were refractory to corticosteroids. Compared with controls, 22 patients (62.86%) with ICIaM developed LGE. LVEF decreased in CR ICIaM compared with the CS group and controls. GLSendo (-14.61 ± 2.67 vs. -18.50 ± 2.53, P < 0.001) and GLSepi (-14.75 ± 2.53 vs. -16.68 ± 2.05, P < 0.001) significantly increased in patients with CR ICIaM compared with the CS ICIaM. In patients with CS ICIaM, although GLSepi (-16.68 ± 2.05 vs. -19.31 ± 1.80, P < 0.001) was impaired compared with the controls, GLSendo was preserved. There was no difference in CMR parameters between LGE-positive and negative groups. LVEF, GLSendo, and GLSepi were predictors of CR ICIaM. When LVEF, GLSendo, and GLSepi were included in multivariate analysis, only GLSendo remained an independent predictor of CR ICIaM (OR: 2.170, 95% CI: 1.189-3.962, P = 0.012). A GLSendo of ≥-17.10% (sensitivity, 86.7%; specificity, 80.0%; AUC, 0.860; P < 0.001) could predict CR ICIaM in the ICIaM cohort. Kaplan-Meier analysis showed that in patients with impaired GLSendo of ≥-17.10%, cardiovascular adverse events (CAEs) occurred much earlier than in patients with preserved GLSendo of <-17.10% (Log-rank test P = 0.017). CONCLUSIONS CR and CS ICIaM demonstrated different functional and morphological characteristics in different myocardial layers. An impaired GLSendo could be a helpful parameter in early identifying corticosteroid-refractory individuals in the ICIaM population.
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Affiliation(s)
- Zheng Li
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Rui Zhao
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Cong Wang
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Wang
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinyi Lin
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shihai Zhao
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiahui Chen
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuhong Zhou
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianshu Liu
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Wang
- Department of Medical Oncology, Qinhuai Medical Area of General Hospital of Eastern Theater Command, Nanjing, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Mengsu Zeng
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Leilei Cheng
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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Liu G, Chen T, Zhang X, Hu B, Shi H. Immune checkpoint inhibitor-associated cardiovascular toxicities: A review. Heliyon 2024; 10:e25747. [PMID: 38434280 PMCID: PMC10907684 DOI: 10.1016/j.heliyon.2024.e25747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/01/2024] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionary effects on therapeutic strategies for multiple malignancies. Their efficacy depends on their ability to reactivate the host immune system to fight cancer cells. However, adverse reactions to ICIs are common and involve several organs, limiting their use in clinical practice. Although the incidence of cardiovascular toxicity is relatively low, it is associated with serious consequences and high mortality rates. The primary cardiovascular toxicities include myocarditis, pericarditis, Takotsubo syndrome, arrhythmia, vasculitis, acute coronary syndrome, and venous thromboembolism. Currently, the mechanism underlying ICI-associated cardiovascular toxicity remains unclear and underexplored. The diagnosis and monitoring of ICI-associated cardiovascular toxicities mainly include the following indicators: symptoms, signs, laboratory examination, electrocardiography, imaging, and pathology. Treatments are based on the grade of cardiovascular toxicity and mainly include drug withdrawal, corticosteroid therapy, immunosuppressants, and conventional cardiac treatment. This review focuses on the incidence, underlying mechanisms, clinical manifestations, diagnoses, and treatment strategies.
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Affiliation(s)
- Guihong Liu
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Chen
- Tao Chen Department of Cardiology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xin Zhang
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Binbin Hu
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Huashan Shi
- Guihong Liu Department of Biotherapy, State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Egeler M, Lai-Kwon J, Tissier R, Fraterman I, Kuijpers A, Van Houdt W, Wilgenhof S, Rao A, Sandhu S, Lee R, Eriksson H, van Leeuwen M, de Ligt K, van Akkooi A, van de Poll-Franse L. Real-world health-related quality of life outcomes for patients with resected stage III/IV melanoma treated with adjuvant anti-PD1 therapy. Eur J Cancer 2024; 200:113601. [PMID: 38340383 DOI: 10.1016/j.ejca.2024.113601] [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: 11/16/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND While adjuvant therapy with anti-programmed cell death protein-1 (anti-PD1) for patients with resected stage III/IV melanoma has been shown to improve recurrence-free survival, the overall survival benefit remains uncertain. This study aims to evaluate the impact of adjuvant anti-PD1 therapy on the health-related quality of life (HRQOL) of patients with resected stage III/IV melanoma METHODS: Data was used from two melanoma registries in Australia and the Netherlands. Patients with resected stage III/IV melanoma treated with adjuvant anti-PD1 who completed a baseline and at least one post-baseline HRQOL assessment were included. HRQOL was assessed using the EORTC QLQ-C30 at baseline, 3, 6, and 12 months. Established thresholds were used for interpreting changes in QLQ-C30 scores. RESULTS 92 patients were included. Mean symptom and functioning scores improved or remained stable at 12 months compared to baseline. However, a substantial proportion of patients experienced a clinically significant decline in role (39%, μ = -50.8), social (41%, μ = -32.7), or emotional (50%, μ = -25.1) functioning at 12 months compared to baseline. Younger patients were more likely to experience clinically significant deteriorations in role (OR=1.07, 95% CI: 1.02-1.13, p < 0.01) and social (OR=1.06, 95% CI: 1.01-1.11, p = 0.013) functioning. CONCLUSION A significant proportion of patients with resected stage III/IV melanoma who received adjuvant anti-PD1 experienced clinically significant declines in role, social and emotional functioning at 12 months compared to baseline. This highlights the HRQOL issues that may arise during adjuvant anti-PD1 therapy which may require supportive care intervention.
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Affiliation(s)
- Mees Egeler
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Julia Lai-Kwon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Renaud Tissier
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Itske Fraterman
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Anke Kuijpers
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Winan Van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Sofie Wilgenhof
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Aparna Rao
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Shahneen Sandhu
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Rebecca Lee
- Department of Medical Oncology, Christie NHS Foundation Trust, Manchester, UK, University of Manchester, Manchester, UK
| | - Hanna Eriksson
- Theme Cancer, Unit of Head-Neck-, Lung-, and Skin Cancer, Skin Cancer Center, Karolinska University Hospital, SE-17176 Stockholm, Sweden; Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marieke van Leeuwen
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Kelly de Ligt
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Lonneke van de Poll-Franse
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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Jo W, Won T, Daoud A, Čiháková D. Immune checkpoint inhibitors associated cardiovascular immune-related adverse events. Front Immunol 2024; 15:1340373. [PMID: 38375475 PMCID: PMC10875074 DOI: 10.3389/fimmu.2024.1340373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are specialized monoclonal antibodies (mAbs) that target immune checkpoints and their ligands, counteracting cancer cell-induced T-cell suppression. Approved ICIs like cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), its ligand PD-L1, and lymphocyte activation gene-3 (LAG-3) have improved cancer patient outcomes by enhancing anti-tumor responses. However, some patients are unresponsive, and others experience immune-related adverse events (irAEs), affecting organs like the lung, liver, intestine, skin and now the cardiovascular system. These cardiac irAEs include conditions like myocarditis, atherosclerosis, pericarditis, arrhythmias, and cardiomyopathy. Ongoing clinical trials investigate promising alternative co-inhibitory receptor targets, including T cell immunoglobulin and mucin domain-containing protein 3 (Tim-3) and T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). This review delves into the mechanisms of approved ICIs (CTLA-4, PD-1, PD-L1, and LAG-3) and upcoming options like Tim-3 and TIGIT. It explores the use of ICIs in cancer treatment, supported by both preclinical and clinical data. Additionally, it examines the mechanisms behind cardiac toxic irAEs, focusing on ICI-associated myocarditis and atherosclerosis. These insights are vital as ICIs continue to revolutionize cancer therapy, offering hope to patients, while also necessitating careful monitoring and management of potential side effects, including emerging cardiac complications.
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Affiliation(s)
- Wonyoung Jo
- Department of Biomedical Engineering, Johns Hopkins University, Whiting School of Engineering, Baltimore, MD, United States
| | - Taejoon Won
- Department of Pathobiology, University of Illinois Urbana-Champaign, College of Veterinary Medicine, Urbana, IL, United States
| | - Abdel Daoud
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
| | - Daniela Čiháková
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
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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.
