ESC: Primary prevention, management of CV issues important in patients with cancer
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The European Society of Cardiology task force on cardio-oncology has issued its inaugural guideline for the prevention and management of cardiotoxicity before, during and after adult patients are treated with anticancer therapies.
The guideline was developed by the ESC task force on cardio-oncology in collaboration with the European Hematology Association, the European Society for Therapeutic Radiology and Oncology and the International Cardio-Oncology Society and presented at the ESC Congress.
“The impact of prevention is to improve the outcome of oncology patients further by primary cardiovascular prevention with baseline cardiovascular assessment and secondary prevention in patients who have previous cardiovascular disease or cardiovascular toxicity that occurred in previous cancer treatment or in current cancer treatment,” Jutta Bergler-Klein, FESC, FHFA, FEACVI, professor of medicine in the department of cardiology at the Medical University of Vienna, said during the presentation. “Management of cardiovascular disease and cardiovascular risk factors should be performed according to current ESC guidelines as a class I indication. ... Primary prevention and management of cardiovascular risk factors should be performed before, during and after cancer therapy, of course, without delaying the vital cancer treatment.”
The document was simultaneously published in the European Heart Journal.
CV toxicity risk stratification before cancer therapy
“We have done a lot of improvement in cancer treatment. Different new molecules are coming to our patients in daily practice, and they are improving patient survival,” Evandro de Azambuja, MD, PhD, head of the medical support team and oncologist at Institut Jules Bordet in Brussels, said during the presentation. “We know that the new molecules that you are using now are targeting different pathways. And these pathways may ultimately develop some cardiac event. ... We tested these [molecules] first in clinical trials, but the clinical trial patient population is a very selective patient population. So, what we see sometimes in real life is that cardiac events [occur] more often than those reported in the trials.”
To this point, de Azambuja stated that tailored cancer treatments are needed to improve the efficacy of therapy, reduce cardiotoxicity and improve patient prognosis.
Before cancer therapy, the new guidelines recommend the following:
- Cardiotoxicity risk stratification should be completed using the Heart Failure Association of the ESC in collaboration with the International Cardio-Oncology Society (HFA-ICOS) model before cancer therapy initiation.
- Patients should be made aware of the results of risk stratification.
- Patients deemed low risk are recommended to initiate cancer therapy without delay.
- Patients deemed moderate risk should be considered for cardiology referral.
- Patients with a history of CVD or deemed high or very high risk should be referred to a cardiologist.
- A multidisciplinary approach is recommended before cancer therapy initiation.
Monitoring for CV risk during cancer therapy
“The new guidelines offer explicit strategies for prevention and surveillance for each cancer treatment and radiation therapy to avoid cancer therapy-related cardiovascular toxicity,” Bergler-Klein said during the presentation. “The frequency of cardiac surveillance follows the baseline cardiovascular risk ... and the specific cancer treatment. Clinical assessment, blood pressure, lipids, diabetes assessment and ECG should be used. Echocardiography, including ejection fraction 3D, if at any means available, global longitudinal strain and cardiac biomarkers with [B-type natriuretic peptide] and troponin should be used.”
Bergler-Klein detailed the following recommendations for CV risk mitigation during the receipt of cancer therapy:
- It is recommended that CV risk factors be managed in accordance with the 2021 ECG Guidelines on CVD prevention at all points before during and after treatment.
- Dexrazoxane is recommended for adults with cancer at high and very high cardiotoxic risk according to the HFA-ICOS model when anthracyclines are indicated.
- Liposomal anthracyclines are recommended in adults with cancer at high and very high cardiotoxic risk when anthracyclines are indicated.
- ACE inhibitors or angiotensin receptor blockers are recommended for primary prevention of HF among adults with cancer at high and very high risk already receiving anthracyclines and or anti-HER2 therapies.
- ACE inhibitors or angiotensin receptor blockers plus beta-blockers are recommended for primary prevention in HF among adults with cancer at high and very high risk receiving targeted therapies that could cause HF.
- Statins may be considered for primary prevention in adults with cancer at high or very high risk for cardiotoxicity.
Bergler-Klein concluded that preventive treatment for CV risk factors in high-risk patients at baseline and at any sign of cardiotoxicity during cancer therapy should be initiated promptly.
CV risk at end-of-cancer therapy and long-term follow-up
“The end-of-cancer therapy cardiovascular risk assessment period covers the first 12 months after being exposed to cardiotoxic cancer treatment,” Thomas M. Suter, MD, FESC, FHFA, head of the cardio-oncology service and member of the section for heart failure and cardiac transplantation at Bern University Hospital, Switzerland, said during the presentation. “The two main goals of the end-of-cancer therapy risk assessment are ... to identify the patients with cancer treatment-related cardiotoxicity early and to identify the patients at risk for late cancer treatment-related cardiovascular complications.”
Suter, who is also the outgoing president of the ESC task force on cardio-oncology, highlighted the following groups identified in the new guideline as needing surveillance during the 12 months after potentially cardiotoxic cancer therapy:
- patients at high or very high baseline cardiotoxic risk as determined by the HFA-ICOS model;
- patients who received increased doses of doxorubicin, radiation therapy or a combination of the two;
- patients who experienced any cardiotoxic symptoms during therapy, including cancer therapy-related cardiac dysfunction, immune checkpoint inhibitor-associated myocarditis, arrhythmias, ACS, stroke or peripheral vascular disease; and
- patients with any new CV symptoms or asymptomatic abnormalities on echocardiography and/or CV biomarkers.
Potential long-term complications related to cardiotoxic cancer treatments include but are not limited to myocardial dysfunction, HF, CAD, valvular disease, peripheral artery disease, stroke, pericardial complications, arrhythmias, metabolic syndrome and pulmonary hypertension.
“Cancer survivorship programs typically start 2 to 5 years after the completion of cancer therapy,” Suter said during the presentation. “Based on the baseline risk and cancer treatment used, these cancer survivors should particularly be screened [for these complications].”
Please see the document for full details on the ESC task force on cardio-oncology recommendations.
References:
- Advice to prevent heart problems caused by cancer therapy published today. www.escardio.org/The-ESC/Press-Office/Press-releases/Advice-to-prevent-heart-problems-caused-by-cancer-therapy-published-today. Published Aug. 26, 2022. Accessed Aug. 31, 2022.
- ESC Guidelines on cardio-oncology. www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Cardio-oncology-guidelines. Published Aug. 26, 2022. Accessed Aug. 31, 2022.
- Humbert M, et al. Eur Heart J. 2022;doi:10.1093/eurheartj/ehac237/6673929.
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Lyon A, et al. 2022 ESC Guidelines on cardio-oncology. Presented at: European Society of Cardiology Congress; Aug. 26-29, 2022; Barcelona, Spain (hybrid meeting).
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