Essentials of cardio-oncology

Abstract

Cardio-oncology is a subspecialty that provides cardiac care for patients with cancer. Newer oncological agents have not only increased survivorship, but also sprouted novel cardiovascular toxicity (CVT) involving any component of the cardiovascular system, albeit with some preferential targets. Patients with cancer should undergo a baseline cardiovascular risk assessment and have individualised surveillance planned during cancer therapy and post treatment. The early diagnosis of CVT, by clinical history and examination along with imaging and laboratory analysis, is paramount. Management includes cardioprotective strategies and multidisciplinary decision-making regarding the risk-benefit ratio of oncological treatment based on CVT.

Keywords: NEWS; deterioration; hypercapnia; patient safety; respiratory failure.

Fig 1

Cancer treatment-related cardiovascular toxicity (CVT). Despite each therapeutic class having the potential to cause multiple CVTs, some oncological drugs have a predilection for certain components of the cardiovascular system. The most common conventional chemotherapies are alkylating agents (eg cyclophosphamide), anthracyclines (eg doxorubicin and epirubicin), antimetabolites (eg 5-fluorouracil (5-FU) and capecitabine), microtubule-binding agents (eg paclitaxel and docetaxel) and platinum-based agents (eg cisplatin). The target therapies more frequently used are human epidermal growth factor receptor 2 (HER-2) inhibitors (eg trastuzumab and pertuzumab), proteosome inhibitors (eg bortezomib and carfilzomib), vascular endothelial growth factor (VEGF) inhibitors (eg bevacizumab and sunitinib), BCR-ABL1 inhibitors (eg dasatinib, nilotinib and ponatinib) and Bruton tyrosine kinase (BTK) inhibitors (e.g. ibrutinib and acalabrutinib). More recent immunotherapies include immune checkpoint inhibitors (eg pembrolizumab, nivolumab and atezolizumab) and chimeric antigen receptor (CAR) T cell therapy. Side effects of radiation usually occur years or even decades following exposure and can affect any cardiovascular structure.

Fig 2

Cardio-oncology patient clinical trajectory. The patient at the centre is followed up by the multidisciplinary team after diagnosis and during cancer therapy. There has been a paradigm shift in cancer as a chronic disease, because some cancers have sequelae even when they are considered cured. Pretreatment cardiovascular assessment, detection and management of CVT and surveillance of survivors at higher risk for cardiovascular disease (CVD) are key roles of a cardio-oncologist. CAD = coronary artery disease; ECG = electrocardiogram.