Table 4.
Prevention and treatment of cancer patients with cardiovascular disease.
| Prevention and evaluation before cardiovascular complications | Treatment of cardiovascular complications in cancer patients | Clinical advice | |
|---|---|---|---|
| Cardiac dysfunction | During the anti-tumor treatment, assessment should be conducted at least every 3 months, and monitoring should be conducted at least every 6 months for 2 years after the completion of treatment. For patients with pre-existing cardiac insufficiency, it is recommended to monitor once a month. | Beta-blockers and ACEI/ARB should be used as early as possible, while other conventional therapies, such as diuretics and cardiac, should be used as appropriate in conjunction with the patient's symptoms. For most patients with cardiotoxicity, especially patients with left bundle branch block and heart failure, cardiac resynchronization therapy may relieve symptoms and reverse ventricular remodeling. However, ventricular assist devices are generally not recommended. | For advanced heart failure, heart resynchronization therapy and heart transplantation may produce higher returns in addition to drug treatment. |
| Coronary artery disease | Prevention of arterial disease should start with endothelial health, including statins, angiotensin-converting enzyme inhibitors and active exercise (187). Aspirin can be used as the main preventive drug to reduce the occurrence of arterial embolism and the progression of atherosclerotic plaque. | It is recommended to evaluate the severity of the patient's arterial toxicity and then determine whether to continue anti-tumor therapy. The first choice for treating patients with vasospasm is vasodilators, such as nitrates and calcium channel antagonists. When cancer patients are combined with atherosclerosis, drug therapy is the basis. The treatment measures mainly include adequate control of blood pressure and blood sugar, anti-platelet aggregation and lowering blood lipids, stabilizing plaque, slowing down disease progression, and eliminating the cause of myocardial infarction. Combining anticoagulation and interventional therapy may bring longer survival time to cancer patients with myocardial infarction. Drug-eluting stents (DES) are recommended for patients undergoing coronary stent implantation (143). |
Patients who have received coronary revascularization and have a good prognosis can be given cancer treatment based on the benefit of the patient, but aspirin, calcium channel blockers and long-acting nitrate drugs should be given 3 days before the drug, and the ECG should be monitored continuously, and once symptoms such as angina pectoris appear again, treatment should be stopped immediately. |
| Arrhythmia | Re-check the patient's electrolytes, thyroid function and renal function within 7–15 days after treatment and after each treatment plan change, and should be monitored monthly for the first 3 months of treatment. People taking the chemical arsenic trioxide should monitor their ECG at least weekly. | Beta-blockers (atenolol and metoprolol) are the drugs of choice for controlling ventricular rate to treat atrial fibrillation. Non-dihydropyridine-calcium channel blockers are also optional but must be used appropriately according to the patient's heart condition. Cardioversion can be considered, when necessary, but patients who use ibrutinib are more likely to relapse after cardioversion. At the same time, amiodarone and digoxinine interact with certain cancer treatment drugs and should be used with caution. For patients with symptomatic or reduced ejection fraction heart failure and atrial fibrillation, radiofrequency ablation is also a necessary option (152). The anticoagulation strategy for cancers with atrial fibrillation is still based on the CHA2D2-VASC score. However, anticoagulant therapy may not be effective in the hypercoagulable state of cancer. Low molecular weight heparin (LMWH) is the first choice for anticoagulation therapy, followed by oral anticoagulants (DOAC). | - |
| Thrombotic disease and peripheral vascular disease | The use of anticoagulants for primary prevention of cancer patients is generally not recommended, but patients undergoing major cancer surgery should receive prophylaxis at least 7 days before surgery (188). Patients with a Khorana score ≥ 3 or Khorana score ≥ 2 and a high risk of thrombosis can start primary preventive anticoagulation therapy. | All cancer patients with new or recurrent VTE require anticoagulation therapy, and it is recommended to continue anticoagulation therapy for at least 3–6 months. LMWH or edoxaban is the first anticoagulant choice, but there may be technical limitations or patient intolerance. Now you can use LMWH or the oral anticoagulant edoxaban for 5–10 days, and then use DOAC other than warfarin or edoxaban. If active cancer or recurrent VTE occurs under active treatment, systemic treatment should be continued (143). The inferior vena cava filter (IVC) is used for VTE patients with contraindications to anticoagulation, and clinically, it is also used for patients with active anticoagulation therapy but still relapsed VTEa. | Before using IVC, the patient's willingness and life expectancy should be evaluated, and it is generally not the first choice for VTE cancer patients. |
| Others: hypertension, valvular heart disease, pericardium disease | The 2018 ESC/European Society of Hypertension (ESH) Arterial Hypertension Management Guidelines recommend that blood pressure be monitored once a week during the first cycle of cancer treatment, and at least once every 2–3 weeks thereafter (189). Antihypertensive therapy helps maintain the treatment plan and reduce the risk of serious complications, including malignant hypertension and reversible posterior leukoencephalopathy. | Patients with hypertension (≥140/90 mmHg) or elevated diastolic blood pressure (≥20 mmHg) should receive ACE inhibitors, ARBs, calcium channel blockers, or combination therapy. The calcium channel blockers diltiazem and verapamil should be avoided. Since VEGF inhibitors may cause diarrhea and dehydration, electrolyte disturbances caused by diuretics may aggravate, diuretics should be used with caution (190). For moderate hypertension (systolic blood pressure > 160 mmHg, diastolic blood pressure BBB > 0 mmHg), anti-tumor therapy should be suspended and antihypertensive therapy should be given until the blood pressure returns to the pre-treatment level or below 150/100 mmHg, and the treatment can be resumed. Catheter valve implantation is recommended for valvular heart disease related to tumor treatment. | If hypertension is poorly controlled or a hypertensive crisis occurs after 1 month of treatment, anti-tumor angiogenesis drugs should be permanently discontinued. The blood pressure goal of cancer patients is <140/90 mmHg, and patients with diabetes or proteinuria can be reduced to <130/80 mmHg as appropriate. |
a
For patients with venous thrombosis, LMWH is the first choice for anticoagulant drugs. DOAC becomes a secondary option due to the relatively high risk of major bleeding (191). Edoxaban is the preferred oral anticoagulant, but recent studies have shown that rivaroxaban may be the best choice (192). Patients with renal insufficiency should avoid LMWH and DOAC. It is recommended to use warfarin and monitor the INR during use.