Cardio-Oncology: When Cancer and Cardiovascular Health Collide

By Vlad G. Zaha, M.D., Ph.D., Assistant Professor of Internal Medicine, and Anjali Rao, M.D., Cardiology Fellow

The importance of cardiovascular health before, during, and after cancer therapy has received considerable attention, leading to the new field of cardio-oncology. At #AHA20, we both had the opportunity to present work in this field. One of us (VZ) had the privilege to present in a plenary session titled “Novel Practical Concepts in Cardio-Oncology,” along with Drs. Bonny Ky and Javid Moslehi, two nationally recognized leaders in this field. The presentation focused on post-cancer treatment cardiovascular risk and highlighted several key points: 1) traditional and novel cancer therapies have a short-term as well as a latent, long-term cardiovascular risk; 2) preventive cardiovascular interventions are important, targeting blood pressure control, sedentarism, and healthy nutrition; and 3) longitudinal monitoring with blood biomarkers and imaging studies is indicated in patients at risk.

A key development in recent years has been the emergence of immune checkpoint inhibitors (ICIs), agents that have changed the landscape of oncology yet also have been found to have important cardiac complications. One of us (AR) reported a systematic, tiered approach to treatment of ICI-induced autoimmune myocarditis (AIM) based on the clinical course of six consecutive patients with malignancy and ICI-induced AIM diagnosed at UT Southwestern. Severe cardiac manifestations included left ventricular systolic dysfunction and/or arrhythmias within one to three months of the first ICI dose. All patients had elevated cardiac blood biomarkers and cardiac MRI findings typical of myocarditis. A multidisciplinary team of oncology, rheumatology, cardio-oncology, and advanced heart failure specialists actively participated in management. Initial pulse-dose steroids were followed by escalation therapies if patients did not improve. Escalation therapies included: abatacept (1), rituximab (1), plasma exchange (2), and mycophenolate mofetil (2). After clinical improvement, while on a steroid taper, maintenance immunosuppression with methotrexate (5) or mycophenolate mofetil (1) was initiated between four days and five months after presentation to care. This approach resulted in improved blood biomarkers and clinical status in all patients.

Our experience highlights that a multidisciplinary team familiar with immunomodulatory therapies is valuable and that a tiered approach is successful. In turn, we have developed a multidisciplinary immunotherapy working group composed of UTSW faculty members in the areas of cardiology, oncology, rheumatology, endocrinology, neurology, pulmonology, and gastroenterology. We look forward to contributing to multicenter research projects and addressing new questions in the care of oncology patients with cardiovascular disease.