Breast Cancer and CV Health: Key Points

The following are key points to remember from a review about breast cancer and cardiovascular (CV) health:

1. Breast cancer is a significant public health challenge, accounting for 25% of cancer cases.
2. All cardiologists should be able to implement preventive measures for breast cancer patients, optimize CV risk factors, and recognize the CV effects of breast cancer therapy. 
3. Cancer therapy-related CV toxicities (CTR-CVTs) resulting from chemotherapy, radiotherapy, or immunotherapy commonly include CV dysfunction, coronary artery disease, stroke, venous thromboembolism, and atrial fibrillation, and may include other arrhythmias, arterial hypertension, myocarditis, pericarditis, or valvular heart disease.
4. Specific agents are associated with characteristic toxicities, e.g., anthracycline with heart failure, left ventricular dysfunction, and arrhythmias. Typical CV toxicities of each type of agent are delineated in the article. Those associated with radiation therapy may appear years after the conclusion of cancer therapy. 
5. CV risk assessment is recommended prior to initiation of cancer therapy. The HFA-ICOS (Heart Failure Association and International Cardio-oncology Society) risk assessment tool is recommended prior to anthracycline or human epidermal growth factor receptor 2 (HER2) targeted therapies. The European SCORE2/SCORE2-OP (Systematic Coronary Risk Evaluation 2/Systematic Coronary Risk Evaluation 2-Older Persons) is recommended before starting fluoropyrimidines, endocrine therapy, or radiotherapy. 
6. Prevention of CTR-CVT can optimize both oncological and CV outcomes.
   1. Exercise therapy should be started in the early phases of treatment and continued thereafter to diminish declines in cardiorespiratory fitness from cancer therapy.
   2. Liposomal anthracycline or dexrazoxane should be considered in patients at high risk of cancer therapy-related cardiac dysfunction in whom anthracycline treatment is planned.
   3. Beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) have been used in patients receiving anthracycline and/or trastuzumab, although results have been mixed. A meta-analysis found that in patients receiving trastuzumab, beta-blockers (statistically significant), ACEIs, or ARBs conferred greater left ventricular ejection fraction protection.
7. In patients at low or intermediate risk of CTR-CVT, therapy for breast cancer should be promptly initiated, and oncologists should oversee CV monitoring. Referral to a cardio-oncology specialist is recommended for patients at high or very high risk or for those experiencing CTR-CVT. Monitoring may include assessment of electrocardiogram, echocardiogram, and/or biomarkers at baseline and/or at intervals during and after therapy.
8. Management decisions regarding CTR-CVT should be made through a multidisciplinary approach. Clinicians should adhere to the concept of permissive cardiotoxicity, balancing the need for cancer therapy versus the burden of CTR-CVT. Decisions to interrupt cancer therapy or initiate cardioprotective medications should be based on the severity of CV symptoms or cardiac dysfunction and the specific agent(s). 
9. Management recommendations for specific clinical scenarios are outlined below: 
   1. In patients who develop myocarditis within 60 days of initiation of immune checkpoint inhibitor (ICI) therapy, consideration should be given for hospitalization, withdrawal of ICI therapy, cardiac magnetic resonance imaging, and institution of high-dose corticosteroids.
   2. In patients whose blood pressure remains above 160/100 mm Hg, cancer therapy should be postponed or interrupted. To maintain blood pressure <140/90 mm Hg, ACEI or ARB are first-line therapies, and dihydropyridine calcium channel blocker is second-line.
   3. Anticoagulation with atrial fibrillation is recommended in those with an appropriate CHA2DS2-VASc or CHA2DS2-VA score, with non–vitamin K oral anticoagulants as the preferred agents and low molecular weight heparin as an alternative.
   4. In patients requiring revascularization or antithrombotic therapy, treatment should be individualized based on the patient’s thrombotic and bleeding risk, which are both higher in the context of cancer. Special attention is merited in patients with thrombocytopenia.
10. Patients who develop venous thromboembolism, acute coronary syndrome, vasospasm, valvular lesions from radiotherapy, or chronic pericardial disease should be treated according to standard guidelines

https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehae637/7775367