NYU Langone researchers address the challenges of heart failure in cancer patients

A new scientific statement issued today by the Heart Failure Society of America highlights a critical connection between heart failure (HF) and cancer, with shared mechanisms contributing to the incidence and progression of both diseases. Michelle Bloom, MD, director of the Cardio-Oncology Program at NYU Langone Heart and a professor in the Department of Medicine at NYU Grossman School of Medicine, led the effort to advance this work.

The document, published October 15 in the Journal of Cardiac Failure, shows that patients with cancer are at an increased risk of developing HF, while HF patients face a high risk of cancer, emphasizing the need for coordinated care between cardiology and oncology.

"We are only scratching the surface in the expanding field of cancer therapeutics. As we advance, it becomes clear that understanding the full spectrum of cardiac toxicities, including heart failure, is essential for maximizing treatment benefits and safeguarding patient heart health," said Dr. Bloom, the co-lead author.

This statement highlights the need for a multidisciplinary approach to managing heart failure in cancer patients, emphasizing that understanding the intersection of these two complex conditions is vital for enhancing patient outcomes, and addressing disparities in care."

Michelle Bloom, MD, Director, Cardio-Oncology Program, NYU Langone Heart

Dr. Bloom and the team of heart failure specialists, cardio-oncologists, oncologists, and pharmacists developed this document to establish more uniform recommendations, including standardized cardiac imaging protocols during cancer therapies to prevent heart-related complications. More protocols are also needed regarding the notion of "permissive cardiotoxicity," which acknowledges the need to balance some increase HF risk to ensure optimal cancer treatment. Careful assessment by heart failure specialists is crucial in cancer treatments, including during risk assessments for heart transplantation and durable left ventricular assist device (LVAD) placements.

Several key points

1. HF and cancer share common pathophysiological mechanisms that influence disease incidence and progression, demonstrating a reciprocal relationship. Patients with cancer are at increased risk of developing HF, and patients with HF face a higher risk of developing cancer.
2. Beyond anthracyclines and HER2-targeted monoclonal antibodies, very few cancer therapeutics have standardized cardiac imaging surveillance recommendations, resulting in significant variations in clinical practices.
3. The concept of "permissive cardiotoxicity" highlights an emerging approach of maintaining lifesaving cancer therapies while accepting some degree of cardiac toxicity and mitigating risk through cardioprotective strategies.
4. Heart failure with preserved ejection fraction (HFpEF) is an important yet under-recognized aspect of cancer therapy-related cardiac toxicity, described in a wide array of cancer therapeutics, including BTK inhibitors, CAR-T therapies, and hematopoietic stem cell transplantation (HSCT).
5. Cardiogenic shock in cancer patients can arise from various causes, including LV dysfunction due to cancer therapies, acute coronary syndrome, stress-induced cardiomyopathy, and immune checkpoint inhibitor-associated myocarditis.
6. Durable LVADs are feasible for patients with Stage D HF due to chemotherapy-induced cardiomyopathy, with similar survival rates compared to other causes of cardiomyopathy.
7. For candidates with a history of cancer, careful and individualized risk assessment in collaboration with oncology specialists is crucial to determine eligibility for heart transplantation. This includes evaluating the impact of preexisting neoplasms and the risk of cancer recurrence, with a personalized approach essential to prevent unnecessary delays in transplant listing.
8. ICI-associated myocarditis should be recognized and treated urgently due to its severe nature and high mortality risk. Multidisciplinary care is crucial for accurate diagnosis and effective management, especially in hemodynamically unstable patients.
9. Palliative care involvement is essential for enhancing the quality of life in patients with both cancer and HF, and should be integrated early to manage symptoms, psychological stress, and care coordination. There is a growing push to integrate palliative care practices from oncology and cardiology to better support these patients, supported by clinical research and professional recommendations.
10. Racial and ethnic minorities and LGBTQ+ populations experience significant health disparities in cancer and cardiovascular care due to systemic issues like delayed screenings and limited access to quality care. Strategies to address these inequities include community outreach, inclusive research, and improved access to care and clinical trials.

"We hope that this document becomes the go-to resource for anything and everything cardio-oncology in heart failure practices," Dr. Bloom added.

In addition to the statement, two supplemental articles have been published: "Cardio-Oncology and Heart Failure: AL Amyloidosis for the Heart Failure Clinician" and "Heart Failure in Patients with Cancer—A Patient's Perspective."