2023CSCO肿瘤心脏病学-放疗以及处理原则指南更新

The 2023 Chinese Society of Clinical Oncology (CSCO) Guidelines Conference was successfully held in Guangzhou. This conference specially invited Professor Chen Jing from the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology and Professor Fang Fengqi from the First Affiliated Hospital of Dalian Medical University to participate in the grand event. The meeting heatedly discussed topics such as radiotherapy-related cardiotoxicity and principles of treatment of cardiotoxicity caused by anti-tumor therapy. The following article summarizes the key points of the meeting for readers’ reference!

Radiation Therapy-Related Cardiotoxicity Guidelines Update

Professor Chen Jing pointed out that because the technology of radiotherapy is very mature, the radiotherapy part of this year’s guide has not been updated. This year’s focus is on three aspects of radiotherapy prevention:

(1) Emphasize the additional evidence recommending coronary artery delineation;

(2) Supplementary evidence that proton radiotherapy reduces cardiotoxicity;

(3) In terms of heart limits, more reference will be made to the standards and content updates of international guidelines.    

Updated principles for management of cardiotoxicity due to antineoplastic therapy

Professor Fang Fengqi pointed out that this year’s guidelines have been updated in three aspects: tumor cardiotoxicity management process, principles for the treatment of asymptomatic cardiovascular toxicity, and principles for the treatment of symptomatic cardiovascular toxicity:

(1) Update on the management process of cardiovascular toxicity of anti-tumor therapy:

Added "baseline risk stratification, individualized active monitoring, and full life cycle management";

A new “individualized, active monitoring process” that refines cardiovascular toxicities related to tumor treatment has been added.  

(2) Update of principles and guidelines for the management of asymptomatic cardiovascular toxicity:

Newly added cardioprotective therapeutic drugs: "angiotensin receptor neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 (SGLT-2) inhibitor".

(3) Update on principles and guidelines for the management of symptomatic cardiovascular toxicity:

a. Added “ARNI” to myocardial injury and heart failure;

b. For immune myocarditis, "suspected patients should interrupt ICIs treatment and adjust hormone usage and dosage";

c. The reperfusion treatment of coronary heart disease has added "life expectancy, adjust drugs according to platelets";

d. VTE anticoagulant treatment increases with “apixaban”.

The above is the updated content of radiotherapy and treatment principles proposed in this year's guidelines for cardiotoxicity. You may have questions about the efficacy of ARNI and apixaban, the drugs added to the treatment principles for symptomatic cardiovascular toxicity. The following content will answer your questions!

The full name of ARNI is angiotensin receptor neprilysin inhibitor, which is a new type of commonly used antihypertensive drug that effectively lowers blood pressure while exerting cardiorenal protection. Sacubitril-valsartan is the first ARNI drug. The metabolite LBQ657 of sacubitril inhibits the degradation of natriuretic peptides by neprilysin (NEP), exerting diuretic, natriuretic, vasodilatory, and antisympathetic effects. At the same time, valsartan inhibits the activity of the renin-angiotensin-aldosterone system (RAAS), thereby achieving a strong antihypertensive effect. Therefore, for myocardial damage and heart failure that occur during tumor treatment, ARNI drugs can improve left ventricular hypertrophy, reverse cardiac remodeling, improve cardiac function, and reduce the incidence of cardiovascular events through antihypertensive effects.

(English trade name: ELIQUIS) is a new coagulation factor Xa inhibitor jointly developed by BMS and Pfizer. It can reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation, and can also be used to treat deep vein thrombosis and pulmonary embolism. The emergence of this new oral anticoagulant, apixaban, has reduced the risks caused by anticoagulation, made up for the application limitations of warfarin to a certain extent, and also provided new options for patients. Studies have shown that reducing thrombin generation by inhibiting coagulation factor Xa may be more advantageous than directly inhibiting thrombin. Compared with vitamin K antagonists such as warfarin, apixaban has the characteristics of higher safety. Therefore, for patients with tumor cardiotoxicity, apixaban can be the drug of choice during anticoagulation.

In short, cardiovascular-related toxicity caused by tumors requires strengthening multidisciplinary cooperation. Oncologists and cardiologists work together to protect the heart health of patients. They also look forward to the emergence of better anti-tumor drugs that can reduce cardiovascular toxicity in the future, benefiting more cancer patients.

References:

(1) 2023 CSCO Cardiology Special Guidelines Meeting

(2) 2021 EHRA practice guideline "Guidelines for the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation"