Screening for Coronary Artery Disease in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review

Abstract

Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. This review identifies features that could help guide decisions about the benefit of screening to assess the risk or presence of subclinical CAD. Screening may be appropriate in selected survivors based on risk factors and inflammatory burden. In cancer survivors who have undergone genetic testing, polygenic risk scores and clonal hematopoiesis markers may become useful CAD risk prediction tools in the future. The type of cancer (especially breast, hematological, gastrointestinal, and genitourinary) and the nature of treatment (radiotherapy, platinum agents, fluorouracil, hormonal therapy, tyrosine kinase inhibitors, endothelial growth factor inhibitors, and immune checkpoint inhibitors) are also important in determining risk. Therapeutic implications of positive screening include lifestyle and atherosclerosis interventions, and in specific instances, revascularization may be indicated.

Keywords: ACS, acute coronary syndrome; AYA, adolescent and young adult; CAC, coronary artery calcium; CAD, coronary artery disease; CHIP, clonal hematopoiesis of indeterminate potential; CMR, cardiac magnetic resonance; CTA, computed tomography angiography; CVD, cardiovascular disease; IGF, insulin-like growth factor; LDL, low-density lipoprotein; PCE, pooled cohort equations; PCI, percutaneous coronary intervention; PRS, polygenic risk score; ROS, reactive oxygen species; TKI, tyrosine kinase inhibitor; VEGF, vascular endothelial growth factor; calcification; coronary artery calcium; coronary artery disease; prevention; risk factor; risk prediction.

Graphical abstract

Central Illustration

Screening for CAD Risk and Subclinical CAD in Survivors The pillars of a program to identify and reduce risk are based on understanding what population to screen, how to proceed with screening, and the management implications. There are knowledge gaps in each of these aspects and additional research is needed to inform these gaps. CABG = coronary artery bypass grafting; CAC = coronary artery calcium; CAD = coronary artery disease; CT = computed tomography; CTCA = computed tomography coronary angiography; CV = cardiovascular; PCI = percutaneous coronary intervention.

Figure 1

Contribution of Traditional and Cancer-Related Risks to Coronary Artery Disease Cancer potentiates the development of atherosclerosis through factors that contribute to inflammation as well as aspects that potentiate traditional risk factors. CHIP = clonal hematopoiesis of indeterminate potential; GnRH = gonadotropin-releasing hormone; ICAM1 = intercellular adhesion molecule 1; IL = interleukin; LDL = low-density lipoprotein; TNF-α = tumor necrosis factor α; VCAM1 = vascular cell adhesion molecule 1; vWF = von Willebrand factor.

Figure 2

Mechanisms of Radiotherapy-Induced Cardiovascular Disease The cardiovascular effects of radiotherapy include both endothelial injury and tissue injury.^,,, BMDC = bone marrow–derived dendritic cell; SDF = stromal cell–derived factor; TGF = transforming growth factor; other abbreviations as in Figure 1.

Figure 3

Treatment Threshold for Atherosclerosis Based on Cardiovascular Disease Risks The primary determinant of treatment decisions is conventional risk assessment based on noncancer survivors, which may underestimate risk in survivors. For this reason, coronary artery calcium (CAC) scoring may potentially be of even greater value than normal in reclassifying risk and consideration of statin therapy in low- to moderate-risk groups.^, ASCVD = atherosclerotic cardiovascular disease; LDL-C = low-density lipoprotein cholesterol.