How to assess and manage cardiovascular disease in cancer patients? ——Guidelines authoritative answer

 Editor: Jiamo Ren

Cancer and cancer treatment are strongly associated with acute cardiovascular disease, and the incidence of acute cardiovascular disease has increased in patients with active cancer. So, how to manage cancer with acute cardiovascular disease? This is recommended in the Cardio-Oncology Guidelines published at the ESC 2022 Congress, providing important guidance for clinicians. This issue specially invites Professor Alexander Lyon of the Royal Brompton Hospital to give a detailed interpretation.

International Circulation: The conference released the ESC 2022 Cardio-Oncology Guideline. What are the main contents?

Professor Alexander Lyon:  We have presented the ESC’s first ever Guideline on Cardio-Oncology here in Barcelona at the ESC Congress 2022. The Guideline covers cardiovascular health in cancer patients both before starting treatment (as a baseline), then during their cancer treatment if they’re receiving a potentially cardiotoxic treatment, in the first year of followup after completing treatment (which is the end of cancer therapy assessment), and then the long-term followup for survival for those at increased risk.

International Circulation: How to evaluate and manage cancer patients with acute cardiovascular disease?

Professor Alexander Lyon: Patients who are undergoing active cancer treatment and who develop complications that are cardiovascular are very complex, and there are a number of different factors that influence how we manage these patients. The first is, what is the cancer, and how mild or advanced it is, in terms of prognosis? The second is what is the treatment the patient has received and what the known cardiotoxic profile of that treatment is? The third is the intensity or severity of the cardiovascular complications, and how that can be measured, and then optimally followed to look at response to treatment. The key fundamental principle is communication between the cardiologist and the oncologist, so that the whole team knows and understands how important the cancer drug is, what are the alternative treatments that are available if the patient can’t stay on that regimen, and what are the appropriate cardiac treatments and how we might assess the response. This will vary depending on whether it is heart failure, cancer therapy related cardiac dysfunction, or an arrhythmia, including QTc prolongation (which we cover in the Guideline with a new algorithm to manage how you change the dosing in response to QT prolongation on treatment), or thrombosis (arterial or venous), or pulmonary hypertension. So you can see there is a whole range of potential complications, and they are all covered in the Guideline in the section on management of acute cardiovascular toxicities caused by cancer therapies.

International Circulation: What are the common risk factors for cardiovascular disease and cancer? How to intervene?

Professor Alexander Lyon: We are now seeing a rapid increase in the number of cardiovascular complications and diseases in cancer patients. One of the reasons is that there are shared risk factors - risk factors that we have known in cardiology that are increasing the risk of heart disease, are now being identified in oncology to increase the risk of cancer. The most famous, of course, is smoking; but now it is recognized that obesity, dyslipidemia, inactivity and metabolic syndrome, which, of course, may lead to inflammation as well as accelerating cardiovascular disease, also accelerate cancer risk. There are cancers that themselves may potentially increase cardiac disease. We know that some lymphomas are very metabolically active and release cardiotoxic cytokines, and patients can present acutely with both an advanced lymphoma and also with LV impairment due to the malignancy. There are specific examples where the malignancy is known to cause cardiac injuries, such AL amyloidosis secondary to multiple myeloma, or carcinoid valvular heart disease in patients with carcinoid syndrome. Those topics are also covered in the Guideline.

International Circulation:What are the cardiovascular complications caused by anti-tumor therapy, and how can they be prevented?

Professor Alexander Lyon: There are a wide range of complications associated with cancer therapies, and these are all covered in the Guideline. Perhaps the most commonly encountered are cancer therapy related cardiac dysfunction due to either anthracycline chemotherapy, such as doxorubicin, or HER2 targeted therapies, such trastuzumab for HER2-positive breast cancer. In the Guideline, we discuss the risk assessment at baseline. The high-risk patients due to pre-existing heart disease and other abnormalities of cardiovascular health can then be monitored more closely. We discuss the frequency of surveillance for a range of different cancer therapies causing cardiotoxic problems, and then what to do if a problem arises, and how to implement primary prevention and secondary prevention in order to maintain patients on an effective cancer therapy safely.

International Circulation: What are the implications of the publication of the Cardio-Oncology Guidelines?

Professor Alexander Lyon: So we presented this Guideline yesterday morning at this ESC Congress in Barcelona, and today we have had two dedicated sessions on this Guideline. It is the first new Guideline at the ESC for many years. Other Guidelines have been updated. So it has really been an amazing experience, and to feel the energy and hear the feedback from thousands of people coming into the room to listen to the Guideline live for the first time. It is now available on the European Heart Journal website, and if you have the ESC Guideline App, you can find the Pocket Guideline on the App, and you will be able to use the interactive algorithms to help you make decisions on how to manage your patients with cancer who then develop heart problems during their treatment. We hope that is helpful. We have had a lot of support from the Task Force that helped write this guideline. Myself and my Co-Chair, Teresa López-Fernández, from Spain are really grateful for all of the support from the Task Force members, and the reviewers, and the Clinical Practice Guidelines Committee. We hope you will find the Guideline helpful, both to assist your decision making, and to improve the health and well-being of your patients.