November 13, 2025
View Full PaperImmune Checkpoint Inhibitor–Associated Cardiovascular Toxic Effects
Key Result
Immune checkpoint inhibitor therapy is associated with a spectrum of cardiovascular toxic effects, most notably myocarditis, which requires multidisciplinary management.
Structured PICO
What are the cardiovascular toxic effects associated with immune checkpoint inhibitor therapy and how should they be managed?
P
Population
Patients receiving immune checkpoint inhibitor (ICI) therapy
I
Intervention
Immune checkpoint inhibitor (ICI) therapy
O
Outcome
Cardiovascular toxic effects (including myocarditis, pericarditis, vasculitis, atherosclerosis, cardiac dysfunction, and arrhythmias)safety
This position statement outlines the spectrum of cardiovascular toxicities associated with immune checkpoint inhibitors, emphasizing myocarditis as the primary concern and highlighting the need for multidisciplinary management.
Limitations
- Several gaps in knowledge are identified and require further research
Abstract
Importance: The introduction of immune checkpoint inhibitor (ICI) therapy has improved cancer outcomes but at the cost of adverse events, mainly related to the immune system. Cardiovascular (CV) toxic effects, and especially myocarditis, are of particular concern and are the subject of this position statement by the International Cardio-Oncology Society with representation of experts from oncology, hematology, and cardiology. Observations: CV toxic effects of ICI therapies include inflammation-associated diseases, such as myocarditis, pericarditis, and vasculitis, as well as the aggravation of chronic inflammatory conditions, such as atherosclerosis with acute ischemic complications (myocardial infarction and stroke). Patients taking ICI therapies can also develop cardiac dysfunction, stress-induced cardiomyopathy (Takotsubo or apical ballooning syndrome), and heart failure without inflammatory cell infiltration of the myocardium. Atrial and ventricular arrhythmias can emerge in the setting of a systemic inflammatory milieu, myocarditis, or ischemia. Of all potential CV adverse effects, myocarditis remains of highest concern, although fatality rates have declined over time with a broadening spectrum of presentations ranging from troponin elevation of uncertain significance to smoldering, nonsevere, and severe or fulminant myocarditis. Conclusions and Relevance: Concerns for myocarditis continue to dominate the spectrum of CV toxic effects in patients receiving ICI therapy. Recommendations for management vary according to severity. Multidisciplinary collaborations remain key for managing acute toxic effects and future cancer treatment decisions, including ICI rechallenge. Ischemic heart disease constitutes the main differential diagnosis in these patients, while pericarditis can be concomitantly present, and atrial and ventricular arrhythmias can also complicate the clinical picture. Several gaps in knowledge are identified and require further research.