The Diagnosis and Management of Immune Checkpoint Inhibitor Cardiovascular Toxicity: Myocarditis and Beyond

Abstract

Recent years have brought major advancements in the use of immune therapy and specifically immune checkpoint inhibitors (ICIs) in cancer patients, with expanding indications for various malignancies resulting in the treatment of a large and increasing number of patients. While this therapy significantly improves outcomes in a variety of hematologic and solid tumors, the use of ICIs is associated with a substantial risk of immune-related adverse events. Cardiovascular toxicity, while not the most common side effect of ICIs, is associated with significant morbidity and mortality. It is therefore crucial for oncologists and cardiologists, as well as internists and emergency room physicians, to have a good understanding of this increasingly common clinical problem. In the present review, we discuss the cardiac aspects of ICI therapy with special emphasis on the clinical manifestations of their cardiovascular toxicity, diagnostic approaches, treatment and suggested surveillance.

Cardiovascular adverse effects of immune checkpoint inhibitors

“…Inhibitory punktów kontrolnych zatwierdzone początkowo w 2011 r. przez Agencję Żywności i Leków (ang. Food and Drug Administration -FDA) do leczenia przerzutowego czerniaka są obecnie stosowane w ponad 50 wskazaniach w terapii licznych nowotworów, często w ich początkowych stadiach i jako pierwsza linia leczenia [4]. Mimo swojej skuteczności, mogą być przyczyną różnorodnych, nowych działań niepożądanych, określanych jako irAEs (ang.…”

Immune Checkpoint Inhibitor Associated Myocarditis and Cardiomyopathy: A Translational Review

“…The underlying mechanism is still unclear. Different mechanisms have been postulated, ranging from the deregulation of previously tolerated self-tissue, increased cross-reactivity between cancerous and normal cells, and alteration of the humoral immunity and cytokine milieu [ 3 , 57 ]. Common irAEs involve the skin, gastrointestinal tract, liver, lung, and endocrine organs.…”

“…Currently, more than 3000 ICI trials are ongoing, representing about 2/3 of all oncology trials [ 2 ]. More importantly, ICIs are now being utilized in earlier disease stages and are used as single agents or in combination with chemotherapies as first- or second-line treatments [ 3 ]. About 50% of cancer patients are eligible for ICI treatment [ 4 , 5 ].…”

Cardiovascular Complications of Pan-Cancer Therapies: The Need for Cardio-Oncology

“…Some data suggest that before ICI treatment, the ejection fraction measurement of patients could not well distinguish the group of people who are at risk of developing myocarditis [105]. The baseline assessment primarily relied on medical history, physical examination, electrocardiogram, troponin level, and echocardiography if necessary [106]. During ICI treatment, the median onset time for ICI-associated myocarditis is generally within one month, so it can be detected by continuous electrocardiogram and regular cardiac troponin level examination [107].…”