Improved risk stratification with SCORE2 on top of HFA-ICOS in cancer patients without previous cardiovascular disease

Abstract Background The 2022 ESC Guidelines on cardio-oncology recommend using the HFA-ICOS (Heart Failure Association and International Cardio-Oncology Society) four-category risk stratification tool to assess cardiovascular (CVD) risk in cancer patients to guide preventive treatments and follow-up. When used in practice, however, the tool identifies large, heterogeneous groups as either low or moderate risk, without offering further tools to stratify within this group. Integrating traditional continuous risk scores, such as SCORE2/SCORE2-OP, may fill this gap by offering further risk stratification within HFA-ICOS groups. Purpose To evaluate whether the combined use of HFA-ICOS and SCORE2/SCORE2-OP improves risk stratification in cancer patients without prior CVD in comparison to HFA-ICOS alone. Methods We included 2,602 cancer patients from a population-based cohort diagnosed after 2017. After excluding 772 patients due to SCORE2/SCORE2-OP exclusion criteria, 1,830 patients remained eligible for analysis. CVD endpoints (myocardial infarction, stroke, and CVD death) were obtained from the time of cancer diagnosis until December 2023. Cancer treatment data were retrieved from the Norwegian Cancer Registry, and CVD outcomes from hospital and death registries. The cumulative incidence function was used to estimate the risk of CVD events, accounting for competing risks of non-CVD death. Results Mean age was 67.5 years (SD 10.5), 48% male. Most common cancers were gastrointestinal (22%), prostate (16%) and breast (13%). In total, 9% received anthracyclines, 4% vascular endothelial growth factor inhibitors and 5% immune checkpoint inhibitors. HFA-ICOS classified 493 (27%) patients as low, 1,018 (56%) as moderate, and 319 (17%) as high risk. Using age-dependent guideline recommend cut-offs for SCORE2, 526 (29%) were classified as low-moderate risk, 928 (51%) as high risk, and 376 (21%) as very high risk. Notably, within the HFA-ICOS moderate-risk group, SCORE2/ SCORE2-OP reclassified 14% (n=145) as very high risk, where intensified preventive treatment in general is recommended. Additionally, 69% (n=700) were reclassified to high risk, while 17% (n=173) remained low-moderate risk, Figure 1. During a median follow-up of 2.6 years, 94 first CVD events and 384 non-CVD deaths occurred. CVD incidence increased with higher risk categories in both HFA-ICOS (2% in low-risk, 5% in moderate-risk, 11% in high-risk) and SCORE2 (3% in low-moderate risk, 5% in high risk, and 10% in very high risk). Figure 2 shows survival curves for SCORE2 within the HFA-ICOS categories low, moderate and high. Conclusion While the HFA-ICOS risk stratification tool identifies patients at risk of CVD events, there is heterogeneity within the risk categories. The complementary use of continuous risk scores like SCORE2 may aid shared decision-making for preventive treatment and intensified follow-up, especially for patients classified as moderate risk by HFA-ICOS.