Also monitoring cardiac biomarkers in cancer

Today, thanks to modern treatment methods, 80% of patients survive. mammary cancer and up to 10% die not from malignant neoplasms, but from cardiovascular causes, reported Prof. Dr. Jutta Bergler-Klein from the University Hospital of Cardiology in Vienna on the occasion of the 130th DGIM Congress in Wiesbaden (1). Among all cancers, cardiovascular mortality ten years after a cancer diagnosis is six times higher than for people of the same sex and age without a cancer diagnosis, he explained. For some cancers, the long-term risk of cardiovascular mortality exceeds the risk of death from cancer (2).

Basic check for everyone

For this reason, the European Society of Cardiology (ESC), together with the European Society of Radiotherapy ESTRO and the International Society of Cardio-Oncology IC-OS, have issued guidelines on cardio-oncology (3). An initial evaluation to assess the risk of cardiovascular toxicity is recommended in all patients diagnosed with cancer before initiating therapy. In addition to a history and physical examination assessing cardiovascular risk factors, this also includes laboratory values ​​and an ECG, Bergler-Klein emphasized, adding that echocardiography should also be performed if there is an increased risk of cardiotoxicity.

All patients should be informed about a healthy lifestyle and the presence of risk factors for cardiovascular disease or existing cardiovascular disease and the need for appropriate treatment. The goal is to provide effective cancer therapy even at high cardiovascular risk.

It also increases BNP and troponin.

Bergler-Klein recommended measuring BNP (B-type natriuretic peptide) or NT-proBNP (N-terminal proBNP) and cardiac troponin (cTn) before treatment, as part of monitoring during and periodically after treatment, and as an ECG. perform with the same frequency. “This can happen not only heart failure“, he emphasized. Depending on the treatment, one should also expect arrhythmias, myocarditis, arterial hypertensionischemia or cerebrovascular accidents.

Cardiovascular side effects or worsening of existing cardiovascular diseases may occur not only with therapy anthracycline, but also in cancer treatments targeting HER2 inhibitors. vascular endothelial growth factor receptor (VEGFR), BCR-ABL tyrosine kinase inhibitors, RAF and MEK inhibitors, proteasome inhibitors., immunotherapy or androgen deprivation therapy. The ESC has developed specific protocols for basic screening and monitoring of various cancer treatments.

Risks of different treatments

Cardiovascular risks vary depending on cancer therapy and need to be taken into account.

Anthracyclines

The incidence of cardiovascular events during anthracycline therapy is dose dependent and reaches about 65% at a dose of 250 mg/m². daunorubicin and even more radiation therapy for childhood cancer.

HER2-targeted therapy

With HER2-targeted therapy, the incidence of asymptomatic and symptomatic left ventricular dysfunction ranges from 15% to 20%. Due to the potential for additive effects, concomitant use of HER2 therapy and anthracyclines is not recommended. The risk of cardiotoxicity with HER2-targeted therapies is particularly high in patients with cardiovascular risk factors or existing cardiovascular disease.

Bergler-Klein recommended frequent monitoring and effective treatment of risk factors and pre-existing heart disease. In addition to determining BNP and troponin, as well as an ECG, echocardiography should be performed before starting treatment and every three months or after every second or third cycle if there is a high cardiovascular risk.

EGFR inhibitors

Heart failure and venous thromboembolic events occur frequently (1–<10%) during treatment osimertinib, epidermal growth factor receptor (EGFR) inhibitor. Therefore, echocardiography is recommended before starting treatment and every three months during treatment.

VEGF inhibitors

Multiple cardiovascular toxicities may occur with both drugs. monoclonal antibodies anti-VEGF and with anti-VEGF receptor tyrosine kinase inhibitors (TKIs), e.g. hypertension (all), heart failure (e.g. bevacizumab, axitinib, lenvatinib or sorafenib), myocardial ischemia and infarction (eg, axitinib, lenvatinib, pazopanib or sorafenib) or QT prolongation (eg. vandetanib).

In addition to general monitoring for cardiovascular toxicity, patients are advised to self-measure blood pressure and undergo echocardiography and biomarker measurements every three months.

ALA inhibitors

ALK tyrosine kinase inhibitors may cause hyperglycemia and Diabetes. In addition, there is often a risk of side effects associated with hypertension (especially when brigantinib, crizotinib And lorlatinib), sinus bradycardia (especially common with crizotinib), and QT prolongation (eg, with brigantinib and ceritinib).

ECG monitoring is recommended four weeks after initiation of treatment and then every three to six months for all ALK inhibitors. Patients should self-monitor their blood pressure during treatment with brigantinib, crizotinib and lorlatinib.

TKI BCR-ABL

Anti-BCR-ABL TKIs used in chronic myelogenous leukemia And in acute lymphoblastic leukemia a positive BCR-ABL result may cause or worsen hypertension (especially ponatinib), but they also have many other cardiovascular side effects. Also in this case, periodic echocardiography is part of the recommended surveillance.

BTK inhibitors

Bruton’s tyrosine kinase (BTK) inhibitors are associated with an increased risk of arrhythmias. The risk is lower with second generation inhibitors. acalabrutinib And zanubrutinib than with the first generation TKI ibrutinib. In addition, treatment with BTK inhibitors is associated with a risk of bleeding, including cerebral hemorrhage; This should be taken into account, especially in elderly patients. In certain circumstances, dual platelet inhibition should be discontinued during this therapy, Bergler-Klein said.

Long-term monitoring

ESC guidelines recommend an ECG, blood pressure measurement and BNP and lipid supplementation every five years if people are at moderate cardiovascular risk (3). Patients who have received radiation doses greater than 15 Gy should undergo noninvasive screening for coronary artery disease every five to ten years. For head and neck irradiation, it is recommended to perform a carotid ultrasound every five years. In patients who have received irradiation to the abdominal and pelvic organs, if renal function deteriorates or arterial hypertension occurs, the renal arteries should also be examined using ultrasound.

Fountain: Gelbe