Table 2.

Immuno-related cardiovascular events with treatment strategies, adapted from ESMO guidelines [26]

Cardiotoxicity	Clinical presentation	Biomarkers and Instrumental Diagnosis	ICI strategy	Immunosuppression	Cardiac treatment
Myocarditis	Chest pain Dyspnea Pulmonary edema Cardiogenic shock	Troponin NT-proBNP ECG Echocardiography CMR imaging (modified Lake Louis criteria) FAPI-PET-CT Endomyocardial biopsy (Multifocal inflammatory cell infiltrates with overt cardiomyocyte loss by light microscopy) Coronary angiography (exclude ACS)	Stop ICI	First-line: i.v. methylprednisolone 500–1000 mg daily for 3 days or until clinically stable, Follow with oral prednisolone 1 mg/kg o.d. with tapering schedule of 10 mg/week with troponin monitoring High-risk myocarditis: abatacept and ruxolitinib	i.v. diuretics ± nitrates if pulmonary edema ACE inhibitors, Beta blockers
Pericarditis complicated by cardiac tamponade	Chest pain Dyspnea Cardiogenic shock	ECG Echocardiography CMR imaging (for concomitant myocarditis)	Interrupt ICI Consider ICI re-administration when stable and no evidence of ongoing pericarditis	Colchicine 500 μg b.i.d i.v. methylprednisolone 500–1000 mg daily until clinically stable, follow with oral prednisolone 1 mg/kg o.d. with tapering 10 mg/week	Emergency pericardiocentesis Colchicine
Acute pericarditis (with or without effusion but without cardiac tamponade)	Chest pain Dyspnea	ECG Echocardiography CMR imaging (for concomitant myocarditis)	Interrupt ICI Consider ICI re-administration when stable and no evidence of ongoing pericarditis	Colchicine 500 μg b.i.d. and oral prednisolone 0.5 mg/kg o.d. with tapering 10 mg/week
New advanced conduction disease (second- or third- degree heart block)	Syncope Lipothymia	ECG Holter ECG Serum electrolytes count	Multidisciplinary approach for optimal management of immunological treatment	Consider i.v. methylprednisolone if progressive PR prolongation or any evidence of co-existing myocarditis e.g. elevated troponin, CMR evidence	Emergency pacing
Acute MI	Chest pain Dyspnea Pulmonary edema Cardiogenic shock	Troponin NT pro-BNP ECG Echocardiography CMR Coronary angiography	Multidisciplinary approach for optimal management of immunological treatment	Consider i.v. methylprednisolone if evidence of coronary vasculitis on angiography	Follow ESC/ACC/AHA guidelines for STEMI or NSTEMI Consider vasculitis if atherosclerosis is excluded by coronary angiography
New onset AF	Palpitations Dyspnea Weakness Asymptomatic	ECG Holter ECG Exclude myocarditis	Multidisciplinary approach for optimal management of immunological treatment		Follow ESC guideline for AF Anticoagulation unless contraindication or limited life expectancy
VT or VF	Syncope Hypotension Palpitations Cardiac arrest	ECG Holter ECG	Multidisciplinary approach for optimal management of immunological treatment	First-line: i.v. methylprednisolone 500–1000 mg daily if myocarditis evident until clinically stable and troponin-negative followed by oral prednisolone 1 mg/kg o.d. with tapering 10 mg/week	Emergency defibrillation Beta blockers and/or antiarrhythmics
Takotsubo syndrome	Chest pain Dyspnea Pulmonary edema Cardiogenic shock	Troponin NT pro-BNP ECG Echocardiography CMR ± biopsy Exclusion of ACS according to AHA and ESC guidelines	Multidisciplinary approach for optimal management of immunological treatment		HFA position statement management algorithm
New early conduction abnormality on ECG	Asymptomatic Palpitations Weakness	Troponin NT pro-BNP ECG Holter ECG	Multidisciplinary approach for optimal management of immunological treatment		If high-grade heart block excluded, monitoring with ECG before each cycle
New asymptomatic rise in BNP or NT-proBNP	Asymptomatic	BNP or NT-pro-BNP Troponin ECG Echocardiogram CMR if suspected myocarditis	Multidisciplinary approach for optimal management of immunological treatment		Periodic monitoring Myocarditis treatment if diagnosed
New onset Left Ventricle Systolic Dysfunction (LVSD)	Asymptomatic Dyspnea Pulmonary edema Cardiogenic shock	BNP or NT-pro-BNP Troponin ECG Echocardiogram	Multidisciplinary approach for optimal management of immunological treatment		AHA/ACC/ESC guidelines for heart failure