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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
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Haj-Yehia E, Mincu RI, Korste S, Lampe L, Margraf SM, Michel L, Mahabadi AA, Ferdinandy P, Rassaf T, Totzeck M. High neutrophil-to-lymphocyte ratio is associated with cancer therapy-related cardiovascular toxicity in high-risk cancer patients under immune checkpoint inhibitor therapy. Clin Res Cardiol 2024; 113:301-312. [PMID: 37955712 PMCID: PMC10850199 DOI: 10.1007/s00392-023-02327-9] [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: 09/06/2023] [Accepted: 10/17/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Cancer therapy-related cardiovascular toxicity (CTR-CVT) from immune checkpoint inhibitor (ICI) therapy is still incompletely characterized, and patients with pre-existing cardiovascular disease represent a particularly high-risk cohort. Valid parameters for risk stratification of these patients are missing. Neutrophil-to-lymphocyte ratio (NLR) has been shown to predict mortality and adverse events in other cardiovascular cohorts. The present study aims to examine the predictive capacity of NLR for risk stratification of patients particularly vulnerable for CTR-CVT under ICI therapy. METHODS We performed an analysis of 88 cancer patients (69 ± 11 years, 25% female) with pre-existing cardiovascular disease under ICI therapy from the prospective Essen Cardio-Oncology Registry (ECoR). NLR was assessed at patient enrollment and the population was divided through receiver operator characteristic (ROC) curve analysis in patients with low (< 4.57) and high (≥ 4.57) NLR. Endpoint was the whole spectrum of CTR-CVT, according to the European guidelines on cardio-oncology. The median follow-up was 357 days (interquartile range (IQR): 150-509 days). RESULTS We observed 4 cases of myocarditis, 17 cases of vascular toxicity, 3 cases of arterial hypertension, 22 cases of arrhythmia or QTc prolongation and 17 cases of cardiovascular dysfunction. NLR was associated with overall CTR-CVT by univariable Cox regression (hazard ratio (HR): 1.443; 95% confidence interval (CI) 1.082-1.925; p = 0.013). However, this association was attenuated after adjusting for further confounders. CONCLUSION NLR is moderately associated with CTR-CVT in cancer patients with pre-existing cardiovascular disease under ICI therapy. Surveillance of NLR during ICI therapy might be an effective and economically biomarker for risk stratification in these high-risk patients.
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Affiliation(s)
- Elias Haj-Yehia
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Raluca I Mincu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Sebastian Korste
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Lena Lampe
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Simone M Margraf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Amir A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Péter 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 Essen, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany.
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Mitsuboshi S, Hamano H, Zamami Y. Reply to: Comments on "Association between immune checkpoint inhibitor-induced myocarditis and concomitant use of thiazide diuretics". Int J Cancer 2024; 154:586-587. [PMID: 37850308 DOI: 10.1002/ijc.34767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023]
Affiliation(s)
| | - Hirofumi Hamano
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
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10
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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.
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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.
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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.
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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.
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12
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Xu L, Xu M, Sun W, Zhang W, Song Z. Clinical characteristics and prognostic impact of immune checkpoint inhibitor-associated myocarditis in advanced non-small cell lung cancer. Invest New Drugs 2023; 41:816-824. [PMID: 37902905 DOI: 10.1007/s10637-023-01400-4] [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: 06/27/2023] [Accepted: 10/04/2023] [Indexed: 11/01/2023]
Abstract
Myocarditis is a rare immune-related adverse events (irAEs) with high mortality rates, with few reports on its clinical characteristics and prognostic impact. This study designed to explore the associations between cardiac parameters and outcomes of myocarditis in advanced non-small cell lung cancer (NSCLC) who treated with immune checkpoint inhibitor (ICI). Fourteen patients diagnosed with ICI-associated myocarditis by clinicians were admitted to the study analysis. By Cox univariate and multivariate survival analyses, potential risk factors for the development of severe myocarditis were identified. Survival analysis was also performed to explore the prognosis of patients with myocarditis. Among patients with myocarditis, higher B-type natriuretic peptide (BNP) levels (P = 0.04) and conduction block (P = 0.03) were associated with progression to severe myocarditis. In addition, high lactate dehydrogenase (LHD) levels (P = .04) and myocarditis onset within 2 months (P = 0.02) were prognostic factors of severe myocarditis. The median progression-free survival (PFS) time and median overall survival (OS) time for all patients were 5.9 months and 18.5 months, respectively. However, there were no statistical differences between mild and severe cohorts in terms of PFS and OS (PFS: 4.5 vs. 8.5 months, P = 0.17; OS: 21.3 vs. 18.5months, P = 0.36). And we found that the earlier occurrence of myocarditis, worse PFS prognosis (4.5 months vs. 10.5 months, P = 0.008), while no difference in OS (18.5 months vs. 21.3 months, P = 0.35). Compared to mild myocarditis, severe myocarditis presented with higher BNP levels and cardiac conduction abnormalities. In addition, patients with mild and early myocarditis tended to have better survival rates.
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Affiliation(s)
- Lan Xu
- The third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Manyi Xu
- The second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Wei Sun
- Wenzhou Medical University, Wenzhou, China
| | - Weiping Zhang
- The third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhengbo Song
- Department of Clinical Trial, The Chinese Academy of Sciences University Cancer Hospital (Zhejiang Cancer Hospital), Hangzhou Institute of Medicine (HIM), No.1 East Banshan Road, Gongshu District, Hangzhou, Zhejiang, 310022, China.
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13
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Zatarain-Nicolás E, Martín P, Márquez Rodas I, Virizuela J, Martín García A, Mitroi C, Cosín Sales J, Barrios V, Sánchez-Cabo F, Ibañez B, de Castro Carpeño J, López Fernández T. Cardiovascular toxicity of checkpoint inhibitors: review of associated toxicity and design of the Spanish Immunotherapy Registry of Cardiovascular Toxicity. Clin Transl Oncol 2023; 25:3073-3085. [PMID: 37227656 DOI: 10.1007/s12094-023-03217-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/29/2023] [Indexed: 05/26/2023]
Abstract
Immune checkpoint inhibitors (ICI) have changed the prognosis of many tumors. However, concerning associated cardiotoxicity has been reported. Little is known about the real-life incidence-specific surveillance protocols or the translational correlation between the underlying mechanisms and the clinical presentation of ICI-induced cardiotoxicity. The lack of data from prospective studies led us to review the current knowledge and to present the creation of the Spanish Immunotherapy Registry of Cardiovascular Toxicity (SIR-CVT), a prospective registry of patients receiving ICI that aims to examine the role of hsa-miR-Chr8:96, (a specific serum biomarker of myocarditis) in the early diagnosis of ICI-induced myocarditis. An exhaustive prospective cardiac imaging study will be performed before and during the first 12 months of treatment. The correlation between clinical, imaging, and immunologic parameters may improve our understanding of ICI-induced cardiotoxicity and enable simpler surveillance protocols. We assess ICI-induced cardiovascular toxicity and describe the rationale of the SIR-CVT.
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Affiliation(s)
- Eduardo Zatarain-Nicolás
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBER-CV (Instituto de Salud Carlos III), Universidad Complutense, Madrid, Spain.
| | - Pilar Martín
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Iván Márquez Rodas
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Virizuela
- Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Seville, Spain
| | - Ana Martín García
- Cardiology Department, Complejo Asistencial Universitario de Salamanca, IBSAL, USAL, CIBER-CV (Instituto de Salud Carlos III), Salamanca, Spain
| | - Cristina Mitroi
- Cardiology Department, Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Juan Cosín Sales
- Agencia de Investigación de la Sociedad Española de Cardiología (AISEC), Madrid, Spain
- Cardiology Department, Hospital Arnau de Vilanova, Universidad CEU-Cardenal Herrera, Valencia, Spain
| | - Vivencio Barrios
- Agencia de Investigación de la Sociedad Española de Cardiología (AISEC), Madrid, Spain
- Cardiology Department, Hospital Universitario Ramon y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Fátima Sánchez-Cabo
- Bioinformatics Unit, Centro Nacional de Investigaciones Cardiovasculares (CNIC), CIBER-CV (Instituto de Salud Carlos III), Madrid, Spain
| | - Borja Ibañez
- Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, CIBER-CV (Instituto de Salud Carlos III), CNIC, Madrid, Spain
| | | | - Teresa López Fernández
- Cardiology Service, Cardio-Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Madrid, Spain.
