Cardiotoxicity and peri-operative considerations in immune checkpoint inhibitor and chimeric antigen receptor T-cell therapy: a narrative review.

Abstract

Immunotherapy has transformed cancer treatment, particularly with immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy. Despite their efficacy, these therapies can induce cardiotoxicity, presenting significant clinical challenges. Immune checkpoint inhibitors can cause myocarditis; pericarditis; arrhythmias; and myocardial infarction through immune-mediated inflammation. Chimeric antigen receptor T-cell therapy may result in cardiovascular complications due to cytokine release syndrome, including myocardial dysfunction, endothelial damage and arrhythmias. We used PubMed, Embase and Google Scholar to search for peer-reviewed articles in September 2024 without setting any date limits. Our selection criteria encompassed studies focusing on cardiotoxicity related to immune checkpoint inhibitors or chimeric antigen receptor T-cell therapy, comprising original research, meta-analyses, clinical trials and review articles. The findings were reported narratively. Early diagnosis of cardiotoxicity is critical but challenging due to non-specific symptoms. Diagnostic tools include ECG; cardiac biomarkers; echocardiography; cardiac magnetic resonance imaging; and endomyocardial biopsy. However, no single tool is definitive. High-dose corticosteroids are the first-line treatment for immune checkpoint inhibitor-induced myocarditis, with additional immunosuppressive therapies for refractory cases. Standard heart failure management protocols should be followed in cases of heart failure. Tocilizumab and corticosteroids are utilised for chimeric antigen receptor T-cell therapy-induced cytokine release syndrome, alongside supportive care, including fluid resuscitation and vasopressors for severe cases. As the use of immunotherapy expands, understanding the mechanisms, risk factors and management strategies for cardiotoxicity is increasingly important. Collaborative efforts among oncologists, cardiologists and anaesthetists are essential to mitigate these risks, especially in peri-operative settings. Ongoing research is vital to improve the safe and effective use of immunotherapeutic drugs while minimising cardiovascular adverse effects.