De Perna Maria Luisa, Rigamonti Elia, Zannoni Raffaele, Espeli Vittoria, Moschovitis Giorgio
Istituto Cardiocentro Ticino, Department of Cardiology, Ente Ospedaliero Cantonale, Lugano, Switzerland.
Service de Médicine Interne générale, Département de médecine interne, Hopitaux Universitaires de Genève (HUG), rue Gabrielle-Perret-Gentil 4, Genève, Switzerland.
ESC Heart Fail. 2025 Apr 10. doi: 10.1002/ehf2.15281.
In the last years, we assisted to a tremendous increase in therapeutic options for the management of cancers, with immunotherapy at the forefront of this innovation. Immune checkpoint inhibitors (ICIs) have been developed to enhance the activity of the immune system against cancer cells (1) and the number of approvals for ICIs has rapidly increased. ICIs have also been associated with disinhibited cytotoxic T cells that damage healthy tissue in multiple organs, causing immune-related adverse events (AEs). Cardiovascular AEs (CVAe) are increasingly reported: myocarditis, Takotsubo syndrome, pericarditis and pericardial effusion, worsening of atherosclerosis, acute coronary syndromes, non-inflammatory heart failure, and ischaemic stroke. They are classified into five grades, based on presenting symptoms, level of cardiac biomarkers, and imaging. Even though myocarditis occurs more frequently than previously thought, clinically relevant myocarditis is a rare irAE compared to other irAE (0.5-1.2%). The clinical manifestations range from mild symptoms such as to chest pain, heart failure, and cardiogenic shock. The prognosis is severe, with mortality rates ranging from 25% to 50%. It is frequently associated with the concomitant use of combination of checkpoint inhibitors. The treatment strategies are tripartite: (i) holding ICI to prevent further toxicity, (ii) immunosuppression to alleviate inflammatory changes, and (iii) supportive therapy to address cardiac complications. Glucocorticoids represent the first-line treatment. In hemodynamically unstable patients, treatment with high-dose steroids should be initiated (intravenous methylprednisolone 1000 or 1250 mg oral methylprednisolone during 4 days). ICI-associated pericarditis can be accompanied by no/mild pericardial effusion up to cardiac tamponade. The treatment is made of nonsteroidal anti-inflammatory drugs and colchicine, corticosteroids if needed, and pericardiocentesis for the large effusions. ICIs could be continued for Grade 1 pericarditis, while temporary suspension of ICI is warranted for more severe cases. There is significant potential for accelerated atherosclerosis with ICIs as a long-term effect, but atherosclerosis-related CVAEs are not frequent, especially during treatment; increasing evidence associates ICIs with progression of atherosclerosis and increased atherosclerotic cardiovascular disease. ICIs can lead to arrhythmias: atrial fibrillation, supraventricular and ventricular tachycardias. Non-inflammatory heart failure syndrome have been observed in ICI-treated patients. Immune checkpoint inhibitors seem to be involved in the development of right ventricular dysfunction and pulmonary arterial hypertension. It is of the outmost importance to improve the collaboration among the different medical figures, such as cardiologists, oncologists, endocrinologists, and immunologists, both in clinical practice and in basic science research, to better recognize these adverse events, to understand their pathophysiological mechanisms, and to improve the overall survival and quality of life of the affected patients.
在过去几年中,我们见证了癌症治疗选择的大幅增加,免疫疗法处于这一创新的前沿。免疫检查点抑制剂(ICIs)已被开发出来以增强免疫系统对抗癌细胞的活性(1),并且ICIs的获批数量迅速增加。ICIs还与细胞毒性T细胞不受抑制有关,这些细胞会损害多个器官的健康组织,导致免疫相关不良事件(AEs)。心血管不良事件(CVAe)的报告越来越多:心肌炎、Takotsubo综合征、心包炎和心包积液、动脉粥样硬化恶化、急性冠状动脉综合征、非炎性心力衰竭和缺血性中风。根据出现的症状、心脏生物标志物水平和影像学检查,它们被分为五个等级。尽管心肌炎的发生比以前认为的更频繁,但与其他免疫相关不良事件相比,临床相关的心肌炎是一种罕见的免疫相关不良事件(0.5 - 1.2%)。临床表现从胸痛、心力衰竭和心源性休克等轻微症状到严重症状不等。预后严重,死亡率在25%至50%之间。它经常与联合使用检查点抑制剂有关。治疗策略包括三个方面:(i)停用ICI以防止进一步的毒性,(ii)免疫抑制以减轻炎症变化,(iii)支持性治疗以处理心脏并发症。糖皮质激素是一线治疗药物。对于血流动力学不稳定的患者,应开始使用高剂量类固醇治疗(静脉注射甲泼尼龙1000毫克或口服甲泼尼龙1250毫克,持续4天)。ICI相关的心包炎可伴有无/轻度心包积液直至心脏压塞。治疗包括使用非甾体抗炎药和秋水仙碱,必要时使用皮质类固醇,对于大量积液进行心包穿刺引流。对于1级心包炎,ICI可以继续使用,而对于更严重的病例,则需要暂时停用ICI。作为长期影响,ICIs有加速动脉粥样硬化的显著可能性,但与动脉粥样硬化相关的CVAe并不常见,尤其是在治疗期间;越来越多的证据表明ICIs与动脉粥样硬化的进展和动脉粥样硬化性心血管疾病的增加有关。ICIs可导致心律失常:心房颤动、室上性和室性心动过速。在接受ICI治疗的患者中观察到了非炎性心力衰竭综合征。免疫检查点抑制剂似乎与右心室功能障碍和肺动脉高压的发生有关。在临床实践和基础科学研究中,改善心脏病专家、肿瘤学家、内分泌学家和免疫学家等不同医学专业人员之间的协作至关重要,可以更好地识别这些不良事件,了解其病理生理机制,并提高受影响患者的总体生存率和生活质量。