Managing and Monitoring Cardiotoxic Risks During Cancer Treatment

Pharmacy Times interviewed Aaron Adkisson, PharmD, an ambulatory clinical pharmacist - cardiooncology/general cardiology at UK HealthCare in Lexington, Kentucky, about the risk of developing heart failure and cardiomyopathy during treatment with cancer therapies. Adkisson discussed collaboration with other cardiology professionals and emphasized the importance of patient education on signs of early heart failure symptoms.

Pharmacy Times: How should pharmacists monitor and manage the cardiotoxic risks?

The cardiovascular comorbidities of these patients really dictate how frequently we follow up with them and monitor for these cardiotoxicities. Image Credit: © Sergey Nivens - stock.adobe.com

Aaron Adkisson, PharmD: The cardiovascular comorbidities of these patients really dictate how frequently we follow up with them and monitor for these cardiotoxicities. The European Society of Cardiology is the guideline that we use predominantly in my clinic, and they have various risk stratification tools that include things like “have they had a prior myocardial infarction? Do they have current heart failure? Do they have other different cardiovascular conditions?” But then it also takes into account important demographic factors such as weight, metabolic risk factors, and the cancer treatment. We can take these risk factors and then essentially put these patients into buckets of if the patient has a low, medium, high, or very high risk, and that would dictate how frequently you get an echocardiogram, how frequently you get electrocardiograms, troponins, and natriuretic peptides. We do use those comorbidities and patient demographic information to help guide our monitoring.

Pharmacy Times: How do age and gender influence the risk and management of drug-induced heart failure?

Adkisson: That's a great question! Regarding age, age is a risk factor for developing cardiotoxicities in several types of cancer therapies. For example, risk stratification tools for HER2 inhibitors split age into 2 categories: age 65 to 79 and age 80 or older, with the former being considered a medium-risk factor and the latter being considered a high-risk factor. In this way, age does play a factor in risk stratification, and, in turn, plays a part in the frequency in which we monitor for cardiotoxicities.

Regarding the management of drug-induced heart failure, age and sex assigned at birth play major factors. For patients who are of childbearing age and are able to become pregnant, we may practice caution and avoid using agents such as angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, which are known teratogens. However, we likely could use a beta blocker like metoprolol succinate that has a safer adverse effect profile in patients who are pregnant or may become pregnant. In our older adults, depending on their blood pressure and heart rates, we may opt to be less aggressive in cardioprotective strategies and start guideline-directed medical therapy, as these patients may not be able to tolerate it from a vitals perspective and a volume perspective. With the fluid shifts involved in our patients with cancer, we have to be very careful in starting diuretic therapy or agents that could lead to volume depletion.

Pharmacy Times: Do pharmacists collaborate with other cardiology health care professionals to make decisions regarding cardiotoxicity from cancer treatment, and what does that look like if so?

Adkisson: Pharmacy practice in cardio-oncology is a new and growing specialty within the worlds of cardiology and oncology. Pharmacists collaborate with cardiology providers as well as oncology providers in the decision-making surrounding cardiotoxicities from cancer treatments. Pharmacists are the medication experts, and one way I have found pharmacists can provide value is through evaluating drug interactions between cardiovascular medications and cancer therapies and evaluating these pharmacokinetic/pharmacodynamic interactions.

Pharmacy Times: What are some strategies available for pharmacists to help educate patients to recognize and report early symptoms of heart failure?

Adkisson: Patients know their bodies better than anyone else. I always think it is important to discuss the signs and symptoms of volume overload and how this may look in a patient. Patients may have unexplained weight gain that accompanies symptoms such as lower extremity edema, shortness of breath, decrease in appetite, and nausea. These are all common symptoms of heart failure but also may be present due to a patient's cancer therapy or as a result of their cancer diagnosis. It's important for patients to let their oncology and cardiology providers know when they first begin to experience these signs and symptoms so they can be assessed holistically and [be treated with] the appropriate treatment.