Cardiovascular immune-related adverse events: Evaluation, diagnosis and management

Cardiotoxicities are associated with immune checkpoint inhibitor (ICI) therapy. Recent case series and retrospective studies have shown that cardiac immune-related adverse events (irAEs) are rare but potentially fatal complications of immunotherapy, with various underlying risk factors such as combinations of different ICIs. High mortality rates and overreactive inflammation have been observed with ICI-associated cardiotoxicities, highlighting the necessity of baseline and serial evaluations and the identification and management of cardiac irAEs as early as possible. The clinical presentations of irAEs range from asymptomatic cardiac biomarker elevation, myocarditis and pericardial diseases to heart failure and mild to fatal arrhythmia. Troponin measurement and electrocardiogram are sensitive initial tests, whereas cardiac magnetic resonance imaging and endomyocardial biopsy are both gold standard components of the diagnostic criteria. Close monitoring and timely consultation with a cardiologist are important for the diagnosis of ICI-related cardiotoxicities, with decisions of stopping or rechallenging ICIs and strategies to manage heart injuries. Treatment principles are made according to risk stratifications. The first-line medication is glucocorticoids of various doses, and the second-line immunosuppression includes intravenous immunoglobin, antithymocyte globulin and other immunosuppressants, which are recommended in life-threatening cases or in cases of resistance/no response to steroids.