Cardio-oncology care in the era of the coronavirus disease 2019 (COVID-19) pandemic: An International Cardio-Oncology Society (ICOS) statement

Abstract

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has given rise to a pandemic of unprecedented proportions in the modern era because of its highly contagious nature and impact on human health and society: coronavirus disease 2019 (COVID-19). Patients with cardiovascular (CV) risk factors and established CV disease (CVD) are among those initially identified at the highest risk for serious complications, including death. Subsequent studies have pointed out that patients with cancer are also at high risk for a critical disease course. Therefore, the most vulnerable patients are seemingly those with both cancer and CVD, and a careful, unified approach in the evaluation and management of this patient population is especially needed in times of the COVID-19 pandemic. This review provides an overview of the unique implications of the viral outbreak for the field of cardio-oncology and outlines key modifications in the approach to this ever-increasing patient population. These modifications include a shift toward greater utilization of cardiac biomarkers and a more focused CV imaging approach in the broader context of modifications to typical practice pathways. The goal of this strategic adjustment is to minimize the risk of SARS-CoV-2 infection (or other future viral outbreaks) while not becoming negligent of CVD and its important impact on the overall outcomes of patients who are being treated for cancer.

Keywords: best practice; cancer; cardiac safety; cardio-oncology; coronavirus disease 2019 (COVID-19); pandemic; recommendations; virus.

FIGURE 1.

Cardio-Oncology Care in the Era of Coronavirus Disease 2019 (COVID-19). This is an overview of the changes in medical practice for patients with cancer in the setting of a viral pandemic such as COVID-19. These include proper preparation, execution of modified workflows, and maintenance of excellent care. Some modified practices evolving before and during peak times of a pandemic will likely remain in place to address persistent residual risk and resurges and/or those recognized to contribute to practice optimization in general. CV indicates cardiovascular; PPE, personal protection equipment.

FIGURE 2.

Workflow Outline for Cardio-Oncology in Times of a Viral Pandemic. Initial triage should take cardiovascular (CV) disease (CVD) acuity into consideration as well as the broader scope of the patient’s cancer care and the specific viral pandemic practice environment. COVID-19 indicates coronavirus disease 2019.

FIGURE 3.

Outline of High-Risk and Low-Risk Cardiovascular (CV) Conditions. All cases should be addressed on an individual basis. The type of clinical encounter is driven by the clinical presentation. Coronavirus disease 2019 (COVID-19) screening should be obtained for any patient to be seen in person and, ideally, for all patients proceeding with cancer therapy. Repeat and serial testing might be required. CVD indicates cardiovascular disease.

FIGURE 4.

Action Grid for Cardiac Biomarker Profile. This is an outline of recommendations based on the constellation of troponin and natriuretic peptide values and within the context of the clinical presentation. CV indicates cardiovascular. *NP indicates natriuretic peptides (B-type natriuretic peptide [BNP] and N-terminal pro-BNP [NT-proBNP]); troponin, troponin I or troponin T (normal vs abnormal levels are based on the institutional reference range). ϕAsymptomatic indicates the absence of symptoms of heart failure (HF) or acute coronary syndrome (ACS); symptomatic, symptoms of HF or ACS. #A consultation can happen in person or by telemedicine. Discussion should include initiation of cardioprotective therapy. ‡High-risk cancer therapy is that known to be associated with HF or left ventricular dysfunction (LVD). βCardioprotective therapy indicates that an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and/or carvedilol with or without a statin (if the patient is receiving anthracycline-containing chemotherapy) is recommended.