Immune checkpoint inhibitors and cardiotoxicity: possible mechanisms, manifestations, diagnosis and management

ABSTRACT

Introduction

Immune checkpoint inhibitors (ICIs) are a new class of anticancer drugs that enhance the immune system function and activate T cells against cancerous cells. Although cardiac complications are not common, they could be accompanied with high morbidity and mortality.

Areas covered

Regarding the importance of cardiac complications and their subsequent burden on individuals and the healthcare system, this review attempts to discuss the mechanism, diagnosis, and management of myocarditis, besides recapitulating the possible mechanism of other cardiac adverse events. Moreover, we briefly discuss the concurrent administration of other chemotherapeutic agents.

Expert opinion

Due to insufficient knowledge concerning the physiopathology of immune-related adverse events (irAEs) and their potential further complications, cardiovascular complications in particular and in the context of this paper’s focus, cooperation of oncologists, immunologists, and cardiologists is necessary for the management of patients. Experimental approaches such as using corticosteroids are becoming a part of guidelines for managing cardiac irAEs. However, a unique algorithm for diagnosis and management is necessary, especially in myocarditis cases. Furthermore, more studies are required to resolve current challenges, including prevention of myocarditis, concurrent administration of other chemotherapeutic agents, and re-introducing patients with ICIs.

KEYWORDS:

• Immune checkpoint inhibitors
• cardiotoxicity
• complication
• cancer
• adverse events

Article highlights

• Immune checkpoint inhibitors are a new class of anticancer drugs that enhance the immune system function and activate T cells against cancerous cells.

• Cardiac side effects could lead to discontinuation of treatment and even increase the risk of morbidity and mortality.

• Although there are no specific findings for the diagnosis of myocarditis, cardiovascular magnetic resonance imaging and endomyocardial biopsy could facilitate the diagnosis besides clinical and laboratory evidence.

• Corticosteroids are the mainstay of immune checkpoint inhibitors-related myocarditis management. However, a proper approach for management and diagnosis is necessary.

• Other cardiac adverse events include pericardial disorders, arrhythmia, left ventricle dysfunction, and coronary artery disease. Although these complications are not common, they could be associated with morbidity and mortality.

• Concurrent administration of other chemotherapeutic agents with immune checkpoint inhibitors might be associated with an increased risk of developing complications; indeed, more studies are necessary.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

SPE conceptualized the study and prepared the initial draft of the paper. NY revised and edited the initial draft. NR critically revised the manuscript and supervised the project. All the authors have read the final draft of the manuscript and approved it.

Additional information

Funding

This paper received no funding.