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Iengo M, Topa E, Cuomo A, Marone G, Poto R, Varricchi G, Cristinziano L, Galdiero MR, Ferrara AL, Loffredo S, Formisano L, Troiani T, Mercurio V, Tocchetti CG. The broad spectrum of cardiotoxicities from immunotherapies. Front Cardiovasc Med 2023; 10:1259620. [PMID: 37781307 PMCID: PMC10540439 DOI: 10.3389/fcvm.2023.1259620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Affiliation(s)
- Martina Iengo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ester Topa
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giancarlo Marone
- Department of Pharmacy, Moscati Hospital Pharmacy, Aversa, Italy
| | - Remo Poto
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | | | - Maria Rosaria Galdiero
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
| | - Anne Lise Ferrara
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- World Allergy Organization (WAO) Center of Excellence, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Luigi Formisano
- Department of Medicine and Surgery, Federico II University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Teresa Troiani
- Medical Oncology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
- Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
- Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
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15
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Tamura Y, Tamura Y. Usefulness of Longitudinal Strain to Assess Cancer Therapy-Related Cardiac Dysfunction and Immune Checkpoint Inhibitor-Induced Myocarditis. Pharmaceuticals (Basel) 2023; 16:1297. [PMID: 37765105 PMCID: PMC10535915 DOI: 10.3390/ph16091297] [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] [Received: 07/22/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Longitudinal strain (LS) measured by echocardiography has been reported to be useful not only for the diagnosis and risk stratification of various cardiac diseases, but also in cardio-oncology. Most previous studies have been conducted on patients undergoing treatment with anthracyclines and human epidermal growth factor receptor 2-targeted therapies. Existing guidelines recommend that global LS (GLS) should be measured before and after the administration of cancer drugs. This recommendation is based on many reports showing that a decline in GLS is indicative of early or mild cancer therapy-related cardiac dysfunction. The main purpose of this article is to provide insight into the importance of LS in patients undergoing cancer treatment and highlight the role of LS evaluation in patients undergoing immune checkpoint inhibitor (ICI) treatment, which is being used with increasing frequency. Among cancer drug therapies, immune checkpoint inhibitors (ICIs) have an important place in cancer treatment and are used for the treatment of many types of cancer. Although the efficacy of ICIs in cancer treatment has been reported, immune-related adverse events (irAEs) have also been reported. Among these irAEs, cardiovascular complications, although rare, are recognized as important adverse events that may result in ICI treatment discontinuation. Myocarditis is one severe adverse event associated with ICIs, and it is important to standardize diagnostic and therapeutic approaches to it. Several studies have reported a relationship between LS and cardiac complications associated with ICIs which may contribute to the early diagnosis of ICI-induced cardiac complications.
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Affiliation(s)
- Yudai Tamura
- Cardiovascular Center, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan;
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita 286-8686, Japan
| | - Yuichi Tamura
- Cardiovascular Center, International University of Health and Welfare Mita Hospital, Tokyo 108-8329, Japan;
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita 286-8686, Japan
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16
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Raschi E, Rossi S, De Giglio A, Fusaroli M, Burgazzi F, Rinaldi R, Potena L. Cardiovascular Toxicity of Immune Checkpoint Inhibitors: A Guide for Clinicians. Drug Saf 2023; 46:819-833. [PMID: 37341925 PMCID: PMC10442274 DOI: 10.1007/s40264-023-01320-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/22/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment and care of patients with cancer owing to unique features, including the occurrence of the so-called immune-related adverse events (irAEs). A multidisciplinary team, possibly including a cardio-oncology specialist, is warranted to achieve a favorable patient outcome. Cardiovascular toxicity, especially myocarditis, emerged as a life-threatening irAE in the real-word setting, and the European Society of Cardiology has recently published the first guideline on cardio-oncology to increase awareness and promote a standardized approach to tackle this complex multimodal issue, including diagnostic challenges, assessment, treatment, and surveillance of patients with cancer receiving ICIs. In this article, through a question & answer format made up of case vignettes, we offer a clinically oriented overview on the latest advancements of ICI-related cardiovascular toxicity, focusing on myocarditis and associated irAEs (myositis and myasthenia gravis within the so-called overlap syndrome), with the purpose of assisting clinicians and healthcare professionals in daily clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy.
| | - Simone Rossi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea De Giglio
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Fusaroli
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Flavio Burgazzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luciano Potena
- Unit of Heart Failure and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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17
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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.
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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
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18
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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: 0] [Impact Index Per Article: 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.
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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.
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19
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Moradi A, Kodali A, Okoye C, Klein DH, Mohamoud I, Olanisa OO, Parab P, Chaudhary P, Mukhtar S, Mohammed L. A Systematic Review of Myocarditis Induced by Immune Checkpoint Inhibitors: How Concerning Is the Most Common Cardiotoxicity of Immune Checkpoint Inhibitors? Cureus 2023; 15:e42071. [PMID: 37602125 PMCID: PMC10434730 DOI: 10.7759/cureus.42071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Novel cancer therapies have revolutionized the management of various cancers. An immune checkpoint inhibitor (ICI) is one of these antitumor medications. ICIs, which are immune therapies, enhance the immune system's capacity to fight cancer cells. Based on the receptors that they inhibit, such as PD-1, PD-L1, and CTLA-4, ICIs are subdivided. Although this class of drugs is extremely beneficial for cancer patients, their adverse effects can be fatal. Multiple organs, such as the cardiovascular system, may be impacted by immune-related adverse effects (irAEs). These cardiotoxic irAEs can occur at a rate of up to 1% and can be fatal. Myocarditis is the most prevalent of all cardiotoxicities. The purpose of this systematic review is to assess the seriousness of myocarditis, the most prevalent cardiotoxicity of ICIs, and the importance of screening. We chose studies based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria. Therefore, from 2018 to 2023, we gathered articles from databases such as PubMed, ScienceDirect, Web of Science, the Cochrane Library, and Google Scholar. Of the 665 studies identified based on various screening methods and quality assessment tools, 13 were selected for inclusion in the study. This study shows that although the risk of myocarditis in ICI therapy is low and the majority of cases are asymptomatic or mild, some cases can be deadly and disastrous, and physicians should be aware that if myocarditis is suspected based on clinical symptoms, troponin, electrocardiogram, and echocardiogram, treatment should be initiated accordingly.
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Affiliation(s)
- Ali Moradi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Athri Kodali
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chiugo Okoye
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dhadon Hannah Klein
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Iman Mohamoud
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Olawale O Olanisa
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Panah Parab
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Priti Chaudhary
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sonia Mukhtar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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20
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Sadeq MA, Ashry MH, Ghorab RMF, Afify AY. Causes of death among patients with cutaneous melanoma: a US population-based study. Sci Rep 2023; 13:10257. [PMID: 37355743 PMCID: PMC10290704 DOI: 10.1038/s41598-023-37333-4] [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: 04/15/2023] [Accepted: 06/20/2023] [Indexed: 06/26/2023] Open
Abstract
Research on mortality outcomes and non-cancer-related causes of death in patients with cutaneous melanoma (CM) remains limited. This study aimed to identify the prevalence of non-cancer-related deaths following CM diagnosis. The data of 224,624 patients diagnosed with malignant CM in the United States between 2000 and 2019 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. We stratified our cohort based on their melanoma stage at diagnosis and further calculated standardized mortality ratios (SMRs) for each cause of death, comparing their relative risk to that of the general US population. The total number of fatalities among melanoma patients was 60,110, representing 26.8% of the total cases. The percentage of deaths is directly proportional to the disease stage, reaching 80% in distant melanoma. The highest fatalities among the localized melanoma group (25,332; 60.5%) occurred from non-cancer causes, followed by melanoma-attributable deaths (10,817; 25.8%). Conversely, melanoma is the leading cause of death in regional and distant melanoma cohorts. Cardiovascular and cerebrovascular diseases were the most prevalent non-cancer causes of death among the three disease-stage cohorts. Compared to the general population, we did not observe an increased risk of death due to non-cancer causes in the localized CM cohort, while patients diagnosed with regional and distant CMs had a statistically significant higher risk of death from all the reported major causes of death.
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Affiliation(s)
- Mohammed Ahmed Sadeq
- Faculty of Medicine, Misr University for Science and Technology, 6th of October, Giza, Egypt
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21
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Delombaerde D, De Sutter J, Croes L, Vervloet D, Moerman V, Van de Veire N, Willems AM, Wouters K, Peeters M, Prenen H, Vulsteke C. Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study. Pharmaceuticals (Basel) 2023; 16:ph16040625. [PMID: 37111382 PMCID: PMC10142365 DOI: 10.3390/ph16040625] [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: 03/21/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.
