Preventive Cardio-Oncology: Cardiovascular Disease Prevention in Cancer Patients and Survivors

To review the most common forms of cardiovascular toxicities from anti-cancer drugs, with a focus on their prevention via cardioprotective pharmacologic or lifestyle therapy, risk factors management, screening, monitoring, and surveillance methods. There are almost 20 million cancer survivors in the USA, and their leading cause of death besides cancer recurrence or a secondary cancer is cardiovascular disease (CVD). CVD is prevalent in this population, with the most common forms being cardiomyopathy, ischemia, atrial fibrillation, and hypertension from cancer drugs or radiation therapy. The field of cardio-oncology is continuously evolving with multi-modality risk prediction strategies, moving towards precision surveillance and interventions that allow for safe continuation of life-saving chemotherapy. Preventative measures with implementation of novel drugs (including sodium-glucose cotransporter inhibitors) and modulated chemotherapy administration can aid in cardiotoxicity risk reduction. Recently, clonal hematopoiesis of indeterminate potential has been identified as a common risk factor for atherosclerotic cardiovascular disease present in > 10% of those age 70 or older. Also, risk stratification for atrial fibrillation appears pivotal. Multidisciplinary team management might have a central role in patient management and care. There is a central role for the optimization of cardiovascular disease risk for cancer patients and survivors in multidisciplinary teams, with descriptions of four forms of cardiovascular toxicities. In addition to pharmacologic cardioprotection, lifestyle modification is becoming more prominent as a preventive tool. Moreover, studies relevant to one type of toxicity should be scrutinized routinely to determine how those result may play out in the setting of other types of toxicities. All of these areas of investigation should ultimately be pursued in the setting of personalized medicine, and will likely benefit from the integration of artificial intelligence methods. Studies in genomics and transcriptomics have identified variations in the genome and gene expression profiles that associate with induction of or protection from cardiovascular toxicity and can affect cardioprotection efforts. Larger randomized clinical trials will be needed for all patients, with a focus on incorporation of ethnic minorities likely by intentional oversampling, to overcome decades of demographic homogeneity in the trials.