Multimodality imaging for the detection of cardiotoxicity in cancer patients treated with immune checkpoint inhibitors

Introduction Immune checkpoint inhibitors (ICIs) may cause cardiotoxicity, mainly myocarditis, with potential life-threatening consequences. To date, large-scale prospective data on cardiac imaging after ICI are still lacking. Thus, our primary aim was to assess the diagnostic value of speckle tracking echocardiography (STE) for ICI-related cardiotoxicity according to current international recommendations, while our secondary aims were to assess the prognostic value of STE for adverse clinical outcome and evaluate the agreement between STE and CMR in patients with ICI-related myocarditis. Methods In this prospective study, cancer patients referred for cardiologic evaluation before ICIs initiation were enrolled. Patients with known cardiac dysfunction (LV ejection fraction < 40%) were excluded. All patients underwent clinical, biohumoral and echocardiographic evaluation completed by STE at baseline and at approximately 6 months after immunotherapy. Patients with suspected myocarditis underwent CMR. Then, over a longer follow up, the clinical events were registered: all-cause or cardiovascular death, acute myocarditis, acute heart failure, pulmonary embolisms, acute coronary syndromes, atrial or ventricular arrhythmias, extra-cardiac toxicity. Results We enrolled 122 patients (65±14 years) referred for ICIs. Over 7±6 months follow up, mean LV GLS showed a slight reduction after therapy with ICI (-20±4% at baseline vs. -18±7%), although remaining within the normal ranges. During 22±17 months of follow up, 65 patients developed events. Among ICI-related myocarditis, 4 patients showed a significant reduction of GLS with a regional distribution similar to regional myocardial injury at CMR (97±7% agreement), the fifth had a minimal involvement of the right ventricle, with normal LV GLS. Conclusion Our results suggest that multimodality imaging combining different techniques may optimize the subclinical diagnosis of cardiotoxicity and the overall management of cancer patients undergoing ICIs.