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Affiliation(s)
- Danielle Delombaerde
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | - Johan De Sutter
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Lieselot Croes
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Nico Van de Veire
- Department of Cardiology, AZ Maria Middelares, 9000 Ghent, Belgium
- Department of Cardiology, Free University Brussels, 1000 Brussels, Belgium
| | | | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, 2650 Edegem, Belgium
| | - Marc Peeters
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hans Prenen
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Oncologic Center Antwerp (MOCA), Antwerp University Hospital, 2650 Edegem, Belgium
| | - Christof Vulsteke
- Integrated Cancer Center Ghent, Department of Medical Oncology, AZ Maria Middelares, 9000 Ghent, Belgium
- Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp, 2610 Wilrijk, Belgium
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22
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Ndjana Lessomo FY, Wang Z, Mukuka C. Comparative cardiotoxicity risk of pembrolizumab versus nivolumab in cancer patients undergoing immune checkpoint inhibitor therapy: A meta-analysis. Front Oncol 2023; 13:1080998. [PMID: 37064101 PMCID: PMC10090546 DOI: 10.3389/fonc.2023.1080998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
ObjectiveRecently, several researchers have reported the incidence of cardiac-related toxicities occurring with nivolumab (Opdivo) and pembrolizumab (Keytruda). There is still a need for balance between oncology treatment efficacy and reduction of cardiotoxicity burden in immune checkpoint inhibitor (ICI)-treated patients. Thus, the primary aim was to determine whether pembrolizumab or nivolumab would present with a greater risk for cardiotoxicity reports.Materials and methodsThis meta-analysis was performed with respect to the MOOSE reporting guidelines. Studies were retrieved by searching PubMed, Embase, and Google Scholar; the search terms were Keytruda or Pembrolizumab, PD1 inhibitors, anti-PD1 drugs, Nivolumab or Opdivo, and cardiotoxicities or cardiac toxicity. The study was restricted to original articles investigating ICI-induced cardiac immune-related adverse events (irAEs). The targeted population was cancer patients treated with either pembrolizumab or nivolumab monotherapy, of which those with records of any cardiac events following the therapy were labeled as events. The measures used to achieve the comparison were descriptive proportions, probabilities, and meta-analysis pooled odds ratios (ORs).ResultsFifteen studies were included in this meta-analysis. Nivolumab accounted for 55.7% cardiotoxicity and pembrolizumab, for 27.31% (P = 0.027). The meta-analysis was based on the Mantel–Haenszel method, and the random-effect model yielded a pooled OR = 0.73 (95% CI [0.43–1.23] P = 0.24), with considerable heterogeneity (I2 = 99% P = 0). Hence, the difference in cardiotoxicity odds risk between pembrolizumab and nivolumab was not statistically significant. On subgroup analysis based on cardiotoxicity type, the “myocarditis” subgroup in which there was no statistical heterogeneity was associated with a significant cardiotoxicity risk increase with pembrolizumab (OR = 1.30 [1.07;1.59], P< 0.05; I2 = 0%, Ph = 0.4).ConclusionTo our knowledge, this is the first meta-analysis to compare the cardiotoxicity potentials of nivolumab and pembrolizumab. In contrast to previous reports, the overall findings here demonstrated that nivolumab-induced cardiotoxicity was more commonly reported in the literature than pembrolizumab; however, myocarditis seemed more likely to occur with pembrolizumab therapy.
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Affiliation(s)
| | - Zhiquan Wang
- Cardiovascular Internal Medicine Department, Zhongnan Hospital of Wuhan University, Wuhan, China
- *Correspondence: Zhiquan Wang, ,
| | - Chishimba Mukuka
- Internal Medicine Department, MANSA General Hospital, Mansa, Luapula, Zambia
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23
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Kyaw T, Drummond G, Bobik A, Peter K. Myocarditis: causes, mechanisms, and evolving therapies. Expert Opin Ther Targets 2023; 27:225-238. [PMID: 36946552 DOI: 10.1080/14728222.2023.2193330] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Myocarditis is a severe lymphocyte-mediated inflammatory disorder of the heart, mostly caused by viruses and immune checkpoint inhibitors (ICIs). Recently, myocarditis as a rare adverse event of mRNA vaccines for SARS-CoV-2 has caused global attention. The clinical consequences of myocarditis can be very severe, but specific treatment options are lacking or not yet clinically proven. AREAS COVERED This paper offers a brief overview of the biology of viruses that frequently cause myocarditis, focusing on mechanisms important for viral entry and replication following host infection. Current and new potential therapeutic targets/strategies especially for viral myocarditis are reviewed systematically. In particular, the immune system in myocarditis is dissected with respect to infective viral and non-infective, ICI-induced myocarditis. EXPERT OPINION Vaccination is an excellent emerging preventative strategy for viral myocarditis, but most vaccines still require further development. Anti-viral treatments that inhibit viral replication need to be considered following viral infection in host myocardium, as lower viral load reduces inflammation severity. Understanding how the immune system continues to damage the heart even after viral clearance will define novel therapeutic targets/strategies. We propose that viral myocarditis can be best treated using a combination of antiviral agents and immunotherapies that control cytotoxic T cell activity.
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Affiliation(s)
- Tin Kyaw
- Inflammation and Cardiovascular Disease Laboratory, Baker Heart and Diabetes Institute
- Centre for Inflammatory Diseases, Monash Medical Centre, Monash University, Melbourne, Australia
- Department of Cardiometabolic Health, University of Melbourne Melbourne Australia
| | - Grant Drummond
- Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University Melbourne Australia
- Centre for Cardiovascular Biology and Disease Research, La Trobe University, Melbourne, Australia
| | - Alex Bobik
- Inflammation and Cardiovascular Disease Laboratory, Baker Heart and Diabetes Institute
- Centre for Inflammatory Diseases, Monash Medical Centre, Monash University, Melbourne, Australia
- Department of Cardiometabolic Health, University of Melbourne Melbourne Australia
- Centre for Cardiovascular Biology and Disease Research, La Trobe University, Melbourne, Australia
- Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Karlheinz Peter
- Inflammation and Cardiovascular Disease Laboratory, Baker Heart and Diabetes Institute
- Department of Cardiometabolic Health, University of Melbourne Melbourne Australia
- Department of Microbiology, Anatomy, Physiology and Pharmacology, La Trobe University Melbourne Australia
- Heart Centre, Alfred Hospital, Melbourne, Australia
- Department of Immunology, Monash University Melbourne Australia
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24
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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: 0] [Impact Index Per Article: 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.
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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
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25
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Mohammad KO, Fanous H, Vakamudi S, Liu Y. Refractory right ventricular myocarditis induced by immune checkpoint inhibitor despite therapy cessation and immune suppression. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:15. [PMID: 36941689 PMCID: PMC10026228 DOI: 10.1186/s40959-023-00165-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are currently widely used for treatment of various types of cancers. ICI-induced myocarditis, though uncommon, accounts for high risk of major adverse cardiac events and mortality, which makes appropriate diagnosis important. We here present a unique, challenging case of ICI-induced, refractory and isolated right ventricular (RV) myocarditis. CASE PRESENTATION A 32-year-old female with breast cancer presented with newly onset chest pain and dyspnea shortly after initiation of Pembrolizumab. Coronary angiography showed normal coronary arteries and a cardiac magnetic resonance (CMR) revealed myocarditis involving the right ventricle with chamber dilation and severe dysfunction. ICI therapy was stopped, and high dose steroid therapy was initiated and symptoms resolved. However, three months after initial presentation, the patient was hospitalized for DKA and decompensated right heart failure, and a repeat cardiac MRI at that time showed recurrent, isolated right ventricular myocardial inflammation/edema without LV involvement. High dose steroid therapy was started again and at 6-month follow up, surveillance CMR continued to show persistent right-sided myocarditis, patient was eventually treated with Abatacept with resolution of HF symptoms, RV dysfunction and biomarkers at 10-month follow up. CONCLUSIONS We describe a unique case of isolated ICI-induced right ventricular myocarditis leading to right ventricular failure, that was refractory despite ICI therapy cessation and immune suppression by repeated high dose steroids. Co-stimulatory pathway modulation with Abatacept eventually lead to the normalization of RV function and dilation ten months after initial myocarditis onset.
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Affiliation(s)
- Khan O Mohammad
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA
| | - Hanna Fanous
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA
| | - Sneha Vakamudi
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA
| | - Yan Liu
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA.
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26
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Gergely TG, Kucsera D, Tóth VE, Kovács T, Sayour NV, Drobni ZD, Ruppert M, Petrovich B, Ágg B, Onódi Z, Fekete N, Pállinger É, Buzás EI, Yousif LI, Meijers WC, Radovits T, Merkely B, Ferdinandy P, Varga ZV. Characterization of immune checkpoint inhibitor-induced cardiotoxicity reveals interleukin-17A as a driver of cardiac dysfunction after anti-PD-1 treatment. Br J Pharmacol 2023; 180:740-761. [PMID: 36356191 DOI: 10.1111/bph.15984] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/06/2022] [Accepted: 10/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Immune checkpoint inhibitors (ICI), such as anti-PD-1 monoclonal antibodies, have revolutionized cancer therapy by enhancing the cytotoxic effects of T-cells against tumours. However, enhanced T-cell activity also may cause myocarditis and cardiotoxicity. Our understanding of the mechanisms of ICI-induced cardiotoxicity is limited. Here, we aimed to investigate the effect of PD-1 inhibition on cardiac function and explore the molecular mechanisms of ICI-induced cardiotoxicity. EXPERIMENTAL APPROACH C57BL6/J and BALB/c mice were treated with isotype control or anti-PD-1 antibody. Echocardiography was used to assess cardiac function. Cardiac transcriptomic changes were investigated by bulk RNA sequencing. Inflammatory changes were assessed by qRT-PCR and immunohistochemistry in heart, thymus, and spleen of the animals. In follow-up experiments, anti-CD4 and anti-IL-17A antibodies were used along with PD-1 blockade in C57BL/6J mice. KEY RESULTS Anti-PD-1 treatment led to cardiac dysfunction and left ventricular dilation in C57BL/6J mice, with increased nitrosative stress. Only mild inflammation was observed in the heart. However, PD-1 inhibition resulted in enhanced thymic inflammatory signalling, where Il17a increased most prominently. In BALB/c mice, cardiac dysfunction was not evident, and thymic inflammatory activation was more balanced. Inhibition of IL-17A prevented anti-PD-1-induced cardiac dysfunction in C57BL6/J mice. Comparing myocardial transcriptomic changes in C57BL/6J and BALB/c mice, differentially regulated genes (Dmd, Ass1, Chrm2, Nfkbia, Stat3, Gsk3b, Cxcl9, Fxyd2, and Ldb3) were revealed, related to cardiac structure, signalling, and inflammation. CONCLUSIONS PD-1 blockade induces cardiac dysfunction in mice with increased IL-17 signalling in the thymus. Pharmacological inhibition of IL-17A treatment prevents ICI-induced cardiac dysfunction.
