Cardio-oncology 2023: insights from the National Societies of Cardiology Journals of the European Society of Cardiology

Cardiovascular diseases and cancer are the leading causes of death worldwide. The co-occurrence of both is common and defines a high-risk patient cohort with high adverse outcome rates. Several issues related to cardio-oncology have been addressed by studies published in 2023 in the National Societies of Cardiology (NSC) journals. In a German study by Finke et al.,1 which included 40 329 patients who underwent a coronary angiography during a 10-year period, 3666 had a diagnosis of cancer prior to catheterization. The 5-year follow-up after catheterization showed higher all-cause mortality rates among cancer patients with either left ventricular dysfunction, coronary stenoses, or elevated cardiac biomarkers N terminal-pro brain natriuretic peptide or high sensitivity c troponinin T(NT-proBNP or hs-cTnT), suggesting that monitoring of cardiac biomarkers should be considered in these patients. Based on a 6-year nationwide French administrative hospital discharge database of 3 380 412 patients, the 497 593 patients with a history of cancer had a higher incidence of all-cause mortality, cardiovascular mortality (1.61% vs. 1.17% per year), myocardial infarction (0.82% vs. 0.61% per year), and ischaemic stroke (0.91% vs. 0.62% per year) compared with patients without cancer. However, after adjustment for competing risks, the cumulative incidence of cardiovascular death, myocardial infarction, and stroke was found to be lower in patients with cancer because death from non-cardiac causes was more prevalent.2 Pericardial involvement of thoracic malignancies severely impacts prognosis of these patients. In a Turkish report of 73 patients with symptomatic pericardial effusion requiring pericardiocentesis, Sezenöz et al.3 reported that cytological examination of pericardial fluid provides additional information because the presence of tumoural cells isolated from the fluid is associated with a worse prognosis. Magnetic resonance imaging (MRI) is required in many instances for staging and follow-up purposes in patients with cancer. However, MRI is often not performed in patients with non-MRI–conditional devices despite the recommendations of the 2021 European Society of Cardiology Guidelines for Cardiac Pacing and Cardiac Resynchronization to perform MRI in MRI-conditional devices provided that the manufacturer’s guidelines are followed. A Polish study by Tajstra et al.4 described characteristics and outcomes of 122 cancer patients with cardiac implantable electronic devices (CIEDs) who underwent 149 MRI examinations. The study showed that a structured, rigorously planned, and implemented MRI strategy under the surveillance of a cardiologist experienced in the interrogation and management of CIEDs enables a safe procedure and enhances the availability of this imaging modality. Faced with the increased bleeding risk of patients with cancer, long-term anticoagulation for concomitant atrial fibrillation (AF) may also be of concern. This issue was addressed by Raposeiras-Roubin et al.5 of Spain in a 5-year follow-up of 1137 patients with cancer receiving anti-coagulants for AF. An increased risk of bleeding was observed, but this was seen only in patients with active cancer and those with prior radiotherapy. On the other hand, caring for cardiac patients should not preclude giving careful attention to potential concomitant malignant diseases, as reported by Koleva et al.6 of Bulgaria who described unsuspected cardiac infiltrations of lung adenocarcinoma during echocardiographic examination. Prevention and management of cardiac side effects from cancer chemotherapy, especially anthracycline-based chemotherapy, remains a challenging issue. Rahimi et al.7 of Iran reported a protective effect from pre-treatment for each dose of doxorubicin with an 8 h infusion of 50 mg/kg deferoxamine administered to 62 children with cancer as evidenced by lowering of NT-proBNP even before it can be detected by echocardiographic assessment. Nettersheim et al.8 of Germany provided new insights into the mechanisms and potential targets which may be considered in the future to limit cardiotoxicity of anthracyclines. Since increased plasma levels of the neutrophil-derived enzyme myeloperoxidase (MPO) predict occurrence of anthracycline-induced cardiotoxicity, they developed an animal model to assess the protective effect of MPO deactivation. Indeed, doxorubicin-treated wild-type mice exhibited pronounced cardiac apoptosis and inflammation which was attenuated in MPO-deficient mice. In addition, the anticancer efficacy of doxorubicin was unaffected by MPO deficiency. The monoclonal antibody trastuzumab, which is given to patients with HER2-positive breast cancer, may also impair left ventricular ejection fraction (LVEF). In a study of 26 patients from Croatia, Levicki et al.9 showed that trastuzumab and trastuzumab emtansine induce progressive QTc (QT corrected intercal on the ECG) prolongation preceding the decrease in LVEF after successive drug applications, reaching a peak value just before the fifth cycle of both drugs. Both QTc interval and LVEF returned to baseline values after treatment discontinuation. The 2022 ESC Guidelines on Cardio-oncology have classified cancer therapy–related cardiac dysfunction (CTRCD) as mild when troponin is elevated or when there is >15% change in global longitudinal strain (GLS) from baseline with a LVEF > 50%.10 Accordingly, in a study of 95 patients with HER2-positive breast cancer, Oristrell et al.11 of Spain investigated the predictive value of hs-cTnI and GLS for the appearance of moderate-to-severe cardiotoxicity, as well as their potential as tools to aid in the decision to start cardioprotective treatment. While the sensitivity, specificity, and positive predictive value were poor for hs-cTnI and GLS, the negative predictive value was 95.1% and 99%, respectively. In contrast, only one of the four patients with moderate-to-severe CTRCD had hs-cTnI elevation, and although all of them also exhibited >15% change in GLS, this change was not documented until moderate-to-severe CTRCD was diagnosed. Although the presence of mild CTRCD warrants close follow-up, none of the 53 patients who had such a mild CTRCD progressed to moderate-to-severe CTRCD during follow-up despite not starting angiotensin converting enzyme inhibitor (ACEI) or beta-blocker therapy. Cardio-oncology has emerged as a dominant subspecialty to optimize treatment and follow-up of patients with cancer. Many of the ongoing related topics have been recently addressed in the National Societies of Cardiology journals affiliated with the European Society of Cardiology. The novel findings provide unique insights that complement current knowledge and may facilitate the clinical decision-making process for management of these challenging patients. The authors would like to thank the ESC staff: Michael Alexander, Publications Team Manager, and Margot Lauret, Publications Officer. All authors declare no disclosure of interest for this contribution. Editors Network of the National Societies of Cardiology Journals, European Society of Cardiology: Jean-Jacques Monsuez (Editor-in-Chief of Archives des Maladies du Cœur et des Vaisseaux Pratique), France; Plamen Gatzov (Editor-in-Chief of Forum for Interventional Cardiology Journal), Bulgaria; Hala Mahfouz Badran (Editor-in-Chief of Egyptian Heart Journal), Egypt; Michael Böhm (Editor-in-Chief Clinical Research in Cardiology), Germany; Ariel Cohen (Editor-in-Chief of Archives of Cardiovascular Diseases), France; Cetin Erol (Editor-in-Chief Anatolian Journal of Cardiology), Turkey; Gerd Heusch (Editor-in-Chief of Basic Research in Cardiology), Germany; Juan Sanchis (Editor-in-Chief of Revista Española de Cardiología), Spain; Anetta Undas (Editor-in-Chief Kardiologia Polska), Poland; Fernando Alfonso (past Chairman of the Editors’ Network of the European Society of Cardiology), Spain.