Immunotherapy management in active cancer patients after atherosclerosis-associated acute coronary syndromes during immune checkpoint inhibitors treatment

Background There is growing evidence that immune checkpoint inhibitors (ICIs) may have pro-atherogenic adverse effects that increase the risk of atherosclerotic cardiovascular disease (ASCVD) in cancer patients on long-term treatment. Purpose To gain insight on the attitude of clinicians towards ICIs continuations and to collect cardiovascular safety data on immunotherapy resumption after atherosclerosis-related acute coronary syndrome (ACS). Methods We retrospectively gathered information on ACS from patients with active cancer who had been using ICIs for longer than six months at our Institution in the previous two years. In addition to ACS diagnosis, care, and outcome, baseline data on cancer site, ICI type, treatment line, and physician attitude toward ICIs continuation after ACS were documented. Results Twenty-one patients were identified (16/5 M/F; median age 72[66-81]years; advanced lung cancer was the prevalent site followed by metastatic renal-cell carcinoma and ICIs were mostly delivered as first-line (18/21) treatment (10 ICIs + chemotherapy; 5/21 single agents ICIs and 3/21 ICIs + TKIs). Prevalent cardiovascular risk factors were smoking (78% active and former), hypertension (63%), lipids disorders (32%) and diabetes (16%). NSTEMI was the prevalent clinical presentation (14/21), STEMI was reported in 5/21 and 2 pts presented with unstable angina. All pts underwent coronary angiography with 18/21 PTCA-stenting (3 MINOCA) with no procedure-related complications. All cases received guideline-oriented medical therapy. Immunotherapy was resumed in all cases but 4 (3 planned stop after near 2yrs of treatment with disease control and 1 case due to the supposed high risk of new CV toxicities). No new cardiovascular toxicities or new ASCVD episodes were recorded after ICIs resumption at one year follow-up. Conclusions Resuming immunotherapy following ICIs-associated ASCVD seems to be safe and does not result in any additional ACS events. Confirmation of these preliminary results requires a prospective study on bigger sample size.