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Cardiotoxicity of Immune Checkpoint Inhibitors

  • Cardio-oncology (M Fradley, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Abstract

Purpose of review

Immunotherapies, particularly immune checkpoint inhibitors (ICI), are revolutionary cancer therapies being increasingly applied to a broader range of cancers. Our understanding of the mechanism, epidemiology, diagnosis, and treatment of cardiotoxicity related to immunotherapies remains limited. We aim to synthesize the limited current literature on cardiotoxicity of ICIs and to share our opinions on the diagnosis and treatment of this condition.

Recent findings

The incidence of ICI-associated myocarditis ranges from 0.1 to 1%. Patients with ICI-associated myocarditis often have a fulminant course with a case fatality rate of 25–50%. The diagnosis of this condition poses many challenges because independently a normal electrocardiogram, biomarkers, or a preserved left ventricular function do not rule out ICI-associated myocarditis. Endomyocardial biopsy should be pursued when clinical suspicion remains despite normal non-invasive tests. Data on optimal screening and surveillance tools are lacking. Cessation of ICIs, combined with high dose corticosteroids and other immunosuppressant approaches are the cornerstones of the treatment of ICI-associated myocarditis. This condition may recur when patients are re-challenged with these agents and the decision to resume ICIs should be made through a multidisciplinary discussion.

Summary

Immunotherapies have changed the landscape of cancer treatment. Recognizing and managing cardiotoxicity related to ICIs is of critical importance. Our understanding of ICI-cardiotoxicity has improved, but large information gaps remain for further research. Due to the high case fatality rate, any type of cardiac symptoms or signs in a patient who has recently started an ICI should prompt consideration of ICI-cardiotoxicity.

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Authors and Affiliations

  1. Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Suite 400, 165 Cambridge Street, Boston, MA, 02114, USA

    Lili Zhang MD, ScM, Magid Awadalla MD & Tomas G. Neilan MD, MPH

  2. Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Lili Zhang MD, ScM, Magid Awadalla MD, Daniel A. Zlotoff MD, PhD & Tomas G. Neilan MD, MPH

  3. Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Maeve Jones-O’Connor MD

  4. Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada

    Paaladinesh Thavendiranathan MD

  5. Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    John D. Groarke MB, BCh, MPH

  6. Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA

    Alexandra-Chloe Villani PhD

  7. Cardio-Oncology Program, Royal Brompton Hospital, London, UK

    Alexander R. Lyon MD, PhD

  8. Imperial College London, London, UK

    Alexander R. Lyon MD, PhD

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  1. Lili Zhang MD, ScM
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  9. Tomas G. Neilan MD, MPH
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Correspondence to Tomas G. Neilan MD, MPH.

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Conflict of Interest

Lili Zhang, Maeve Jones-O’Connor, Magid Awadalla, and Daniel A. Zlotoff each declare no potential conflicts of interest.

Paaladinesh Thavendiranathan reports consulting fees from Takeda, BI, Janssen, and Amgen unrelated to the contents of this manuscript.

John D. Groarke has received research support from Amgen.

Alexandra-Chloe Villani reports an Innovation Award from Damon Runyon-Rachleff.

Alexander R. Lyon has received speaker, advisory board or consultancy fees and/or research grants from Pfizer, Novartis, Servier, Amgen, Clinigen Group, Takeda, Roche, Eli Lily, Eisai, Bristol Myers Squibb, Ferring Pharmaceuticals and Boehringer Ingelheim, and Stealth Peptides.

Tomas G. Neilan reports consulting fees from Parexel, Intrinsic Imaging, and Takeda, unrelated to the contents of this manuscript. Dr. Neilan reports being a member of a scientific advisor board to Bristol-Myers Squibb related to ICI myocarditis.

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Zhang, L., Jones-O’Connor, M., Awadalla, M. et al. Cardiotoxicity of Immune Checkpoint Inhibitors. Curr Treat Options Cardio Med 21, 32 (2019). https://doi.org/10.1007/s11936-019-0731-6

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