Arrhythmias in patients with cancer: Pathophysiology, risk stratification and clinical implications

Arrhythmias are increasingly recognized cardiovascular complications in patients with cancer, arising from both the malignancy and its therapies. Once considered unimportant compared to cancer treatment-related heart failure, arrhythmias, particularly atrial fibrillation (AF) and ventricular arrhythmias (VA), are now recognized to play a major role in cardio-oncology due to their prognostic impact and effect on treatment continuity. Anthracyclines, immune checkpoint inhibitors and Bruton's tyrosine kinase inhibitors are linked to higher arrhythmic risk, ranging from asymptomatic ECG abnormalities to QT prolongation (QTp), conduction disorders and AF. Cellular therapies are linked to AF, mainly driven by cytokine-mediated myocardial inflammation. Cyclin-dependent kinase 4/6 inhibitors, especially ribociclib, may induce dose-related QTp and, less commonly, VA. Additionally, Takotsubo syndrome may occur in patients with active cancer due to stress and is often accompanied by early arrhythmic complications. Awareness and prevention of arrhythmias are essential to optimize patients' outcomes. Arrhythmias management requires individualized assessment, ECG surveillance, and multidisciplinary follow-up. We additionally propose a six-step framework to support early detection and prompt intervention of arrhythmias.