Cardiovascular toxicity of immune checkpoint inhibitors in cancer patients: A review when cardiology meets immuno-oncology

Abstract

Immune checkpoint inhibitors (ICIs) are a novel treatment option for cancer therapy, which help direct the immune system to recognize and target cancer cells. ICIs have been shown to provide significant mortality benefits for cancer patients, but they are also associated with immune-mediated toxicity. Unlike most immune-related adverse events, which are a common occurrence, reversible and can be treated effectively with glucocorticoid therapy, ICI-associated cardiotoxicities are uncommon, with serious complications and a relatively high mortality even when treated with glucocorticoids. ICI-associated cardiotoxicity can manifest in various ways, including myocarditis, arrhythmias and conduction disease, pericardial disease, myocardial infarction, non-inflammatory cardiomyocyte dysfunction, and even Takotsubo-like cardiomyopathy. The present review summarizes the current understanding of ICI-associated cardiotoxicities, examining the epidemiology and timing of onset, as well as their clinical presentation, diagnostic modalities, pathophysiology, clinical management and outcomes. Although the literature describing ICI-associated cardiotoxicity remains limited to case reports, case series and early clinical trials, strategies for the surveillance, diagnosis and management of this potentially fatal cardiovascular complication of cancer therapy have been proposed.

Keywords: Arrhythmias; Cardiotoxicity; Immune system; Myocarditis.