Close BP monitoring important before, during and after cancer therapy
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In a scientific statement, the American Heart Association issued guidance on the epidemiology, diagnosis and management of cancer therapy-induced hypertension.
The joint statement from the AHA councils on hypertension; arteriosclerosis, thrombosis and vascular biology; and the kidney in CVD was published in Hypertension.
Data were derived from Cohen JB, et al. Hypertension. 2023;doi:10.1161/HYP.0000000000000224.
“While newer anticancer drugs have been very beneficial in treating cancers, several of these drugs — particularly VEGF inhibitors, tyrosine kinase inhibitors (TKIs) and proteosome inhibitors — can increase the risk for hypertension and worsen BP control among people with hypertension, as can agents used as adjunctive therapy in cancer treatment, such as [calcineurin inhibitors], steroids and NSAIDs,” Jordana B. Cohen, MD, MSCE, assistant professor of medicine and of epidemiology in biostatistics and epidemiology at the Perelman School of Medicine of the University of Pennsylvania and vice chair of the statement writing committee, told Healio. “Patients receiving anticancer drugs associated with hypertension should have careful baseline assessment and longitudinal monitoring of their BP and other CV risk factors. Given the high risk for worsening hypertension on these drugs, we recommend at least weekly BP monitoring for the first 2 months of treatment.”
Concurrent cancer and hypertension is frequent, according to the statement, and the increased CV risk in patients with cancer is commonly explained by the presence of risk factors, including smoking, diabetes, chronic kidney disease, sedentary lifestyle, obesity, oxidative stress and inflammation.
In this scientific statement, Cohen and colleagues reviewed the epidemiology and diagnosis of cancer therapy-induced hypertension; identified specific cancer therapies associated with increased BP; and the management of cancer therapy-related hypertension among cancer survivors.
Cancer therapies associated with hypertension
Cancer therapies associated with hypertension include: VEGF signaling pathway inhibitors, BRAF/MEK inhibitors, BTK inhibitors, RET receptor-TKIs, poly(ADP-ribose) polymerase inhibitors, proteasome inhibitors, platinum-based compounds, alkylating antineoplastic agents, calcineurin inhibitors, inhibitors of mTOR, antiandrogens/aromatase inhibitors and certain adjunctive therapies used in cancer management.
The committee added that many of these cancer therapies may also worsen BP control in patients with existing hypertension; however, their impact on BP is often reversible after discontinuation, according to the statement.
“There are still major gaps in our understanding of how several anticancer drugs cause hypertension,” Cohen told Healio. “We do not have high-quality evidence to guide antihypertensive management in these patients, and thus extrapolate a lot of our recommendations from what we recommend to the general population. For example, there is limited evidence on whether targeted therapy with specific antihypertensive medications may be helpful. Additionally, we do not have data on optimal timing or frequency of BP monitoring and CV risk assessment during and after treatment with anticancer drugs.”
Management before, during and after cancer therapy
Before cancer therapy initiation, the committee recommends standardized BP measurement with automated office or ambulatory BP monitoring and initiation of lifestyle modification and therapy in patients with BP greater than 140/90 mm Hg or with BP of 130/80 mm Hg plus elevated 10-year atherosclerotic CVD risk or other comorbidities.
Antihypertensive therapy should be optimized before cancer therapy initiation, according to the statement.
The committee recommends that while patients are on cancer therapies associated with increased BP, weekly BP monitoring should be conducted for the first 4 to 8 weeks of use and upon treatment discontinuation. Options of first-line antihypertensive agents remain the same as the general population, according to the statement.
After discontinuation of cancer therapy, deintensification of antihypertensive therapy may be necessary to reduce risk for hypotension, the committee wrote.
In addition, use of 12-lead ECG, cardiac imaging, creatinine cystatin C and urinalysis may be necessary for continued monitoring for hypertension and associated target organ damage from cardiotoxic cancer therapies.
“Cancer survivors are at higher risk of hypertension than the general population, even after completing treatment,” Cohen told Healio. “While researchers try to better understand the mechanisms and best approaches to managing and mitigating risk in these patients, it’s important as providers to ensure close BP monitoring over the long term, including education on home BP monitoring using appropriate technique, with a validated device.”
For more information:
Jordana B. Cohen, MD, MSCE, can be reached at jco@pennmedicine.upenn.edu.
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