Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations

Abstract

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.

Keywords: Clinical Practice Guidelines; cardiac disease; cardiovascular toxicity; diagnosis; recommendations.

Figure 1.. Proposed monitoring and management approach for patients undergoing potentially cardiotoxic anticancer therapy.

ECG, electrocardiogram; GLS, global longitudinal strain; HF, heart failure; LVEF, left ventricular ejection fraction. ^a LVEF assessment may include GLS as well if available. ^b Cardiac biomarkers include: troponin and natriuretic peptides. ^c Under certain circumstances, if cardiotoxic therapy is the only viable option for anticancer treatment, it can be considered after close collaboration with cardio-oncology. ^d Cardioprotective therapy includes: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, carvedilol, spironolactone ± statin.