Assessment of ESC risk stratification for cancer therapy-related cardiovascular toxicity in a real-world urban population

Background Cancer therapy-related cardiac dysfunction (CTRCD) and other cancer therapy related-cardiovascular toxicities (CTR-CVT) are significant complications of oncologic treatments. The 2022 European Society of Cardiology (ESC) cardio-oncology guidelines provide a risk stratification framework to predict these adverse outcomes; however, its generalizability to racially and ethnically diverse populations remains unvalidated. Purpose This study evaluates the predictive performance of the ESC risk stratification model in a diverse urban cohort, with a focus on historically underrepresented racial and ethnic groups. Methods A retrospective cohort study was conducted at a tertiary urban institution, including 1,569 adult patients who received multiple myeloma (MM) therapies or anthracyclines (ANT) between 2010 and 2023. Patients self-identified as Non-Hispanic Black (NHB), Hispanic/Latinx (HL), or Non-Hispanic White (NHW). Primary outcomes of CTRCD and CTR-CVT were defined according to ESC guidelines. Clinical data including ICD-coded diagnoses of heart failure and other cardiovascular comorbidities were extracted from electronic health records. Patients were stratified into ESC risk categories (Low, Medium, High/Very High), and associations with CTRCD, CTR-CVT, and mortality post-exposure were analyzed. Results Among the cohort, 1,225 patients received MM therapy and 524 received ANT. NHB individuals comprised 47% of the study population. Higher ESC risk classification was associated with increased incidence of heart failure syndrome (p<0.001 for MM, p=0.017 for ANT), hypertension (p=0.003 for MM, p=0.002 for ANT), coronary artery disease (CAD) (p=0.002 for MM and ANT), and mortality (p<0.001 for MM and ANT) post-exposure. However, associations were weaker for acute myocardial infarction (p=0.092 for MM, and p=0.47 for ANT). Atrial fibrillation/flutter (p=0.011) and thromboembolic events (p<0.001) were significantly correlated with MM exposure but not with ANT exposure (p=0.877 and p=0.640). Notably, ESC risk categorization did not correlate with CTRCD development (p=0.744 for MM, p=0.735 for ANT). Utilization of transthoracic echocardiography (TTE) was significantly higher among High/Very High-risk patients pre- and post-exposure (p<0.001), with NHB patients more likely to undergo pre-exposure TTE. Conclusions The ESC risk stratification model effectively identifies patients at risk for heart failure, hypertension, CAD, and mortality following cardiotoxic cancer therapy. However, its predictive accuracy for other cardiovascular events, including CTRCD, is limited. Further refinement and validation in diverse populations are needed to enhance its clinical utility and ensure equitable cardiovascular care for all cancer patients.