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Affiliation(s)
- Tamás G Gergely
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Dániel Kucsera
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Viktória E Tóth
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Tamás Kovács
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Nabil V Sayour
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Zsófia D Drobni
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Mihály Ruppert
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Balázs Petrovich
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Bence Ágg
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,Pharmahungary Group, Szeged, Hungary.,MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Zsófia Onódi
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
| | - Nóra Fekete
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Éva Pállinger
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Edit I Buzás
- Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Laura I Yousif
- Department of Cardiology, Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Division of Experimental Cardiology, Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wouter C Meijers
- Department of Cardiology, Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Division of Experimental Cardiology, Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,Pharmahungary Group, Szeged, Hungary.,MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Zoltán V Varga
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,HCEMM-SE Cardiometabolic Immunology Research Group, Semmelweis University, Budapest, Hungary.,MTA-SE Momentum Cardio-Oncology and Cardioimmunology Research Group, Semmelweis University, Budapest, Hungary
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27
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Yegya-Raman N, Berlin E, Feigenberg SJ, Ky B, Sun L. Cardiovascular Toxicity and Risk Mitigation with Lung Cancer Treatment. Curr Oncol Rep 2023; 25:433-444. [PMID: 36811807 DOI: 10.1007/s11912-023-01387-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Patients with lung cancer often have concomitant cardiovascular comorbidities and receive potentially cardiotoxic therapies. As oncologic outcomes improve, the relative impact of cardiovascular disease on lung cancer survivors is expected to increase. This review summarizes cardiovascular toxicities observed after treatment for lung cancer, as well as recommended risk mitigation strategies. RECENT FINDINGS A variety of cardiovascular events may be observed after surgery, radiation therapy (RT), and systemic therapy. The risk of cardiovascular events after radiation therapy (RT) is higher than previously appreciated (23-32%), and RT dose to the heart is a modifiable risk factor. Targeted agents and immune checkpoint inhibitors have been associated with cardiovascular toxicities distinct from those of cytotoxic agents; these are rare but can be severe and require prompt intervention. Optimization of cardiovascular risk factors is important at all phases of cancer therapy and survivorship. Recommended practices for baseline risk assessment, preventive measures, and appropriate monitoring are discussed herein.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Lova Sun
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, West Pavilion, 2nd Floor, Philadelphia, PA, 19104, USA.
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28
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Josan K, Neilan TG. Immune checkpoint inhibitors: acute and chronic cardiovascular complications. Nat Rev Cardiol 2023; 20:73-74. [PMID: 36543993 DOI: 10.1038/s41569-022-00827-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Kiranbir Josan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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29
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Li X, Peng W, Wu J, Yeung SCJ, Yang R. Advances in immune checkpoint inhibitors induced-cardiotoxicity. Front Immunol 2023; 14:1130438. [PMID: 36911712 PMCID: PMC9995967 DOI: 10.3389/fimmu.2023.1130438] [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: 12/23/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are approved as the first-line drug for treating many cancers and has shown significant survival benefits; however, it also causes immune-related adverse events (irAEs) while activating the immune system, involving multiple organs. Among them, cardiovascular immune-related adverse events (CV-irAE) are rare, but common causes of death in ICIs treated cancer patients, which manifest as myocardial, pericardial, vascular and other cardiovascular toxicities. Therefore, it is important that irAEs, especially CV-irAE should be carefully recognized and monitored during the whole ICIs treatment because early detection and treatment of CV-irAE can significantly reduce the mortality of such patients. Consequently, it is urgent to fully understand the mechanism and management strategies of CV-irAE. The effects of ICIs are multifaceted and the exact mechanism of CV-irAE is still elusive. Generally, T cells identify tumor cell antigens as well as antigen in cardiomyocytes that are the same as or homologous to those on tumor cells, thus causing myocardial damage. In addition, ICIs promote formation of cardiac troponin I (cTnI) that induces cardiac dysfunction and myocardial dilatation; moreover, ICIs also increase the production of cytokines, which promote infiltration of inflammation-linked molecules into off-target tissues. Currently, the management and treatment of cardiovascular toxicity are largely dependent on glucocorticoids, more strategies for prevention and treatment of CV-irAE, such as predictive markers are being explored. This review discusses risk factors, potential pathophysiological mechanisms, clinical manifestations, and management and treatment of CV-irAE, guiding the development of more effective prevention, treatment and management strategies in the future.
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Affiliation(s)
- Xiang Li
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Wenying Peng
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Jiao Wu
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, TX, United States
| | - Runxiang Yang
- Department of the Second Medical Oncology, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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30
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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.
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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
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Suero-Abreu GA, Zanni MV, Neilan TG. Atherosclerosis With Immune Checkpoint Inhibitor Therapy: Evidence, Diagnosis, and Management: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:598-615. [PMID: 36636438 PMCID: PMC9830225 DOI: 10.1016/j.jaccao.2022.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/13/2022] [Indexed: 12/24/2022] Open
Abstract
As the clinical applications of immune checkpoint inhibitors (ICIs) expand, our knowledge of the potential adverse effects of these drugs continues to broaden. Emerging evidence supports the association between ICI therapy with accelerated atherosclerosis and atherosclerotic cardiovascular (CV) events. We discuss the biological plausibility and the clinical evidence supporting an effect of inhibition of these immune checkpoints on atherosclerotic CV disease. Further, we provide a perspective on potential diagnostic and pharmacological strategies to reduce atherosclerotic risk in ICI-treated patients. Our understanding of the pathophysiology of ICI-related atherosclerosis is in its early stages. Further research is needed to identify the mechanisms linking ICI therapy to atherosclerosis, leverage the insight that ICI therapy provides into CV biology, and develop robust approaches to manage the expanding cohort of patients who may be at risk for atherosclerotic CV disease.
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Affiliation(s)
| | - Markella V. Zanni
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas G. Neilan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Cardiovascular Imaging Research Center, Department of Radiology and Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Address for correspondence: Dr Tomas G. Neilan, Cardio-Oncology Program and Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, Massachusetts 02114, USA. @TomasNeilan
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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.
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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
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Lee C, Drobni ZD, Zafar A, Gongora CA, Zlotoff DA, Alvi RM, Taron J, Rambarat PK, Schoenfeld S, Mosarla RC, Raghu VK, Hartmann SE, Gilman HK, Murphy SP, Sullivan RJ, Faje A, Hoffmann U, Zhang L, Mayrhofer T, Reynolds KL, Neilan TG. Pre-Existing Autoimmune Disease Increases the Risk of Cardiovascular and Noncardiovascular Events After Immunotherapy. JACC CardioOncol 2022; 4:660-669. [PMID: 36636443 PMCID: PMC9830202 DOI: 10.1016/j.jaccao.2022.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
Background The use of immune checkpoint inhibitors (ICI) is associated with cardiovascular (CV) events, and patients with pre-existing autoimmune disease are at increased CV risk. Objectives The aim of this study was to characterize the risk for CV events in patients with pre-existing autoimmune disease post-ICI. Methods This was a retrospective study of 6,683 patients treated with ICIs within an academic network. Autoimmune disease prior to ICI was confirmed by chart review. Baseline characteristics and risk for CV and non-CV immune-related adverse events were compared with a matched control group (1:1 ratio) of ICI patients without autoimmune disease. Matching was based on age, sex, history of coronary artery disease, history of heart failure, and diabetes mellitus. CV events were a composite of myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, stroke, transient ischemic attack, deep venous thrombosis, pulmonary embolism, or myocarditis. Univariable and multivariable Cox proportional hazards models were used to determine the association between autoimmune disease and CV events. Results Among 502 patients treated with ICIs, 251 patients with and 251 patients without autoimmune disease were studied. During a median follow-up period of 205 days, there were 45 CV events among patients with autoimmune disease and 22 CV events among control subjects (adjusted HR: 1.77; 95% CI: 1.04-3.03; P = 0.0364). Of the non-CV immune-related adverse events, there were increased rates of psoriasis (11.2% vs 0.4%; P < 0.001) and colitis (24.3% vs 16.7%; P = 0.045) in patients with autoimmune disease. Conclusions Patients with autoimmune disease have an increased risk for CV and non-CV events post-ICI.
