From the Guidelines
Cardiac risk stratification for cancer patients should involve a comprehensive assessment, including a thorough baseline cardiovascular evaluation and regular monitoring with echocardiograms and biomarkers like troponin, to identify individuals at risk for cardiovascular complications during cancer treatment. This approach is supported by the most recent guidelines, such as the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, which recommends monitoring of cardiac function in patients receiving potentially cardiotoxic anticancer therapies. The guideline suggests that serial measurement of cardiac troponin might be reasonable for further risk stratification in patients being considered for potentially cardiotoxic therapies.
Key components of the cardiac risk stratification approach include:
- A detailed medical history, physical examination, electrocardiogram, and echocardiogram to assess left ventricular ejection fraction
- Laboratory tests, including lipid profile, hemoglobin A1c, and biomarkers like troponin and BNP
- Identification of risk factors, such as hypertension, diabetes, smoking, obesity, prior cardiovascular disease, and age over 65
- More frequent monitoring for patients receiving cardiotoxic therapies, such as anthracyclines, HER2-targeted therapies, or certain tyrosine kinase inhibitors
High-risk patients should receive cardioprotective medications, including beta-blockers and ACE inhibitors, to prevent further left ventricular dysfunction or the development of symptomatic heart failure, as recommended by the 2016 ESC position paper on cancer treatments and cardiovascular toxicity 2. The use of these medications, unless contraindicated, is crucial in reducing morbidity and mortality in cancer survivors. Regular cardiac monitoring should occur at baseline, during therapy, and post-treatment to ensure early detection and management of cardiovascular complications.
From the Research
Approach to Cardiac Risk Stratification
The approach to cardiac risk stratification in patients with cancer involves several key steps and considerations, as outlined in the following points:
- Identification of patients at high risk of cardiovascular complications prior to starting cancer treatment, using risk stratification tools and proformas 3
- Assessment of baseline cardiovascular risk factors, such as age, hypertension, and diabetes, as well as cancer therapies associated with cardiovascular toxicity 4
- Use of cardiac monitoring strategies, including two- and three-dimensional echocardiography, cardiac MRI, and biomarkers (troponin and brain natriuretic peptide [BNP]) 4
- Stratification of patients into low, medium, high, and very high risk of cardiovascular complications, using tools and proformas 3
- Application of pharmacologic and lifestyle strategies to mitigate cardiovascular toxicity during and following completion of cancer therapy, such as angiotensin-converting enzyme inhibitors, β-blockers, statins, diet, and exercise 4
Risk Stratification Tools and Proformas
Several risk stratification tools and proformas have been developed to help clinicians assess the cardiovascular risk of cancer patients, including:
- The Cardio-Oncology Study Group of the Heart Failure Association of the European Society of Cardiology's position statement and risk assessment tools 3
- The patient-patient network clustering methodology, which allows for unbiased cardiac risk stratification and identification of clinically actionable variables 5
- The use of serum levels of NT-proB-type Natriuretic Peptide (NT-proBNP) and Troponin T to predict patient mortality 5
Multidisciplinary Approach
A multidisciplinary approach to cardiac risk stratification and management is recommended, involving collaboration between oncologists, cardiologists, and allied health care providers 4, 6