Real-Life Management of Elevated Troponin Level in Patients Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICIs) have revolutionized the clinical outcomes of cancer. Nevertheless, their use may lead to myocardial injury. The 2022 European Society of Cardiology cardio-oncology guidelines recommend routine follow-up of troponin level; however, current guidelines do not provide specific protocols for managing elevated troponin levels during ICI therapy. We aimed to describe the real-life assessment of patients treated with ICIs, presenting with an elevated high-sensitivity troponin I (hs-TnI) level following therapy.

Tel Aviv Sourasky Medical Center has implemented a routine follow-up of hs-TnI level measurement during ICI therapy. We performed a retrospective analysis evaluating the clinical assessment and management of patients presenting with an elevated hs-Tnl level (> 50 ng/L) following therapy.

Among 455 patients performing baseline and follow-up hs-TnI measurements, 50 patients (11%) presented with an elevated hs-TnI level (median 159 ng/L; interquartile range 76-362) following ICI therapy. All patients underwent an electrocardiogram, showing changes in 5 patients (10%). Among 24 patients (48%) who received echocardiography, 4 (8%) showed abnormalities. A cardiology consultation was ordered for 17 patients (34%), and none received cardiac magnetic resonance imaging or coronary angiography. A total of 13 patients (26%) were diagnosed with probable or possible myocarditis, resulting in corticosteroid therapy and discontinuation of ICI therapy in 84% and 92% of the patients, respectively. Only 2 patients reinitiated ICI therapy at a later stage.

We describe for the first time the management of elevated hs-TnI levels following ICI therapy, which was diagnosed in routine serial surveillance. We found a wide diversity in management, low cardiology involvement, and high interruption of therapy, emphasizing the need for standardized protocol management guidelines.