Exploring the Cardiotoxicity Spectrum of Anti-Cancer Treatments: Definition, Classification, and Diagnostic Pathways

Abstract

Early detection and treatment of cancer have led to a noticeable reduction in both mortality and morbidity. However, chemotherapy and radiotherapy could exert cardiovascular (CV) side effects, impacting survival and quality of life, independent of the oncologic prognosis. In this regard, a high clinical index of suspicion is required by the multidisciplinary care team in order to trigger specific laboratory tests (namely natriuretic peptides and high-sensitivity cardiac troponin) and appropriate imaging techniques (transthoracic echocardiography along with cardiac magnetic resonance, cardiac computed tomography, and nuclear testing (if clinically indicated)), leading to timely diagnosis. In the near future, we do expect a more tailored approach to patient care within the respective community along with the widespread implementation of digital health tools.

Keywords: cancer therapy-related cardiovascular toxicity; cardio-oncology; chemotherapy.

Figure 1

Cardio-oncology: an integrated approach throughout cancer disease [7]. Abbreviations: CV, cardiovascular, CVD, cardiovascular disease.

Figure 2

An integrated multidisciplinary approach in management of cancer patients [7].

Figure 3

Echocardiography in the evaluation of chemotherapy CV side-effects. A 58-year-old female patient with known dyslipidemia and no other cardiovascular disease (Panel A). The patient was affected by stage IIIC high-grade serous ovarian cancer. She underwent four sessions of taxol/carboplatin protocol (S/P 4 cycles) before surgical debulking. After the last chemo session, she developed shortness of breath during mild physical effort which she never experienced before. At TTE, a significant reduction in LVEF and GLS compared with the baseline was seen (Panel B). The patient was put on metoprolol and Lisinopril. Atorvastatin and TTE were repeated after 1 month with evidence of mild improvement in LVEF and GLS (Panel C). Abbreviations: EF, left ventricular ejection function; GLS, global longitudinal strain; TEE, transthoracic echocardiography.

Figure 4

Management of cancer therapy-related CVD: a stepwise approach [2,7,36,38,82,83,84,85,86,87]. BNP = brain natriuretic peptide; CHT = chemotherapy; CMR = cardiac magnetic resonance; CT = computed tomography; CTA = computed tomography angiography; FFR = fractional flow reserve; CVD = cardiovascular disease; HF = heart failure; GLS = global longitudinal strain; LVD = left ventricular dysfunction; LVEF = left ventricular ejection function; NT-proBNP = N-terminal pro-brain natriuretic peptide; PH = pulmonary hypertension; RT = radiotherapy; VHD = valvular heart disease. * It is important to inquire about the presence of ferromagnetic components if the patient has breast tissue expanders. ** Including cardiologists, oncologists, radiotherapist oncologists, and hematologists.