Cardiovascular Imaging in Contemporary Cardio-Oncology: A Scientific Statement From the American Heart Association

Cardiovascular imaging in cardio-oncology

Advances in cancer treatment have improved in patient survival rate. On the other hand, management of cardiovascular complications has been increasingly required in cancer patients. Thus, cardio-oncology has attracted the attention by both oncologists and cardiologists. Cardiovascular imaging has played a key role for non-invasive assessment of cardiovascular alterations complimentary to biomarkers and clinical assessment. Suitable imaging selection and interpretation may allow early diagnosis of cardiovascular injury with potential implications for therapeutic management and improved outcomes after cancer therapy. Echocardiography has been commonly used to evaluate cardiac dysfunction in cardio-oncology area. Cardiac CT is valuable for assessing structural abnormalities of the myocardium, coronary arteries, and aorta. Molecular imaging has an important role in the assessment of the pathophysiology and future treatment strategy of cardiovascular dysfunction. Cardiac MRI is valuable for characterization of myocardial tissue. PET and SPECT molecular imaging has potential roles for quantitative assessment of cardiovascular disorders. Particularly, FDG-PET is considered as an elegant approach for simultaneous assessment of tumor response to cancer therapy and early detection of possible cardiovascular involvement as well. This review describes the promising potential of these non-invasive cardiovascular imaging modalities in cardio-oncology.

Adverse myocardial and vascular side effects of immune checkpoint inhibitors: a prospective multimodal cardiovascular assessment

BACKGROUND

Immune checkpoint inhibitors (ICIs) can induce cardiovascular toxicities.

OBJECTIVES

To prospectively assess the incidence of major cardiovascular events (MACE) on ICIs in solid cancer patients: myocarditis, pericarditis, acute coronary syndrome, heart failure, high-degree conduction abnormalities or sustained ventricular arrhythmias, or cardiovascular death at 6 weeks (early MACE), including asymptomatic clinical changes by an independent adjudication committee using current recommended diagnostic criteria. The secondary objective was the incidence of the above-mentioned events adding atrial fibrillation (AF) at 6 months (late MACE).

RESULTS

Participants underwent pre-ICIs and repeated multimodality cardiac imaging (echocardiogram, cardiac magnetic resonance (CMR)), serum biomarkers (ultrasensitive troponin I), and rhythm surveillance (ambulatory ECG monitoring) at 6 weeks and 6 months. Forty-nine patients (38 (77.6%) male; mean age 64.3 (SD 11.0) years old) were included (June 2020-December 2021). Early MACE were observed in 9 (18.4%) patients at mean 40.1 (SD 5.9) days, with heart failure (HF) in 5 (10.2%), ventricular arrhythmias, or new conduction disorders in 4 (8.2%) patients. History of AF (HR 4.49 (CI 1.11-18.14), P = 0.035) predicted early MACE. At 6 months follow-up, 18 MACE were observed in 15/49 (31%) patients, with 6 (12.2%) HF events, 5 (10.2%) significant ventricular arrhythmias, or conduction disorders, and 4 (8.2%) AF. There was a significant decline in LVEF (P < 0.001) in patients with no MACE (P = 0.003) or HF (P = 0.0028). Higher creatinine at inclusion (HR 0.99 [0.98-1.00], P = 0.006) predicted HF on multivariate analysis. There were no significant T1 or T2 mapping changes in our study cohort on repeated CMR.

CONCLUSIONS

Cardiotoxicity on ICIs is more frequent than previously described when using a thorough detection strategy, consisting mainly in HF and asymptomatic rhythm disorders.

Current use of echocardiography in cardio-oncology: nationwide real-world data from an ANMCO/SIECVI joint survey

Aims

The need for cardio-oncology competencies is constantly growing, and with the establishment of cardio-oncology services, cardiovascular imaging, particularly transthoracic echocardiography (TTE), has become pivotal in patients' management. However, care pathways for oncologic patients largely depend on local health structures' resources. This survey from Associazione Italiana Medici Cardiologi Ospedalieri and the Italian Society of Echocardiography and Cardiovascular Imaging aimed at investigating the use of echocardiography in cardio-oncology services and knowledge levels on cancer patients' care.

Methods and results

Data were obtained via an electronic survey based on a structured questionnaire uploaded to the promoting societies' websites. Responses came from 159 centres with echocardiography. According to one-third of participating centres, workload related to cancer patients represented >30% of the total requests. The most common TTE indication (85%) was left ventricular ejection fraction (LVEF) evaluation. Many centres (55%) still assessed LVEF solely by bidimensional method or visual estimation in case of inadequate acoustic windows. At the same time, almost 40% of centres reported routinely using global longitudinal strain when feasible. We further performed a sub-analysis according to the presence (33%) or absence (77%) of dedicated cardio-oncologists, revealing significant differences in cardiovascular surveillance strategies and cardiotoxicity management.

Conclusion

This survey on echocardiography practice for cancer patients reveals a significant gap between actual clinical practice and standards proposed by recommendations, underlying the need for stronger partnerships between cardiologists and oncologists and dedicated, well-structured cardio-oncology services.

