JAHA: Statement on cardiovascular toxicity related to cancer treatment in France

JAHA: Statement on cardiovascular toxicity related to cancer treatment in France, based on the integration of US and European oncological cardiology guidelines.

Experts focused on anti-cancer drugs with the highest risk of cardiovascular toxicity, and proposed corresponding cardiovascular toxicity management and monitoring programs.

In recent years, tremendous progress has been made in the field of cancer treatment, and the prognosis of cancer patients has improved significantly. However, these treatments benefit patients and also bring different toxicities, which may have adverse effects on the short-term and long-term outcomes of cancer treatment. Among them, cardiovascular toxicity is one of the biggest challenges facing cancer treatment, and the success of the best treatment plan for cancer is closely related to its cardiovascular toxicity. Cardiovascular toxicity is not limited to anthracyclines and other more commonly used chemotherapy drugs. Currently, a variety of emerging targeted drugs and immunotherapy drugs also have cardiotoxicity.

Some oncology and cardiology management societies in the United States and Europe have issued their own guidelines that provide recommendations on the management and monitoring of cardiovascular toxicity related to cancer treatment. However, due to the low level of evidence in the various guidelines, there are large differences between the guidelines, which ultimately leads to no consistent evidence for clinicians to follow.

In this context, the expert team members of the French Oncology and Cardiology Working Group analyzed and synthesized the latest American and European guidelines, and proposed corresponding clinical pathways and decision-making plans, which are convenient for clinicians to apply in practice. In this statement, experts focused on anticancer drugs with the highest risk of cardiovascular toxicity, and proposed corresponding cardiovascular toxicity management and monitoring programs.

This statement comprehensively analyzes many relevant guidelines, including the 2017 and 2018 guidelines of the American Society of Clinical Oncology (ASCO), the 2017 and 2020 guidelines of the European Society of Clinical Oncology (ESMO), and the 2016 guidelines of the European Society of Cardiology (ESC).

For monitoring strategies for cardiovascular toxicity, this statement mainly analyzes high-risk drugs, including anthracyclines, human epidermal growth factor-2 inhibitors (HER2is), vascular endothelial growth factor inhibitors (VEGFis), Bcr-Abl Kinase inhibitors (Bcr-Ablis), proteasome inhibitors (proteasomeis), immune checkpoint inhibitors (ICis) and ibrutinib. This statement does not address cardiovascular toxicity related to hormone therapy and radiation therapy. In addition, this statement does not provide detailed information related to each specific cancer treatment, because this part of the data is already covered in the current guidelines.

Patients at high risk of cardiovascular toxicity

History of exposure to dose anthracyclines (for example, doxorubicin ≥250mg/m², epirubicin ≥600mg/m²)
High-dose radiotherapy with the heart in the irradiation field (≥30Gy)
Low-dose anthracyclines (such as adriamycin <250mg/m², epirubicin <600mg/m²) or HERis or VEGFis or proteasome inhibitors or Bcr-Ablis, and any of the following factors: age ≥ 60 years; Low-dose radiotherapy with the heart in the radiation field (<30Gy); there are ≥2 risk factors, including smoking, hypertension, diabetes, dyslipidemia, chronic renal insufficiency, and obesity
Underlying heart disease
Elevated cardiac biomarkers (NT-proBNP or BNP or troponin) before starting anti-cancer treatment

Comprehensive cardiovascular assessment included

Clinical consultation and evaluation of risk factors (including blood pressure measurement)
ECG examination
Blood glucose, blood lipid level, glomerular filtration rate
Overall cardiovascular risk assessment (in accordance with current guidelines)
Transesophageal ultrasound: Including the measurement of LVEF and GLS. The best choice for measuring LVEF is three-dimensional ultrasound, or at least two-dimensional Simpson biplane measurement; If the longitudinal strain of the left ventricle cannot be measured, then M-mode echocardiography can be used to measure the mitral valve annulus displacement and
The use of contrast agents for left ventricular sonocontrast in two-dimensional echocardiography may have some clinical significance
If the TTE display effect is not good, it is recommended to use CMR
Use the same imaging method for monitoring
Actively manage adjustable cardiovascular risk factors and diseases
Encourage regular exercise and develop healthy eating habits

(Note: All the above indicators should be baseline measured at the first assessment; during follow-up follow-up, they should be repeated only when cancer treatment may affect the corresponding indicators.)

(source:internet, reference only)

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