Cardiovascular risk management in cancer survivors: Are we doing it right?

Although under-recognized, cancer survivors continue to be at an increased risk of death from cardiovascular complications post-remission or cure. This increased burden of cardiovascular disease results from the interplay of various factors. Adequate cardiovascular risk assessment and timely intervention through a multi-disciplinary approach in these patients plays a pivotal role in the prevention of cardiovascular morbidity and mortality. We discuss the shortcomings of using current risk prediction scores in cancer survivors and provide some insights into cardiovascular risk management relevant for primary care physicians, oncologists, and cardiologists alike.     

Pharmacovigilance Analysis of Cardiac Toxicities Associated With Targeted Therapies for Metastatic NSCLC

IntroductionTargeted therapies have transformed treatment of driver-mutated metastatic NSCLC. We compared cardiovascular adverse events between and within targeted therapy classes.MethodsWe used WHO pharmacovigilance database VigiBase to compare odds of heart failure, conduction disease, QT prolongation, supraventricular tachycardia (SVT), and ventricular arrhythmias between inhibitors of EGFR (erlotinib, gefitinib, afatinib, osimertinib), BRAF (dabrafenib), MEK (trametinib), and ALK and ROS1 (alectinib, brigatinib, ceritinib, crizotinib, lorlatinib).ResultsOf 98,765 adverse reactions reported with NSCLC targeted therapies, 1783 (1.8%) were arrhythmias and 1146 (1.2%) were heart failure. ALK and ROS1 inhibitors were associated with increased odds of conduction disease (reporting OR [ROR] = 12.95, 99% confidence interval [CI]: 10.14–16.55) and QT prolongation (ROR = 5.16, 99% CI: 3.92–6.81) relative to BRAF and EGFR inhibitors. Among ALK and ROS1 inhibitors, crizotinib had highest odds of conduction disease (ROR = 1.75, 99% CI: 1.30–2.36) and QT prolongation (ROR = 1.91, 99% CI: 1.22–3.00). Dabrafenib (ROR = 2.24, 99% CI: 1.86–2.70) and trametinib (ROR = 2.44, 99% CI: 2.03–2.92) had higher odds of heart failure than other targeted therapies. Osimertinib was strongly associated with QT prolongation (ROR = 6.13, 99% CI: 4.43–8.48), heart failure (ROR = 3.64, 99% CI: 2.94–4.50), and SVT (ROR = 1.90, 99% CI: 1.26–2.86) relative to other targeted therapies.ConclusionsALK and ROS1 inhibitors are associated with higher odds of conduction disease and QT prolongation than other targeted therapies. Osimertinib is strongly associated with QT prolongation, SVT, and heart failure relative to other EGFR inhibitors and targeted therapies. Monitoring for heart failure and arrhythmias should be considered with NSCLC targeted therapies, especially osimertinib.     

肿瘤心血管病学的循证临床实践

肿瘤疾病和心血管疾病均是目前全球的重大疾病负担和挑战。预期寿命得到延长的肿瘤患者,罹患抗肿瘤治疗相关的心血管疾病的概率明显增加,作为多学科整合的肿瘤心血管病学方兴未艾。现着重介绍当前肿瘤心血管病学的临床管理实践策略,为广大临床医师提供参考。     

Cancer patients with acute coronary syndrome have non-superior bleeding risk compared to patients with similar characteristics – a propensity score analysis from the ProACS registry

IntroductionThe management of acute coronary syndrome (ACS) in malignancy is challenging due to higher bleeding risk.MethodsWe analyzed patients with cancer (active or in the previous five years) prospectively included in the ProACS registry between 2010 and 2019. Our aim was to assess safety (major bleeding, primary endpoint) and secondary efficacy endpoints (in-hospital mortality and combined in-hospital mortality, reinfarction and ischemic stroke) of ACS treatment. Propensity score matching analysis (1:1) was further performed to better understand predictors of outcomes.ResultsWe found 934 (5%) cancer patients out of a total of 18 845 patients with ACS. Cancer patients had more events: major bleeding (2.9% vs. 1.5%), in-hospital mortality (5.8% vs. 3.4%) and the combined endpoint (7.4% vs. 4.9%). The primary endpoint was related to cancer diagnosis (OR 1.97), previous bleeding (OR 7.09), hemoglobin level (OR 4.94), atrial fibrillation (OR 3.50), oral anticoagulation (OR 3.67) and renal dysfunction. Mortality and the combined secondary endpoint were associated with lower use of invasive coronary angiography and antiplatelet and neurohormonal blocker therapy. After propensity score matching (350 patients), there were no statistically significant differences in endpoints between the populations.ConclusionBleeding risk was not significant higher in the cancer population compared to patients with similar characteristics, nor were mortality or ischemic risk. The presence of cancer should not preclude simultaneous ACS treatment.