Abstract
Dear Editor
In recent years, significant milestones have been achieved in anti-cancer therapy, resulting in improved mortality rates, quality of life, and survival rates for cancer patients. However, the use of chemotherapeutic agents has been associated with cardiovascular adverse effects (CVAEs), which can result in morbidity and mortality. CVAEs of chemotherapy can range from mild to severe and can include conditions such as hypertension, heart failure, cardiomyopathy, and arrhythmias. The incidence and severity of CVAEs can vary depending on the specific chemotherapy drug used, the patient’s medical history, and other factors. 1 CVAEs can occur during or after chemotherapy, with varying severity and time of onset. Therefore, preventing and managing CVAEs in cancer patients is of utmost importance to optimize their treatment outcomes and quality of life.
There are several chemotherapy drugs that have been associated with CVAEs. One class of anti-cancer drugs that is commonly associated with CVAEs is anthracyclines. Anthracyclines, such as doxorubicin and epirubicin, are widely used in the treatment of various malignancies, including breast cancer, lymphoma, and leukemia. However, their use can cause cardiotoxicity, leading to congestive heart failure and cardiac dysfunction. The mechanism of anthracycline-induced cardiotoxicity is multifactorial, including oxidative stress, mitochondrial dysfunction, and DNA damage.2, 3 Therefore, preventing and managing anthracycline-induced cardiotoxicity requires a multimodal approach, including baseline cardiac assessment, careful monitoring of cardiac function during treatment, and the use of cardio-protective agents such as dexrazoxane, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Several studies have demonstrated the efficacy of these interventions in reducing the risk of anthracycline-induced cardiotoxicity and improving long-term cardiac outcomes in cancer patients.4, 5 Monoclonal antibodies, such as trastuzumab and bevacizumab, are used in the treatment of breast and colorectal cancer, respectively. These drugs can cause various CVAEs, including hypertension, heart failure, and thromboembolic events. Strategies to prevent complications are using prophylactic anticoagulation, which can help in preventing thromboembolic events. Another strategy is the use of cardioprotective agents such as beta-blockers and ACE inhibitors, which can help prevent hypertension and heart failure.1, 2, 4, 5
Another class of anti-cancer drugs associated with CVAEs is tyrosine kinase inhibitors (TKIs). TKIs, such as imatinib and sunitinib, are commonly used in the treatment of chronic myeloid leukemia and renal cell carcinoma. However, their use can cause hypertension, left ventricular dysfunction, and QT interval prolongation. The mechanism of TKI-induced cardiovascular toxicity is related to their inhibition of vascular endothelial growth factor (VEGF) signaling, which can lead to endothelial dysfunction, vasoconstriction, and impaired cardiac function. Therefore, preventing and managing TKI-induced cardiovascular toxicity requires a careful monitoring of blood pressure, cardiac function, and electrocardiogram (ECG) parameters, as well as the use of anti-hypertensive medications, beta-blockers, and calcium channel blockers.1, 4, 5 Finally, immune checkpoint inhibitors (ICIs) have emerged as a promising class of anti-cancer drugs in recent years, with significant clinical benefits in various malignancies, including melanoma, lung cancer, and renal cell carcinoma. However, ICIs can cause immune-related adverse events (irAEs), including myocarditis, pericarditis, and arrhythmias. The mechanism of ICI-induced cardiovascular toxicity is related to their immune-stimulatory effects, which can lead to immune-mediated tissue damage and inflammation. Therefore, preventing and managing ICI-induced cardiovascular toxicity requires a high index of suspicion, prompt recognition, and early intervention with immunosuppressive therapy, such as corticosteroids and intravenous immunoglobulin.2–5
Unfortunately, these complications can negatively impact and even limit the options available for effective cancer treatment. In cases where patients are at high risk of cardiac complications, avoiding certain chemotherapy agents may be necessary. However, with proper management, cardiac toxicity can be controlled without reducing the overall benefits of chemotherapy. Given the potential risks and complications, it is crucial to carefully consider and assess each individual patient’s situation when selecting cancer treatment options. This includes taking into account their medical history, chemotherapy drug options, and potential risks for CVAEs.
Several clinical trials have investigated the use of beta blockers, ACE inhibitors & Angiotensin receptor-neprilysin inhibitors (ARNIs) in preventing adverse cardiovascular effects during chemotherapy.6, 7 A detailed description of few clinical trials were described below:
Preventing and managing CVAEs in cancer patients receiving chemotherapy is a complex and challenging task, requiring a multidisciplinary approach and close collaboration between oncologists, cardiologists, and other healthcare professionals. Several strategies are available to reduce the risk of CVAEs, including baseline cardiac assessment, careful monitoring of cardiac function during treatment, and the use of cardio-protective agents. During admission, a detailed history of cardiac diseases and family history should be taken. Regular follow-up is needed. Every cancer center should hire at least one cardiologist, who is trained in cardio-oncology. Certificate courses and postgraduate diploma courses can be conducted on cardio-oncology. Regular CME/Continued Medical Education can be conducted in the medical institutions on cardio-oncology. Currently, every international cardiology conference is focusing on cardio-oncology. Hospitals should encourage their doctors in attending these conferences. Most of the International Publishers could start a journal on Cardio-Oncology and Cardio-Oncology societies can be created by most of the nations. This is an era of personalized treatment, so proper guideline for treatment is needed on cardio-oncology. With the help of national cardio-oncology societies, it will be easy to store the case reports and analyse the case reports through a meeting. Gradually, a guideline will be created. Therefore, it is a high time to create Nation based Cardio-Oncology Society. The optimal approach may vary depending on the specific anti-cancer drugs used, the patient’s baseline cardiovascular risk, and the underlying malignancy. Therefore, individualized treatment plans and close follow-up are essential for better outcomes and prognosis of patients.
List of Abbreviation
CVAEs: cardiovascular adverse effects
DNA: deoxyribonucleic acid
ACE: angiotensin-converting enzyme
TKI: tyrosine kinase inhibitors
VEGF: vascular endothelial growth factor
ECG: electrocardiogram
ICI: immune checkpoint inhibitors
irAEs: immune-related adverse events
CME: continued medical education
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
