Cardiovascular Risk Assessment and Management in Cancer Patients Prior to Cancer Therapy
A comprehensive cardiovascular risk assessment including history, physical examination, and screening for cardiovascular risk factors should be performed in all cancer patients before initiating potentially cardiotoxic therapies. 1, 2
Initial Cardiovascular Risk Assessment
Comprehensive Evaluation
- Perform a thorough history and physical examination to identify pre-existing cardiovascular conditions and risk factors 1, 2
- Screen for cardiovascular risk factors including hypertension, diabetes, dyslipidemia, obesity, and smoking 1
- Obtain baseline echocardiogram to assess ventricular ejection fraction and valvular function before initiating potentially cardiotoxic therapies 1, 2
- Consider baseline cardiac biomarker evaluation (troponin, BNP) in selected high-risk patients, particularly those receiving high-dose cardiotoxic chemotherapy 1
Risk Stratification
- Identify patients at higher risk for cardiac dysfunction, including those with: 1
- Multiple cardiovascular risk factors (≥ two risk factors)
- Older age (≥ 60 years) at cancer treatment
- Compromised cardiac function (e.g., borderline low LVEF 50-55%, history of myocardial infarction)
- Planned treatment with high-risk therapies (anthracyclines, HER2-targeted therapies, VEGF inhibitors)
Management Strategies
Risk Factor Modification
- Actively manage modifiable cardiovascular risk factors in all patients receiving potentially cardiotoxic treatments 1
- Treat identified cardiovascular risk factors according to current guidelines 1
- Aggressively control hypertension, especially in patients receiving VEGF inhibitors 2
Treatment Selection and Modification
- Avoid or minimize cardiotoxic therapies if established alternatives exist that would not compromise cancer-specific outcomes 1, 2
- Consider cardioprotective strategies for high-risk patients receiving anthracyclines: 1, 2
- Dexrazoxane
- Continuous infusion of doxorubicin
- Liposomal formulation of doxorubicin
Radiation Therapy Considerations
- For patients requiring mediastinal radiation therapy: 1
- Select lower radiation doses when clinically appropriate
- Use more precise radiation fields with exclusion of as much heart as possible
- Consider techniques like deep-inspiration breath holding for patients with mediastinal tumors or breast cancer
- Utilize intensity-modulated radiation therapy to precisely contour radiation distribution
Multidisciplinary Collaboration
- Establish close and early collaboration between cardiologists, oncologists, hematologists, and radiation oncologists 1
- The multidisciplinary team should aim for a balanced approach to minimize cardiovascular toxicity while limiting reduction or discontinuation of cancer therapy 1
- Refer patients to cardiology based on concerning findings during assessment 2
Monitoring During and After Treatment
- Monitor cardiovascular safety throughout cancer treatment, especially with mediastinal/left-sided chest radiation and certain chemotherapy/targeted agents 1
- Perform regular cardiac surveillance with echocardiography for high-risk patients 2
- Consider serum cardiac biomarkers or echocardiography-derived strain imaging for enhanced monitoring 2
- Complete careful history and physical examination in patients receiving potentially cardiotoxic treatments 1
- For patients who develop clinical signs or symptoms of cardiac dysfunction during treatment, obtain echocardiogram for diagnostic workup 1
Common Pitfalls to Avoid
- Failing to perform baseline cardiovascular assessment before initiating cardiotoxic therapies 1, 2
- Overlooking the importance of cardiovascular risk factor management in cancer patients 1
- Unnecessary discontinuation of cancer therapy without appropriate cardio-oncology consultation 1
- Inadequate monitoring of patients receiving potentially cardiotoxic therapies 1, 2
- Neglecting to consider cardioprotective strategies for high-risk patients 1, 2