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Key Words
- CABG, coronary artery bypass graft
- CTLA-4, cytotoxic T lymphocyte–associated antigen-4
- CV, cardiovascular
- DVT, deep venous thrombosis
- ICI, immune checkpoint inhibitor
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- PD-1, programmed death-1
- PD-L1, programmed death-ligand 1
- PE, pulmonary embolism
- SMD, standardized mean difference
- TIA, transient ischemic attack
- coronary artery disease
- immunotherapy
- irAE, immune-related adverse event
- myocarditis
- thrombosis
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Affiliation(s)
- Charlotte Lee
- Division of Cardiology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Zsofia D. Drobni
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Amna Zafar
- Division of Cardiovascular Diseases and Hypertension, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Carlos A. Gongora
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel A. Zlotoff
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raza M. Alvi
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jana Taron
- Department of Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Paula K. Rambarat
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sara Schoenfeld
- Division of Rheumatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ramya C. Mosarla
- Division of Cardiology, New York University, New York, New York, USA
| | - Vineet K. Raghu
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah E. Hartmann
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hannah K. Gilman
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sean P. Murphy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan J. Sullivan
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexander Faje
- Division of Endocrinology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lili Zhang
- Department of Cardiology, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry L. Reynolds
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tomas G. Neilan
- Cardiovascular Imaging Research Center, Department of Radiology and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Torrente M, Blanco M, Franco F, Garitaonaindia Y, Calvo V, Collazo-Lorduy A, Gutiérrez L, Sánchez JC, González-del-Alba A, Hernández R, Méndez M, Cantos B, Núñez B, Sousa PAC, Provencio M. Assessing the risk of cardiovascular events in patients receiving immune checkpoint inhibitors. Front Cardiovasc Med 2022; 9:1062858. [PMID: 36531707 PMCID: PMC9751318 DOI: 10.3389/fcvm.2022.1062858] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/08/2022] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment. However, despite their excellent therapeutic effect, these medications typically result in a broad spectrum of toxicity reactions. Immune-related cardiotoxicity is uncommon but can be potentially fatal, and its true incidence is underestimated in clinical trials. The aim of this study is to assess the incidence and identify risk factors for developing a cardiac event in patients treated with ICIs. METHODS We conducted a single-institution retrospective study, including patients treated with ICIs in our center. The main outcomes were cardiac events (CE) and cardiovascular death. RESULTS A total of 378 patients were analyzed. The incidence of CE was 16.7%, during a median follow-up of 50.5 months. The multivariable analysis showed that age, a history of arrhythmia or ischemic heart disease, and prior immune-related adverse events were significantly associated with CE. CONCLUSION CE during ICI treatment are more common than currently appreciated. A complete initial cardiovascular evaluation is recommended, especially in high-risk patients, being necessary a multidisciplinary approach of a specialized cardio-oncology team.
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Affiliation(s)
- María Torrente
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
- Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain
| | - Mariola Blanco
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Fabio Franco
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Yago Garitaonaindia
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Virginia Calvo
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Ana Collazo-Lorduy
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Lourdes Gutiérrez
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Juan Cristóbal Sánchez
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | | | - Roberto Hernández
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Miriam Méndez
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Blanca Cantos
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Beatriz Núñez
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Pedro A. C. Sousa
- Department of Electrical Engineering, NOVA School of Science and Technology, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Mariano Provencio
- Department of Medical Oncology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
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Gevaert SA, Halvorsen S, Sinnaeve PR, Sambola A, Gulati G, Lancellotti P, Van Der Meer P, Lyon AR, Farmakis D, Lee G, Boriani G, Wechalekar A, Okines A, Asteggiano R, Combes A, Pfister R, Bergler-Klein J, Lettino M. Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Clinical Consensus Statement of the Acute CardioVascular Care Association (ACVC) and the ESC council of Cardio-Oncology—part 2: acute heart failure, acute myocardial diseases, acute venous thromboembolic diseases, and acute arrhythmias. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:865-874. [DOI: 10.1093/ehjacc/zuac107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 12/05/2022]
Abstract
Abstract
Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to cancer itself or cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. The management of acute coronary syndromes and acute pericardial diseases in cancer patients was covered in part 1 of a clinical consensus document. This second part focusses on acute heart failure, acute myocardial diseases, venous thromboembolic diseases and acute arrhythmias.
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Affiliation(s)
- Sofie A Gevaert
- Department of Cardiology, Ghent University Hospital , Gent , Belgium
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo , Oslo , Norway
| | - Peter R Sinnaeve
- Department of Cardiology, University Hospital Leuven , Leuven , Belgium
| | - Antonia Sambola
- Department of Cardiology, University Hospital Vall d’Hebron, Universitat Autonòma, CIBER-CV , Barcelona , Spain
| | - Geeta Gulati
- Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo , Oslo , Norway
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Science, Department of Cardiology , CHU Sart Tilman, Liège , Belgium
| | - Peter Van Der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Alexander R Lyon
- Cardio-Oncology Clinic at Royal Brompton Hospital and Imperial College London , London , UK
| | | | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College , London , UK
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia , Policlinico Di Modena, Modena , Italy
| | - Ashutosh Wechalekar
- Department of Haematology, University College London/University College London Hospitals , London , UK
| | - Alicia Okines
- Department of Medicine, The Royal Marsden NHS Foundation Trust , London , UK
| | - Riccardo Asteggiano
- Insubria University , Varese , Italy
- LARC (Laboratorio Analisi e Ricerca Clinica) , Turin , Italy
| | - Alain Combes
- Medical-Surgical ICU, Hôpital Pitié–Salpêtrière , Paris , France
- Sorbonne University, Institute of Cardiometabolism and Nutrition , Paris , France
| | - Roman Pfister
- Department III of Internal Medicine, Heart Center, University of Cologne , Cologne , Germany
| | - Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna , Vienna , Austria
| | - Maddalena Lettino
- Department of Cardiology, San Gerardo Hospital, ASST-Monza , Monza , Italy
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Thuny F, Naidoo J, Neilan TG. Cardiovascular complications of immune checkpoint inhibitors for cancer. Eur Heart J 2022; 43:4458-4468. [PMID: 36040835 PMCID: PMC10263267 DOI: 10.1093/eurheartj/ehac456] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/07/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Over the last decade or so, there has been a paradigm shift in the oncologic care of patients with a range of solid tumour and haematologic malignancies, away from traditional cytotoxic chemotherapy and towards personalized cancer treatments, using both targeted therapy and immunotherapy. This shift has contributed to the remarkable and sustained increase in the number of cancer survivors and the longevity of patients with a cancer diagnosis. This review will focus on the cardiovascular effects of immune checkpoint inhibitors and will present a background on immune checkpoint inhibition for cancer, the epidemiology, potential mechanisms, the potential insights into cardiovascular biology, and a diagnostic and therapeutic approach to potential cases. Our understanding of the cardiovascular effects of immune checkpoint inhibitors needs to improve. However, the evolution necessarily needs to be rapid. Initial observations noted that immune checkpoint inhibitor therapy can lead to a fulminant myocarditis. Recent reports have expanded the effect of immune checkpoint inhibitor therapy on the cardiovascular system to include an increase in cardiac dysfunction without myocarditis, arrhythmias, venous thromboembolic disease, accelerated atherosclerosis, and atherosclerosis-related cardiovascular events. The association between immune checkpoint inhibitor therapy and an increase in these cardiovascular events is not only limited to events occurring within the first few weeks after starting therapy but can also include events that occur months to years after therapy. The latter observation is especially of relevance in those treated with adjuvant or neoadjuvant therapy. There needs to be a shift from recognition of an increase in cardiovascular events to currently approved immune checkpoint inhibitor therapies to understanding the mechanisms that lead to adverse cardiovascular effects, understanding who is at risk, and understanding what we can do about it.
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Affiliation(s)
- Franck Thuny
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France
| | - Jarushka Naidoo
- Sidney Kimmel Comprehensive Cancer Center, John Hopkins University, Baltimore, MD, USA
- Beaumont Hospital and RCSI University of Health Sciences, Dublin, Ireland
| | - Tomas G Neilan
- Division of Cardiology and Department of Radiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Boston, MA, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Chen R, Zhou M, Zhu F. Immune Checkpoint Inhibitors Related to Cardiotoxicity. J Cardiovasc Dev Dis 2022; 9:jcdd9110378. [PMID: 36354777 PMCID: PMC9697232 DOI: 10.3390/jcdd9110378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have now emerged as a mainstay of treatment for various cancers. Along with development of ICIs, immune-related adverse effects (irAEs) have aroused wide attention. The cardiac irAE, one of the rare but potentially fatal effects, have been reported recently. However, the clinical comprehension of cardiac irAEs remains limited and guidelines are inadequate for cardio-oncologists to tackle the problem. In this review, we have summarized current classifications of, manifestations of, potential mechanisms of, and treatment for ICI-related myocardial injury in order to provide some clues for the understanding of cardiac irAEs in clinical work.
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Affiliation(s)
- Ru Chen
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Min Zhou
- Department of Pulmonary and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Key Laboratory of Respiratory Diseases, National Ministry of Health of the People’s Republic of China and National Clinical Research Center for Respiratory Disease, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
| | - Feng Zhu
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Clinic Center of Human Gene Research, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Correspondence: (M.Z.); (F.Z.)
