Cardio-oncology: an overview on outpatient management and future developments

Abstract

Recent advances in the early detection and treatment of cancer have led to increasing numbers of cancer survivors worldwide. Nonetheless, despite major improvements in the outcome of these patients, long-term side effects of radio- and chemotherapy affect both patient survival and quality of life, independent of the oncological prognosis. Chemotherapy-related cardiac dysfunction is one of the most notorious short-term side effects of anticancer treatment, occurring in ~10% of patients. Progression to overt heart failure carries a strikingly poor prognosis with a 2-year mortality rate of 60%. Early detection of left ventricular damage by periodic monitoring and prompt initiation of heart failure treatment is key in improving cardiovascular prognosis. To meet the growing demand for a specialised interdisciplinary approach for the prevention and management of cardiovascular complications induced by cancer treatment, a new discipline termed cardio-oncology has evolved. However, an uniform, multidisciplinary approach is currently lacking in the Netherlands. This overview provides an introduction and comprehensive summary of this emerging discipline and offers a practical strategy for the outpatient management of this specific patient population.

Keywords: Cardio-oncology; Cardiotoxicity; Chemotherapy; Heart failure.

Fig. 1

Time frame of detection and treatment of cardiotoxicity. Early initiation of heart failure treatment (green, blue line) leads to better outcomes regarding recovery of contractile function. Initiation of heart failure treatment at time when symptoms are present (red line) results in poor outcomes regarding recovery of cardiac function. cTn Cardiac troponin, CTRCD chemotherapy-related cardiac dysfunction, NYHA New York Heart Association classification

Fig. 2

Echocardiographic deformation imaging. Longitudinal follow-up of a 51-year-old female with breast cancer with a high cardiovascular risk (Cardiotoxicity Risk Score 7: female, hypertension, concurrent anthracyclines, and high-risk agent trastuzumab). After the initial 4 × AC (adriamycin-cyclophosphamide) there was a significant decrease of >15% in global longitudinal strain (GLS) with preservation of left ventricular ejection fraction (LVEF). During the trastuzumab treatment there was a subsequent decrease in LVEF of >10%. After interruption of the trastuzumab treatment, the LVEF showed a complete recovery

Fig. 3

a–c Cardiac magnetic resonance imaging. Cardiac magnetic resonance imaging with T1 mapping in a female breast cancer survivor, treated with anthracyclines. Extracellular volume fraction (ECV) is a non-invasive measurement of diffuse myocardial fibrosis and can be calculated from the haematocrit; pre-contrast (a), post-contrast (b) T1 maps. In this patient, the ECV map (c) reveals diffuse elevated ECV values up to 42% (normal is <28%), in particular in the septal segments, reflecting widespread myocardial fibrosis after anthracycline exposure

Fig. 4

a–c Response and outcome to heart failure (HF) treatment in patients with chemotherapy-related cardiac dysfunction. a Percentage of (partial) responders according to the time elapsed from diagnosing left ventricular dysfunction and start of HF therapy. b Left ventricular ejection fraction in patients with cardiotoxicity and with no (square/red), partial (triangle/blue) or full (dot/green) recovery following heart failure therapy. c Cumulative cardiac event rate during follow-up. Reprinted from: [3, 49]. CT Chemotherapy

Fig. 5

Cardio-oncology care at the University Medical Centre Utrecht, The Netherlands. AC Anthracyclines; BNP brain natriuretic peptide; CMR cardiac magnetic resonance; CRS Cardiotoxicity Risk Score; CTRCD chemotherapy-related cardiac dysfunction; GLS global longitudinal strain; LVEF left ventricular ejection fraction; SCT stem-cell transplantation. *To be considered, depending on local policy