Chemotherapy Related Cardiotoxicity Evaluation-A Contemporary Review with a Focus on Cardiac Imaging

The long-term survivorship of patients diagnosed with cancer has improved due to accelerated detection and rapidly evolving cancer treatment strategies. As such, the evaluation and management of cancer therapy related complications has become increasingly important, including cardiovascular complications. These have been captured under the umbrella term "cardiotoxicity" and include left ventricular dysfunction and heart failure, acute coronary syndromes, valvular abnormalities, pericardial disease, arrhythmia, myocarditis, and vascular complications. These complications add to the burden of cardiovascular disease (CVD) or are risk factors patients with cancer treatment are presenting with. Of note, both pre- and newly developing CVD is of prognostic significance, not only from a cardiovascular perspective but also overall, potentially impacting the level of cancer therapy that is possible. Currently, there are varying recommendations and practices regarding CVD risk assessment and mitigating strategies throughout the cancer continuum. This article provides an overview on this topic, in particular, the role of cardiac imaging in the care of the patient with cancer. Furthermore, it summarizes the current evidence on the spectrum, prevention, and management of chemotherapy-related adverse cardiac effects.

Breast Cancer Immunotherapy: A Clinical Review for the Plastic Surgeon

Background

Immunotherapy has transformed breast cancer management. However, it can be challenging to remain familiar with the adverse events, contraindications, and perioperative recommendations for each agent.

Methods

We used FDALabel to identify all Food and Drug Administration-approved immunotherapies indicated for the treatment of breast cancer. We extracted details regarding warnings and precautions, indications, and adverse events from each package insert.

Results

We identified nine immunotherapies belonging to three classes: anti-human epidermal growth factor receptor 2 (HER2) agents, anti-programmed cell death protein 1 (PD-1) agents, and anti-trophoblast cell-surface antigen 2 (TROP-2) agents. Cardiotoxicity, including heart failure and cardiomyopathy, was common among those receiving anti-HER2 agents, and hypothyroidism was common among patients receiving the anti-PD-1 agent. The anti-TROP-2 agent was associated with diarrhea and neutropenia. Given the adverse event profile for each drug, we recommend preoperative evaluation components, including transthoracic echocardiography, liver function tests, and thyroid panels. We also indicate here which immunotherapies raise concern for venous thromboembolism, hematoma, and infection.

Conclusions

Using data from clinical trials, we recommend a preoperative evaluation tailored to the immunotherapeutic regimen of individual patients.

Heartbreaker: Detection and prevention of cardiotoxicity in hematological malignancies

Cancer survivors are at significant risk of cardiovascular (CV) morbidity and mortality; patients with hematologic malignancies have a higher rate of death due to heart failure compared to all other cancer subtypes. The majority of conventional hematologic cancer treatments is associated with increased risk of acute and long-term CV toxicity. The incidence of cancer therapy induced CV toxicity depends on the combination of patient characteristics and on the type, dose, and duration of the therapy. Early diagnosis of CV toxicity, appropriate referral, more specific cardiac monitoring follow-up and timely interventions in target patients can decrease the risk of CV adverse events, the interruption of oncological therapy, and improve the patient's prognosis. Herein, we summarize the CV effects of conventional treatments used in hematologic malignancies with a focus on definitions and incidence of the most common CV toxicities, guideline recommended early detection approaches, and preventive strategies before and during cancer treatments.

Current national availability of advanced echocardiography imaging: real world data from an Italian Society of Echocardiography and Cardiovascular Imaging survey

Aims

Advanced echocardiographic imaging (AEI) techniques, such as three-dimensional (3D) and multi-chamber speckle-tracking deformation imaging (strain) analysis, have been shown to be more accurate in assessing heart chamber geometry and function when compared with conventional echocardiography providing additional prognostic value. However, incorporating AEI alongside standard examinations may be heterogeneous between echo laboratories (echo labs). Thus, our goal was to gain a better understanding of the many AEI modalities that are available and employed in Italy.

Methods and results

The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey over a month (November 2022) to describe the use of AEI in Italy. Data were retrieved via an electronic survey based on a structured questionnaire uploaded on the SIECVI website. Data obtained from 173 echo labs were divided into 3 groups, according to the numbers of echocardiograms performed: <250 exams (low-volume activity, 53 centres), between 251 and 550 exams (moderate-volume activity, 62 centres), and ≥550 exams (high-volume activity, 58 centres). Transthoracic echocardiography (TTE) 3D was in use in 75% of centres with a consistent difference between low (55%), medium (71%), and high activity volume (85%) (P = 0.002), while 3D transoesophageal echocardiography (TEE) was in use in 84% of centres, reaching the 95% in high activity volume echo labs (P = 0.006). In centres with available 3D TTE, it was used for the left ventricle (LV) analysis in 67%, for the right ventricle (RV) in 45%, and for the left atrium (LA) in 40%, showing greater use in high-volume centres compared with low- and medium-volume centres (all P < 0.04). Strain analysis was utilized in most echo labs (80%), with a trend towards greater use in high-volume centres than low- and medium-volume centres (77%, 74%, and 90%, respectively; P = 0.08). In centres with available strain analysis, it was mainly employed for the LV (80%) and much less frequently for the RV and LA (49% and 48%, respectively).

Conclusion

In Italy, the AEI modalities are more frequently available in centres with high-volume activity but employed only in a few applications, being more frequent in analysing the LV compared with the RV and LA. Therefore, the echocardiography community and SIECVI should promote uniformity and effective training across the Italian centres. Meanwhile, collaborations across centres with various resources and expertise should be encouraged to use the benefits of the AEI.