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38
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Michel L, Rassaf T. Medikamentös bedingte Kardiomyopathien. Dtsch Med Wochenschr 2022; 147:1513-1522. [DOI: 10.1055/a-1810-9275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 673] [Impact Index Per Article: 336.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Irabor OC, Nelson N, Shah Y, Niazi MK, Poiset S, Storozynsky E, Singla DK, Hooper DC, Lu B. Overcoming the cardiac toxicities of cancer therapy immune checkpoint inhibitors. Front Oncol 2022; 12:940127. [PMID: 36185227 PMCID: PMC9523689 DOI: 10.3389/fonc.2022.940127] [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: 05/10/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have led recent advances in the field of cancer immunotherapy improving overall survival in multiple malignancies with abysmal prognoses prior to their introduction. The remarkable efficacy of ICIs is however limited by their potential for systemic and organ specific immune-related adverse events (irAEs), most of which present with mild to moderate symptoms that can resolve spontaneously, with discontinuation of therapy or glucocorticoid therapy. Cardiac irAEs however are potentially fatal. The understanding of autoimmune cardiotoxicity remains limited due to its rareness. In this paper, we provide an updated review of the literature on the pathologic mechanisms, diagnosis, and management of autoimmune cardiotoxicity resulting from ICIs and their combinations and provide perspective on potential strategies and ongoing research developments to prevent and mitigate their occurrence.
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Affiliation(s)
- Omoruyi Credit Irabor
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Philadelphia, PA, United States
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
- *Correspondence: Omoruyi Credit Irabor,
| | - Nicolas Nelson
- Sidney Kimmel Medical College (SKMC), Philadelphia, PA, United States
| | - Yash Shah
- Sidney Kimmel Medical College (SKMC), Philadelphia, PA, United States
| | - Muneeb Khan Niazi
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Philadelphia, PA, United States
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Spencer Poiset
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Philadelphia, PA, United States
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Eugene Storozynsky
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Dinender K. Singla
- Division of Metabolic and Cardiovascular Sciences, Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, United States
| | - Douglas Craig Hooper
- Sidney Kimmel Medical College (SKMC), Philadelphia, PA, United States
- Department of Pharmacology, Physiology, and Cancer Biology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Bo Lu
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Philadelphia, PA, United States
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, United States
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Jiménez-Alejandre R, Ruiz-Fernández I, Martín P. Pathophysiology of Immune Checkpoint Inhibitor-Induced Myocarditis. Cancers (Basel) 2022; 14:cancers14184494. [PMID: 36139654 PMCID: PMC9497311 DOI: 10.3390/cancers14184494] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Myocarditis is an infrequent but highly hazardous complication of the cancer therapy of immune checkpoint inhibitors (ICIs). The study of the pathophysiology of this disease is an active field of research and a clearer comprehension of the mechanisms is crucial to provide an accurate diagnosis, appropriate therapy, and to prevent cardiac adverse toxicities occurring during ICI treatment that compromise the continuation of the cancer treatment. This review provides an update of the currently approved ICIs and their relationship with myocarditis induction through boosting the immune system. It also discusses preclinical models of ICI-associated myocarditis and their contribution to the state of the art and presents recent advances in the pathogenesis of the disease. Abstract Immune checkpoint inhibitors (ICIs) have recently emerged as strong therapies for a broad spectrum of cancers being the first-line treatment for many of them, even improving the prognosis of malignancies that were considered untreatable. This therapy is based on the administration of monoclonal antibodies targeting inhibitory T-cell receptors, which boost the immune system and prevent immune evasion. However, non-specific T-cell de-repression can result in a wide variety of immune-related adverse events (irAEs), including gastrointestinal, endocrine, and dermatologic, with a smaller proportion of these having the potential for fatal outcomes such as neurotoxicity, pulmonary toxicity, and cardiotoxicity. In recent years, alarm has been raised about cardiotoxicity as it has the highest mortality rate when myocarditis develops. However, due to the difficulty in diagnosing this cardiac condition and the lack of clinical guidelines for the management of cardiovascular disease in patients on therapy with ICIs, early detection of myocarditis has become a challenge in these patients. In this review we outline the mechanisms of tolerance by which this fatal cardiomyopathy may develop in selected cancer patients treated with ICIs, summarize preclinical models of the disease that will allow the development of more accurate strategies for its detection and treatment, and discuss the challenges in the future to decrease the risks of its development with better decision making in susceptible patients.
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Affiliation(s)
| | | | - Pilar Martín
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
- CIBER de Enfermedades Cardiovasculares (CIBER-CV), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-91-453-1200
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Xiao Q, Yu X, Shuai Z, Yao T, Yang X, Zhang Y. The influence of baseline characteristics on the efficacy of immune checkpoint inhibitors for advanced lung cancer: A systematic review and meta-analysis. Front Pharmacol 2022; 13:956788. [PMID: 36176428 PMCID: PMC9513719 DOI: 10.3389/fphar.2022.956788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: To investigate the impact of different baseline characteristics on the efficacy of immune checkpoint inhibitors (ICIs) for advanced lung cancer.Methods: In order to identify eligible randomized controlled trials (RCTs), a systematic search was conducted in PubMed, Embase, Web of Science, and Scopus Cochrane Library databases. The primary outcomes were hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS). To explore the potential interaction during the administration of ICI, patients were stratified by baseline characteristics.Results: The meta-analysis included 24 RCTs. ① Compared with non-ICI therapy, patients with lung cancer benefitted more from immunotherapy (HR, 0.78; p < 0.0001). ② Patients without liver metastases could get more survival benefits than those with liver metastases (HR, 1.20; p = 0.0139). Similar outcomes were also observed in the following subgroups: small-cell lung cancer (HR, 1.20; p = 0.0433), subsequent line (HR, 1.40; p = 0.0147), and ICI monotherapy (HR, 1.40; p = 0.0147). ③ Subgroup analysis showed that tumor type affected the efficacy of immunotherapy in patients with brain metastases (HR, 0.72 vs. 1.41; interaction, p < 0.01). Among patients with smoking history (HR, 0.87 vs. 1.23; interaction, p = 0.05) and brain metastases (HR, 0.69 vs. 1.21; interaction, p = 0.05), the type of therapy (i.e., monotherapy or combination therapy) had potential influences on the efficacy of immunotherapy.Conclusion: Some critical baseline characteristics could indicate the efficacy of ICI therapy. Liver metastasis status could predict the efficacy of ICI therapy for lung cancer. Compared with small-cell lung cancer, patients with brain metastases might have durable OS in non-small-cell lung cancer. The smoking history or brain metastasis status of patients could indicate the potential clinical benefits of monotherapy or combination therapy.
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Affiliation(s)
- Qionghua Xiao
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaolin Yu
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Zhihao Shuai
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Ting Yao
- The 2nd Department of Pulmonary Disease in Traditional Chinese Medicine (TCM), China-Japan Friendship Hospital, Beijing, China
| | - Xiaohua Yang
- Department of Respiratory, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yanxia Zhang
- Department of Respiratory, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Yanxia Zhang,
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Ahmed T, Marmagkiolis K, Ploch M, Irizarry-Caro JA, Amatullah A, Desai S, Aziz MK, Yarrabothula A, Fossas-Espinosa J, Koutroumpakis E, Hassan S, Karimzad K, Kim P, Cilingiroglu M, Iliescu C. The year in Cardio-oncology 2022. Curr Probl Cardiol 2022; 48:101435. [DOI: 10.1016/j.cpcardiol.2022.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 10/14/2022]
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Myocarditis Induced by Immunotherapy in Metastatic Melanoma—Review of Literature and Current Guidelines. J Clin Med 2022; 11:jcm11175182. [PMID: 36079112 PMCID: PMC9457343 DOI: 10.3390/jcm11175182] [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: 06/25/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Immunotherapy is a widely used treatment modality in oncology. Immune checkpoint inhibitors, as a part of immunotherapy, caused a revolution in oncology, especially in melanoma therapy, due to the significant prolongation of patients’ overall survival. These drugs act by activation of inhibited immune responses of T lymphocytes against cancer cells. The mechanism responsible for the therapy’s high efficacy is also involved in immune tolerance of the patient’s own tissues. The administration of ICI therapy to a patient can cause severe immune reactions against non-neoplastic cells. Among them, cardiotoxicity seems most important due to the high mortality rate. In this article, we present the history of a 79 year-old patient diagnosed with melanoma who died due to myocarditis induced by ICI therapy, despite the fast administration of recommended immunosuppressive therapy, as an illustration of possible adverse events of ICI. Additionally, we summarize the mechanism, risk factors, biomarkers, and clinical data from currently published guidelines and studies about ICI-related myocarditis. The fast recognition of this fatal adverse effect of therapy may accelerate the rapid introduction of treatment and improve patients’ outcomes.
