Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Abstract

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Keywords: Heart failure; and social determinants; bone marrow/stem cell transplant; cancer; cancer survivorship; cancer treatment-related cardiac dysfunction; cardio-oncology; cardiomyopathy; cardiotoxicity; health disparities; heart failure with preserved ejection fraction; heart failure with reduced ejection fraction; mechanical circulatory support; multidisciplinary care; myocarditis; palliative care; pregnancy; pulmonary hypertension; stress cardiomyopathy.

Fig. 1.

Definitions of heart failure and cancer treatment-related cardiac dysfunction (CTRCD) in select professional society statements and oncology clinical trials. AHA American Heart Association; ACC, American College of Cardiology; HFSA, Heart Failure Society of America; HF, Heart Failure; IC-OS, International Cardio-Oncology Society; ESC, European Society of Cardiology; NCI, National Cancer Institute; CTCAE v5, Common Terminology Criteria for Adverse Events, version 5. Adapted from 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, Universal Definition and Classification of Heart Failure, IC-OS Consensus Statement on Definitions of Cardiovascular Toxicities, 2022 ESC Guidelines on Cardio-Oncology, and CTCAEv5.

Fig. 2.

Role of palliative care across the spectrum of disease in patients with heart failure and patients with cancer. The figure depicts existing recommendations for patient populations most likely to benefit from palliative care referral and highlight the intersection of disease processes and opportunity for palliative care involvement in cardio-oncology. ^aSuggested populations are not comprehensive.

Fig. 3.

Multidisciplinary team approach to cardio-oncology and heart failure. Multidisciplinary team approach spans from the time of cancer diagnosis, during treatment and after cancer treatment completion. Goals and objectives of the cardio-oncology team aid with coordinated and optimized care.