BSH 2024 | The ESC guidelines on cardio-oncology: incorporating the guidelines into clinical practice

So these guidelines follow the journey of cancer patients from their diagnosis through their treatment and then, after completion of treatment their follow-up, in order to optimize their cardiovascular health. And I think for hematologists who nowadays use a range of treatments which we recognize cause cardiac problems, some have been known for several decades, such as anthracycline chemotherapy and mediastinal radiotherapy, others are much more modern targeted cancer therapies for chronic myeloid leukemia, chronic lymphocytic leukemia. And now for some of the new acute leukemia drugs, as well as myeloma drugs, we’re wanting to provide guidance on how to monitor patients, pick up any problems early so we can prevent them, and how to treat them if they occur. 

The most important role of the hematologist when we think of the guideline is the baseline risk assessment, because you are making the diagnosis, you’re then choosing the treatment, and it’s at that point, if a treatment could have cardiovascular complications that this guideline provides tools on how to risk stratify patients. So, it’s personalizing the approach to their potential cardiac risk in the way that we personalize to the treatment choices for efficacy. 

And in essence, we have structures and guidance on how to do this for any patient receiving anthracycline chemotherapy, Bcr-Abl tyrosine kinase inhibitors, that’s the second and third generation drugs, not imatinib, the first generation, but the second and third generation that carry more cardiovascular problems, for Bruton kinase inhibitors and for multiple myeloma patients, particularly those who are going to be prescribed a proteasome inhibitor, but there’s also guidance for patients receiving IMiDs and other myeloma therapies. 

And in principle, a patient is then either low, moderate, or high risk at baseline before they’ve started. Low-risk patients start treatment, usual care and would only need cardiac reviews if a problem develops. Moderate-risk patients have a bit more closer cardiac monitoring, but stay with the hematologist and only are referred into cardiology if a problem develops. But it’s the high-risk patient where, providing it’s not an acute hematological emergency, that actually they would be referred to cardiology first, ideally a cardio-oncology service where these specialists know about the cancer treatments and drugs, to be able to optimize their cardiovascular health. And the high-risk patients we also then provide guidance on closer monitoring, and that depends on the hematology drug, what its cardiovascular risk profile is, as to what tools are required. Is it blood test monitoring, ECG monitoring, echocardiogram, monitoring of ventricular function, or pulmonary pressures in certain examples, such as dasatinib, which is recognized to cause pulmonary hypertension. 

A lot of the next phase, or part of the guideline, is about how you treat the cardiovascular complications when they’re caused by cancer therapies. Now, that’s mainly for cardiology, but I think it’s always good for hematologists to know what we’re advising. And in particular, in the data supplements, there’s the tables of drug-drug interactions between oncology drugs and commonly used cardiology drugs. And this is particularly relevant for a lot of the tyrosine kinase inhibitors that do have interactions with some of the statins or some of the DOACs, and therefore, if you need to start a patient on a statin or on a DOAC or other cardiac drugs, you can just ensure that you’re picking the right one. Or if a cardiologist has started them on, you can at least check that they have made the right decision. 

And then the next part of the guideline, and this is back with the hematologist, is at the end of treatment. Who needs an assessment at some point in the first year after completing their treatment? So this is now as we get into the survivor group who’ve been cured. Particularly relevant for anthracycline chemotherapy, so that’s the lymphoma patients and leukemia patients who’ve recovered and completed treatment. Who requires long-term and lifelong surveillance? Well, that depends on their risk, and we provide the data on how to calculate someone’s risk at the end. And also, just that everybody who’s had anthracycline chemotherapy should get an echocardiogram at 12 months, even if they’re low-risk, because we know from large studies that you can pick up 9% of people at 12 months after their final cycle of anthracycline chemotherapy as having LV dysfunction. And that group is obviously the ones who, maybe years later, would then present with heart failure. So, picking them up early is key. We also have some guidance on patients who are going to receive high-dose mediastinal radiotherapy, where more the risk is a vascular risk on coronary health, although it can in later years also lead to valve disease and pericardial disease. So about having a vascular risk score performed before to pick up people who are probably high vascular risk, and then they can be referred into primary care to get the risk factors treated, whether it’s high cholesterol, diabetes, blood pressure, obviously smoking, the support for smoking cessation. And then of those group who have had a high dose, and a lot of patients with mediastinal lymphomas will receive high doses of radiation to a volume where the heart is included, to then what their long-term surveillance is for the radiation-induced cardiovascular disease, which tends to occur much later, five, ten, 15 years after treatment. 

So that’s the sort of summary and overview of the guideline. And I think one useful tool that I hope will help hematologists all around the world is that all of our European Society of Cardiology guidelines can exist within the pocket guideline app. So if you go to the App Store, type in ESC pocket guideline, then you can get the app. Now, that covers all the cardiology guidelines, but you probably don’t want to download them all, but you can selectively download the cardio-oncology guideline. And then it will have these risk calculators for anthracyclines and those other hematology drugs I mentioned, in the app. And with a bit of practice, it takes about 60 seconds to do the baseline risk assessment using the app. 

So I hope that’s helpful, and obviously the guideline is aimed to not only treat and prevent, ideally, cardiovascular disease but actually improve cancer outcomes for hematology patients by keeping people on their evidence-based hematology treatments. So that’s a sort of summary, there’s a lot of information in the guideline, but if you have a patient, depending on what part of their journey it is, you can just go to that section and hopefully find the relevant guidance for you.