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45
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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46
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Lorente-Ros Á, Rajjoub-Al-Mahdi EA, Monteagudo Ruiz JM, Rivas García S, Ortega Pérez R, Fernández Golfín C, Álvarez-García J, Zamorano Gómez JL. Checkpoint Immunotherapy-Induced Myocarditis and Encephalitis Complicated With Complete AV Block: Not All Hope Is Lost. JACC Case Rep 2022; 4:1032-1036. [PMID: 36062054 PMCID: PMC9434642 DOI: 10.1016/j.jaccas.2022.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 01/16/2023]
Abstract
Immune checkpoint inhibitors are associated with a myriad of autoimmune adverse events. We present a 70-year-old patient with renal-cell carcinoma treated with nivolumab/ipilimumab complicated with myocarditis and encephalitis in which gradual impairment of the His-Purkinje system progressed to complete atrioventricular block. Full recovery was achieved after treatment with corticosteroids and immunoglobulins. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Álvaro Lorente-Ros
- Cardiology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain.,Centro de Investigación Biomédica en Red, CIBER Cardiovascular, Madrid, Spain
| | | | | | - Sonia Rivas García
- Cardiology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | | | - Covadonga Fernández Golfín
- Cardiology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain.,Centro de Investigación Biomédica en Red, CIBER Cardiovascular, Madrid, Spain
| | - Jesús Álvarez-García
- Cardiology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain.,Centro de Investigación Biomédica en Red, CIBER Cardiovascular, Madrid, Spain
| | - José L Zamorano Gómez
- Cardiology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain.,Centro de Investigación Biomédica en Red, CIBER Cardiovascular, Madrid, Spain
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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.
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48
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Laenens D, Yu Y, Santens B, Jacobs J, Beuselinck B, Bechter O, Wauters E, Staessen J, Janssens S, Van Aelst L. Incidence of Cardiovascular Events in Patients Treated With Immune Checkpoint Inhibitors. J Clin Oncol 2022; 40:3430-3438. [PMID: 35772044 DOI: 10.1200/jco.21.01808] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE In rare cases, immune checkpoint inhibitors (ICIs) cause immune-mediated myocarditis. However, true incidence of other major adverse cardiovascular events (MACEs) after ICI treatment remains unknown, mainly because late occurring side effects are rarely reported in prospective clinical trials. The aims of this study were (1) to identify incidence and risk factors of MACE in a real-life ICI-treated cancer cohort and (2) to compare incidence rates with patients with cancer who are not treated with ICIs and population controls. METHODS In total, 672 patients treated with ICIs were included. The primary end point was MACE, a composite of acute coronary syndrome, heart failure (HF), stroke, and transient ischemic attack. Secondary outcomes were acute coronary syndrome and HF separately. Incidence rates were compared between groups after matching according to age, sex, cardiovascular history, and cancer type. RESULTS The incidence of MACE was 10.3% during a median follow-up of 13 (interquartile range 6-22) months. In multivariable analysis, a history of HF (hazard ratio 2.27; 95% CI, 1.03 to 5.04; P = .043) and valvular heart disease (hazard ratio 3.01; 95% CI, 1.05 to 8.66; P = .041) remained significantly associated with MACE. Cumulative incidence rates were significantly higher in the ICI group compared with the cancer cohort not exposed to ICI and the population controls, mainly driven by a higher risk of HF events. CONCLUSION Cardiovascular events during and after ICI treatment are more common than currently appreciated. Patients at risk are those with a history of cardiovascular disease. Compared with matched cancer and population controls, MACE incidence rates are significantly higher, suggesting a potential harmful effect of ICI treatment besides the underlying risk.
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Affiliation(s)
- Dorien Laenens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Yuling Yu
- Research Unit Environment and Health, KU Leuven Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Béatrice Santens
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Johanna Jacobs
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Benoit Beuselinck
- Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Oliver Bechter
- Department of Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Els Wauters
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Staessen
- Non-Profit Research Institute, Alliance for the Promotion of Preventive Medicine, Mechelen, Belgium.,Biomedical Sciences Group, Faculty of Medicine, University of Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Lee SH, Cho I, You SC, Cha MJ, Chang JS, Kim WD, Go KY, Kim DY, Seo J, Shim CY, Hong GR, Kang SM, Ha JW, Rha SY, Kim HS. Cancer Therapy-Related Cardiac Dysfunction in Patients Treated with a Combination of an Immune Checkpoint Inhibitor and Doxorubicin. Cancers (Basel) 2022; 14:cancers14092320. [PMID: 35565449 PMCID: PMC9100163 DOI: 10.3390/cancers14092320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 02/01/2023] Open
Abstract
Backgrounds: There are scarce data on whether immune checkpoint inhibitors (ICIs) increase the risk of cardiac dysfunction when used with cardiotoxic agents. Thus, we evaluated cardiac dysfunction in patients with sarcoma receiving doxorubicin with or without ICI using echocardiography and left ventricular global longitudinal strain (LVGLS). Methods: A total of 95 patients were included in this study. Echocardiography and LVGLS were evaluated at baseline and follow-up (at 3 and 6 months of chemotherapy) and compared with the doxorubicin (Dox; n = 73) and concomitant ICI with doxorubicin (Dox-ICI; n = 22) groups. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a left ventricular ejection fraction (LVEF) drop of >10% and LVEF of <50% (definite CTRCD), LVEF drop of >10%, LVEF of ≥50%, and LVGLS relative reduction of >15% (probable CTRCD) at six months. Results: There were no significant differences in age, cumulative dose of doxorubicin, and cardiovascular risk factors between the two groups. At baseline, the LVEF was similar in the Dox and Dox-ICI groups (p = 0.493). In the Dox group, LVEF decreased to 59 ± 6% (Δ −7 ± 1.3%, p < 0.001) and LVGLS decreased from −17.3 ± 3.2% to −15.4 ± 3.2% (Δ −10.1 ± −1.9%, p < 0.001) at six months. In the Dox-ICI group, LVEF decreased to 55 ± 9% (Δ −9 ± 2.1%, p < 0.001), along with a significant decrease in LVGLS (from −18.6 ± 1.9% to −15.3 ± 3.6%, Δ −12.4 ± −2.4%, p < 0.001). Over a median follow-up of 192 days, there were no cases with clinical manifestations of fulminant myocarditis. In the Dox group, definite and probable CTRCD were observed in seven (10.1%) and five (7.4%) patients, respectively. In the Dox-ICI group, definite and probable CTRCD were observed in four (19%) and four (19%) patients, respectively. The total number of patients who developed CTRCD was significantly higher in the Dox-ICI group than in the Dox group (38.1% vs. 17.4%, p = 0.042). Serum troponin-T level was significantly higher in the Dox-ICI group than in the Dox group (53.3 vs. 27.5 pg/mL, p = 0.023). Conclusions: ICIs may increase the risk of CTRCD when used with cardiotoxic agents. CTRCD should be monitored in patients treated with ICIs by cardiac biomarkers and echocardiography, including LV-GLS.
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Affiliation(s)
- Seon-Hwa Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
- Correspondence: (I.C.); (H.-S.K.); Tel.: +82-2-2228-8124 (H.-S.K.); Fax: +82-2-393-3652 (H.-S.K.)
| | - Seng-Chan You
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - Min-Jae Cha
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 03722, Korea;
| | - Jee-Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - William D. Kim
- Chung-Ang University College of Medicine, Seoul 03722, Korea;
| | - Kyu-yong Go
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Dae-Young Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Chi-Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (S.-H.L.); (K.-y.G.); (D.-Y.K.); (J.S.); (C.-Y.S.); (G.-R.H.); (S.-M.K.); (J.-W.H.)
| | - Sun-Young Rha
- Division of Oncology, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - Hyo-Song Kim
- Division of Oncology, Yonsei University College of Medicine, Seoul 03722, Korea;
- Correspondence: (I.C.); (H.-S.K.); Tel.: +82-2-2228-8124 (H.-S.K.); Fax: +82-2-393-3652 (H.-S.K.)
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Bergler-Klein J, Rainer PP, Wallner M, Zaruba MM, Dörler J, Böhmer A, Buchacher T, Frey M, Adlbrecht C, Bartsch R, Gyöngyösi M, Fürst UM. 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. Wien Klin Wochenschr 2022; 134:654-674. [PMID: 35507087 PMCID: PMC9065248 DOI: 10.1007/s00508-022-02031-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/18/2022] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria.,BioTechMed Graz, Graz, Austria
| | - Markus Wallner
- Division of Cardiology, Medical University of Graz, Graz, Austria.,Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Dörler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria.,Department of Internal Medicine and Cardiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Armin Böhmer
- Department of Internal Medicine 1, Krems University Clinic, Krems, Austria
| | - Tamara Buchacher
- Department of Internal Medicine and Cardiology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Maria Frey
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | | | - Rupert Bartsch
- Department of Medicine 1, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Mariann Gyöngyösi
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ursula-Maria Fürst
- Department of Internal Medicine, Hospital of the Brothers of St. John of God (Krankenhaus Barmherzige Brüder) Salzburg, Salzburg, Austria
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