Hypertension in Cancer Patients and Survivors: Epidemiology, Diagnosis, and Management

Abstract

Cancer patients and survivors of cancer have a greater burden of cardiovascular disease compared to the general population. Much of the elevated cardiovascular risk in these individuals is likely attributable to hypertension, as individuals with cancer have a particularly high incidence of hypertension following cancer diagnosis. Treatment with chemotherapy is an independent risk factor for hypertension due to direct effects of many agents on endothelial function, sympathetic activity, and renin-angiotensin system activity as well as nephrotoxicity. Diagnosis and management of hypertension in cancer patients requires accurate blood pressure measurement and consideration of potential confounding factors, such as adjuvant treatments and acute pain, that can temporarily elevate blood pressure readings. Home blood pressure monitoring can be a useful tool to facilitate longitudinal blood pressure monitoring for titration of antihypertensive medications. Selection of antihypertensive agents in cancer patients should account for treatment-specific morbidities and target organ injury.

Keywords: Cancer Survivorship; Hypertension; Outcomes; Pharmacotherapy.

Graphical abstract

Central Illustration

Multidimensional Relationship Between Cancer, Hypertension, and Cardiovascular Disease Hypertension, chronic kidney disease, and cancer have a number of common risk factors, including smoking, diabetes, and obesity, which in turn are associated with increased risk of major adverse cardiovascular events. Cancer and cancer treatment are risk factors for hypertension and chronic kidney disease. Hypertension and chronic kidney disease have a bidirectional relationship. Chronic kidney disease is associated with an increased risk of several cancers, including urothelial cancer, skin cancer, and thyroid cancer.

Figure 1

Approach to Home BP Monitoring in Cancer Patients and Survivors High-risk cancer therapies include anti-VEGF therapy, tyrosine kinase inhibitors, alkylating agents, and high-dose corticosteroids. BP = blood pressure; VEGF = vascular endothelial growth factor.

Figure 2

Approach to Treating Hypertension in Patients Receiving Cancer Therapy The blood pressure threshold for initiation and titration of treatment will vary depending on an individual’s risk factors and goals of care (1). It may be beneficial to defer ACE inhibitors, ARBs, diuretic agents, and mineralocorticoid antagonists in individuals at risk of volume depletion, or to employ sick-day protocols (104). The yellow box at the lower left indicates fourth-line agents; we recommend exhausting other options before using these agents. The orange box at the lower right indicates a possible choice of action, made in collaboration with the patient and medical providers, when the blood pressure remains uncontrolled despite the addition or titration of multiple antihypertensive agents. ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker.