Division of Medical Oncology, Department of Internal Medicine, Ashland Bellefonte Cancer Center, Ashland, KY.
Division of Nephrology, The Nephrology Group, Fresno, CA; and.
Am J Ther. 2020 Nov/Dec;27(6):e591-e598. doi: 10.1097/MJT.0000000000000988.
Immunotherapy is a significant breakthrough in cancer therapy in the last decade. Immunotherapy is better tolerated compared with chemotherapy. However, it does have side effects, and one of the rare and serious side effects of immunotherapy is cardiotoxicity. Cardiotoxicity has been described with other cancer-related treatments such as chemotherapy and targeted therapy. A high index of suspicion is required, and prompt management with immunosuppression needs to be instituted as soon as possible to prevent fatal outcomes.
Research is still ongoing to identify biomarkers that will help us to choose the patients, who will respond well to immunotherapy. Tumor-infiltrating lymphocytes, tumor PD-L1 expression, and tumor mutational burden explored as potential biomarkers. There are no predictive biomarkers to identify patients who are at higher risk of severe cardiotoxicity. Both cardiologists and oncologists should be aware of cardiac toxicity from immune checkpoint inhibitors.
All patients who are starting immune checkpoint inhibitors should undergo baseline cardiac risk factor assessment with referral to a cardiologist in a patient with multiple risk factors or previous history of cardiovascular disease. Cardiac immune-related adverse events are higher in patients taking combination therapy with anti-CTLA-4/anti-PD-1 agents compared with monotherapy. Patients with known cardiac comorbidities require a higher level of vigilance to monitor for cardiac toxicity because nonspecific symptoms can lead to rapid clinical deterioration and a higher rate of mortality when treated with checkpoint inhibitors.
免疫疗法是过去十年癌症治疗的重大突破。与化疗相比，免疫疗法的耐受性更好。然而，它确实有副作用，免疫疗法的罕见且严重的副作用之一是心脏毒性。其他与癌症相关的治疗方法，如化疗和靶向治疗，也已经描述过心脏毒性。需要高度怀疑，并尽快进行免疫抑制治疗，以防止致命后果。
研究仍在进行中，以确定有助于我们选择对免疫疗法反应良好的患者的生物标志物。肿瘤浸润淋巴细胞、肿瘤 PD-L1 表达和肿瘤突变负担被探索为潜在的生物标志物。目前还没有预测生物标志物来识别发生严重心脏毒性风险较高的患者。心脏病专家和肿瘤学家都应该意识到免疫检查点抑制剂的心脏毒性。
所有开始使用免疫检查点抑制剂的患者都应进行基线心脏危险因素评估，并在存在多种危险因素或既往心血管疾病史的患者中转诊给心脏病专家。与单药治疗相比，联合使用抗 CTLA-4/抗 PD-1 药物的患者心脏免疫相关不良事件发生率更高。已知患有心脏合并症的患者需要更高水平的警惕性来监测心脏毒性，因为非特异性症状可能导致在接受检查点抑制剂治疗时快速临床恶化和死亡率更高。
