ANMCO/AIOM/AICO Consensus Document on clinical and management pathways of cardio-oncology: executive summary

Abstract

Cardiovascular disease and cancer are leading causes of death. Both diseases share the same risk factors and, having the highest incidence and prevalence in the elderly, they often coexist in the same individual. Furthermore, the enhanced survival of cancer patients registered in the last decades and linked to early diagnosis and improvement of care, not infrequently exposes them to the appearance of ominous cardiovascular complications due to the deleterious effects of cancer treatment on the heart and circulatory system. The above considerations have led to the development of a new branch of clinical cardiology based on the principles of multidisciplinary collaboration between cardiologists and oncologists: Cardio-oncology, which aims to find solutions to the prevention, monitoring, diagnosis and treatment of heart damage induced by cancer care in order to pursue, in the individual patient, the best possible care for cancer while minimizing the risk of cardiac toxicity. In this consensus document we provide practical recommendations on how to assess, monitor, treat and supervise the candidate or patient treated with potentially cardiotoxic cancer therapy in order to treat cancer and protect the heart at all stages of the oncological disease. Cardiovascular diseases and cancer often share the same risk factors and can coexist in the same individual. Such possibility is amplified by the deleterious effects of cancer treatment on the heart. The above considerations have led to the development of a new branch of clinical cardiology, based on multidisciplinary collaboration between cardiologist and oncologist: the cardio-oncology. It aims to prevent, monitor, and treat heart damages induced by cancer therapies in order to achieve the most effective cancer treatment, while minimizing the risk of cardiac toxicity. In this paper, we provide practical recommendations on how to assess, monitor, treat and supervise patients treated with potential cardiotoxic cancer therapies.

Prevention, Monitoring, and Management of Cardiac Dysfunction in Patients with Metastatic Breast Cancer

“…Prior to the initiation of any anticancer therapy, it is widely recommended that cardiovascular risk factors are assessed, including blood pressure, smoking habits, blood sugar and lipid levels, and electrolyte abnormalities . In patients considered to be at high risk of adverse cardiac events (i.e., those with cardiovascular risk factors, previous or pre‐existing cardiac disease, or abnormal baseline cardiac assessments or biomarkers, of older age, or who have received prior radiotherapy or anthracycline therapy), cardioprotective treatments should be considered, including ACE inhibitors, angiotensin receptor blockers, or beta blockers, prior to initiation of anticancer therapy .…”

“…The labeling of several agents, including chemotherapies and targeted therapies, incorporates proactive monitoring of cardiac parameters at baseline and throughout treatment (Table ). In addition, several recent treatment guidelines provide recommendations on how to assess, monitor, and treat cardiac events in patients with cancer, including the use of cardiac imaging, biomarker assessment, and ECG monitoring . The American Society of Clinical Oncology Clinical Practice Guideline on prevention and monitoring of cardiac dysfunction in survivors of adult cancers states, “Clinicians should perform a comprehensive assessment in patients with cancer that includes a history and physical examination, screening for CVD risk factors (hypertension, diabetes, dyslipidemia, obesity, smoking), and an echocardiogram before initiation of potentially cardiotoxic therapies” .…”

“…In particular, patients with a history of QT prolongation, relevant cardiac disease, bradycardia, thyroid dysfunction, electrolyte abnormalities, or receiving potentially QT‐prolonging drugs are advised to be monitored by repeated ECGs . Standard recording involves a 12‐lead ECG with QT interval corrected for heart rate with Bazett's or QTcF . In relation to QT prolongation risk, monitoring of electrolyte imbalances or associated symptoms, including hypokalemia (≤3.5 mEq/L), hypomagnesemia (≤1.6 mg/dL), hypocalcemia (≤8.5 mg/dL), nausea, emesis, and diarrhea, is recommended, along with suitably correcting such imbalances or symptoms before commencing/recommencing treatment .…”

“…The need to provide optimal cancer therapy while minimizing the impact on cardiovascular health has led to the creation of cardio‐oncology . The origins of cardio‐oncology date back to the late 1960s, when the cardiac effects of anthracyclines were initially recognized .…”

Racial disparities in the rate of cardiotoxicity of HER2‐targeted therapies among women with early breast cancer

“…As the field of cardio-oncology is expanding,[30] research is ongoing to develop both preventive and therapeutic strategies for patients who are at risk for, or develop cardiotoxicity. Trastuzumab-induced cardiotoxicity was found to be related to activation of the renin-angiotensin system (RAS) in a murine model, and inhibition of RAS with angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs) and the renin inhibitor aliskerin were found to potentially prevent its development.…”