br necessary upon signs of cardiotoxicity including angina
necessary upon signs of cardiotoxicity, including: angina, dyspnea, arrhythmia including QT N 500 ms, pericardial effusion, edema, conges-tion, acute coronary syndrome, hypertension, hypotension and syncope. Severe 6-diazo-5-oxo-L-nor-Leucine failure and cardiogenic shock are occasionally observed due to anthracycline therapy. Left ventricular assist devices (Impella, LVAD) have been implanted in selected cases for temporary or perma-nent support. We recommend that all breast cancer survivors are re-evaluated by a cardiologist in case of a planned pregnancy.
Myeloma patients are referred to the cardio-oncology service from the hematology department. Proteasome inhibitors, including bortezomib and carfilzomib, come along with an increased risk of heart failure. Due to the high number of referred patients, we routinely assess all patients before and six months after initiation of therapy. A clinical registry has been established for the systematic assessment of clinical status and vascular and left ventricular functions. We recom-mend ambulatory blood pressure tests in all patients to monitor for pos-sible hypertension or hypotension. In cases of cardiotoxicity, beta-blockers and ACE-inhibitors can be given but may worsen hypotension. Mineral corticoid receptor antagonists are an alternative option.
ICI may induce multiple cardiotoxic adverse events, including myo-carditis, pericarditis, pericardial effusion, acute coronary syndromes and advance conduction abnormalities (second and third degree AV Block). Baseline assessments, including clinical history, examination and ECG
Fig. 4. Recommended algorithm for the evaluation of patients with immune checkpoint inhibitor therapy. A cardiac reaction to immune therapy is a rare, but fulminant condition. Clinical signs are dyspnea, arrhythmia (particularly advanced conduction disease) and angina. Electrocardiography (ECG) and troponin (high-sensitive troponin I or T) measurement identify early stages of such myocarditis and are recommended in weeks 1–4 of treatment or when cardiotoxicity is suspected. An acute coronary syndrome is evaluated according to current guidelines and may require coronary angiography. Persistent symptoms should be evaluated despite negative troponin and ECG in cardio-oncology units. Holter-ECG and imaging, including echocardiography, magnetic resonance imaging, possibly in combination with positron emission tomography, are helpful to confirm myocarditis. Severe cases of heart failure with rapid progression should be evaluated by endomyocardial biopsy to confirm immune therapy-related adverse events and exclude other causes. Glucocorticosteroids are the first choice treatment . (ACS, acute coronary syndrome, CT = computed tomography, ECG = electrocardiogram, EMB = endomyocardial biopsy, PET = positron emission tomography, MRI = magnetic resonance imaging).
are performed by the oncologists. The patients are served by clinical consultation together with ECG and troponin tests once in the first four weeks of treatment. In cases of signs of dyspnea, angina and ar-rhythmia or positive ECG/troponin tests, patients are referred to the cardio-oncology unit via the online system. If myocarditis is suspected, we discuss termination of ICI therapy until myocarditis is ruled-out def-initely. The further work-up includes echocardiography and nuclear im-aging (PET/CT or PET/MRI) and in indecisive cases endomyocardial biopsy. Proven myocarditis is treated with 1 mg/kg prednisone as first-line option. Whenever myocarditis has been ruled-out, ICI is only re-challenged after consultation with the oncologist and repeated test-ing at least once four weeks after the initial visit.
8. Adult survivors of childhood, adolescent and young adult malignancies