Heart Failure and Cancer: HFSA Statement Explores the Interplay

Clinicians caring for patients with heart failure (HF) and either current or prior cancer have a new resource to turn to for advice: a scientific statement from the Heart Failure Society of America (HFSA) that covers the shared pathophysiology and risk factors connecting the two diseases, the evidence base so far, as well as tips for management.

Interest in this intersection has grown exponentially in recent years, said Michelle Weisfelner Bloom, MD (NYU Langone Hospital, New York, NY), who co-chaired the document along with Ana Barac, MD, PhD (Inova Heart and Vascular Institute, Falls Church, VA).

Many heart failure specialists have become subspecialists in cardio-oncology, she told TCTMD. “I think that the reason is because—and you see this weaved throughout the theme of the statement—there is a large overlap . . . in a bidirectional way” between the conditions.

For people who are less well versed in this area, the authors aimed for a thorough, “nuts and bolts” approach, Bloom noted.

Some anticancer therapies have long been known to impact the heart and the advent of newer options has made the management of cancer patients’ cardiovascular health even more nuanced, Bloom explained. “Also, there are a large amount of patients who have a cardiomyopathy or heart failure at the time of their cancer diagnosis.”

It’s become clear that heart failure specialists are going to “have to embrace this field,” Bloom said, noting that the HFSA scientific statement is intended help these clinicians feel more comfortable that they have the expertise they need. Patients facing not only cancer but also possibly cardiac dysfunction, she and her colleagues say, can benefit from a team-based approach involving collaboration among heart failure, oncology, palliative care, pharmacy, and nursing.

The HF-focused paper, published in the Journal of Cardiac Failure, comes on the heels of the first ever European Society of Cardiology guidelines for cardio-oncology, released in 2022, and a Society for Cardiovascular Angiography and Interventions consensus statement, released in 2016, to help interventional cardiologists understand the unique needs of cancer patients.

Lessons for Practice

At the root of the “intricate and complex” relationship between HF and cancer are shared mechanisms, Bloom and colleagues note. “What were historically characterized as two independent disease states have more recently been recognized as having shared epidemiology and biology.”

On one hand, HF patients appear to be at higher risk of developing tumors, perhaps due to “a pro-inflammatory state, neurohormonal activation, oxidative stress, and/or a dysregulated immune system,” they observe. On the other, “cancer itself can play a role in the development of HF through indirect mechanisms such as metabolic derangements, oxidative stress, neurohormonal dysregulation, and inflammation.”

To provide clarity amid the complexity, the authors developed user-friendly tables and figures so that clinicians with a solid background in HF care can easily find what they need, said Bloom.

There’s information on cancer therapies that up the risk of cardiomyopathy and heart failure, including the incidence, mechanism, and clinical presentation of these disease states, as well as an explanation of the pharmacokinetics and pharmacodynamics involved.

For anthracyclines, which “are among the oldest cancer therapeutic agents known to cause cardiac toxicity,” Bloom and colleagues devote an entire table to options for dealing with dose-dependent toxicity. Additional recommendations address anti-HER2-targeted agents, alkylating agents, antimetabolites, tyrosine kinase inhibitors, proteasome inhibitors, immune checkpoint inhibitor therapies, chimeric antigen receptor T cell (CAR-T) therapy, and radiation therapy.

Immunotherapy agents, a relatively recent addition, are “probably the most burgeoning area of study right now,” so merited their own section, said Bloom. “Even those of us who are in the world of cardio-oncology struggle a lot with these cases and no case is the same as the next.”

At the outset, clinicians should use the available risk algorithms and prediction models to ascertain their oncology patients’ risks and modify these factors where possible, Bloom et al say. “Receipt of high doses of anthracyclines and chest radiation therapy have been recognized as one of the key treatment-related contributors to HF risk, largely based on the studies in survivors of childhood, adolescent, and young adult cancers.”

A baseline look at cardiac function, typically with transthoracic echocardiography, is recommended for patients slated to receive cancer therapies that have been linked to direct cardiotoxicity (eg, anthracyclines and HER2-targeted therapies), the authors advise. “In these patients, findings of abnormal LVEF (most often defined as LVEF < 50%) require multidisciplinary discussion regarding safety of oncology therapy, further cardiac evaluation, and joint cardiology and oncology management during cancer treatment.”

Whether biomarkers can also aid risk stratification in this setting is an area of active study, they add.

Heart Failure From A to D

The latter half of the HFSA statement contains individual sections devoted to the various levels of HF severity, starting with stage A (prevention in adults with cancer and childhood survivors of cancer) and stage B (management of asymptomatic cardiac dysfunction in cancer patients) and continuing through stage C (diagnosis and management of symptomatic HF across the spectrum of LVEF) and stage D (specific to advanced HF in patients with cancer).

For stage C and stage D, the evidence base is still slim, Bloom acknowledged, pointing to the need for more research. “We wanted to pull together whatever was there and have at least some expert opinion on how to handle those patients, [highlighting] what we know and what we don't know, so that clinicians had that as a usable resource,” she said.

Indeed, there’s much room to grow. Even though “we have learned so much and we have come so far, we still are, I would say, at the precipice of really understanding the field of cardio-oncology and HF, the scope of the issue, and the treatment,” Bloom commented.

For cardio-oncologists, the advances in cancer treatment are in some ways a “double-edged sword,” she pointed out.

“There's a lot of agents that are on the horizon, and the oncologists are lucky in so much as they have agents that are being approved very quickly for a lot of different types of malignancies,” said Bloom. But the flip side of that progress, she added, is that at this point “we don’t have longitudinal data on cardiac risk” in this fast-paced field.