Prepared by Anne Leonard MPH, BSN, RN FAHA, Sr. Science and Medicine Advisor
- With the tremendous development of cancer therapeutics, that has improved cancer survival, cardiovascular (CV) complications can adversely impact overall patient outcomes. The field of cardio-oncology has developed team-based CV care of patients with cancer and survivors. The goal of cardio-oncology is the primary prevention and secondary treatment of cancer therapy- related cardiotoxicity to support cancer care and CV health outcomes.
- Some cancer treatments can lead to electrophysiological disease and subsequent tachy- and brady-arrhythmias. The objective of this scientific statement is to discuss the current state of the science and the relationship between cancer therapeutics and cardiac arrhythmias.
- There are several mechanisms attributed to systemic cancer-induced arrhythmias.
- Autonomic dysfunction attributed to anthracyclines, platinum and vinca alkaloids
- Ischemia due to 5-flurouracil
- Myocardial dysfunction (cardiomyopathies or myocarditis) due to anthracyclines or immune checkpoint inhibitors
- Ion channel and/or intracellular signaling dysfunction due to tyrosine kinase inhibitors.
- Pericardial disease due to platinum compounds
- Systemic inflammatory response/cytokine release due to chimeric antigen receptor T Cell (CAR-T) therapy
- The most prevalent arrhythmia seen in chemotherapy treated patients is atrial fibrillation (AF), but ventricular repolarization abnormalities and QT prolongation, ventricular arrhythmias, and bradycardia and heart block can also occur. With recognition of the potential for cancer therapies causing arrhythmias, strategies to mitigate this risk are needed.
- Epidemiological studies have shown an association between cancer and AF. This is bidirectional as there is a higher incidence of AF in patients with cancer and an increased incidence of cancer in patients with AF, most likely because of shared risk factors between the two.
- Management of AF in patients with newly diagnosed cancer should follow algorithms similar to the others with AF with special consideration taken to avoid unique drug-drug interactions that may exist with certain cancer therapeutics. Management is targeted to rate and rhythm control and preventing thromboembolism during cancer treatment.
- Ventricular arrhythmias (VAs), including those that are chemotherapy induced (e.g., sustained ventricular tachycardia and fibrillation), are relatively rare. Some chemotherapeutics can induce cardiomyopathy. In this setting the use of cardioverter defibrillators has not been specifically examined in these patients.
- The true incidence of bradycardia and atrioventricular conduction disease related to chemotherapy has been hard to determine due to the differences in surveillance and reporting. Table 1 within this statement outlines those chemotherapeutic agents associated with bradycardia or atrioventricular block.
- This scientific statement provides information on anticancer agents and associated arrhythmias related to type of agent and specific type of cancer.
- Cardio-oncology is an important new subspecialty of medicine that is evolving. Strategic clinical and scientific collaborations between oncologists and electrophysiologists is needed to improve care of patients with undergoing cancer treatment who develop cardiac arrhythmias.
Fradley MG, Beckie TM, Brown SA, Cheng RK, Dent SF, Nohria A, Patton KK, Singh JP, Olshansky B; on behalf of the American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; and Council on Cardiovascular and Stroke Nursing. Recognition, prevention, and management of arrhythmias and autonomic disorders in cardio-oncology: a scientific statement from the American Heart Association [published online ahead of print June 17, 2021]. Circulation. doi: 10.1161/CIR.0000000000000986