Left Ventricular Dysfunction in Cancer Treatment: Is it Relevant?

Contemporary cancer therapies have dramatically improved cancer-free and overall survival but have been accompanied by increasing cancer treatment-related cardiovascular toxicity, including left ventricular (LV) systolic dysfunction. Previously, systemic chemotherapy with anthracyclines and radiation therapy were the only cancer treatments with significant cardiotoxicity. However, modern targeted cancer therapies, including HER2 inhibitors, tyrosine kinase inhibitors (TKIs), proteasome inhibitors, and immune checkpoint inhibitors, have all been associated with adverse cardiovascular events. As cancer treatment paradigms successfully move toward prolonged targeted therapy, cardiologists are increasingly needed to assess cardiotoxicity risk and manage asymptomatic and symptomatic LV systolic dysfunction. This state of the art review summarizes the present knowledge about the mechanisms and clinical practices of screening, diagnosis, and management of LV dysfunction associated with cancer therapeutic regimens. We utilize the framework of the ACCF/AHA stages of heart failure (HF) to summarize current evidence for risk stratification and modification (Stage A HF), asymptomatic structural heart disease detection and treatment (Stage B HF), and reduction of HF morbidity and mortality (Stages C and D HF) during cancer treatment and in survivorship. We also present new clinical practice challenges and opportunities for active engagement of cardiologists with multidisciplinary cancer treatment teams in order to ensure optimal patient outcomes.