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Table 9. Cardiovascular Toxicities
9.1 Myocarditis, pericarditis, arrhythmias, impaired ventricular function with
heart failure and vasculitis
Workup/Evaluation
• Electrocardiogram
• Troponin, and CPK to rule out concurrent myositis, especially in patients treated
with combination immune therapies. Alternative reasons for elevation should be
ruled out.
• If elevated, troponin should be serially monitored. With elevated troponin, be aware
of the potential for "triple M" irAEs — myositis, myasthenia, and myocarditis — and
refer to subspecialties.
• Brain natriuretic peptide (BNP)
• Echocardiogram
• Chest X-ray
Additional testing to be guided by cardiology and may include:
• Stress test
• Cardiac catherization
• Cardiac MRI
Grading Management
G1: Abnormal cardiac biomarker
testing without symptoms and
with no ECG abnormalities.
• All grades warrant workup and intervention
given the potential for cardiac compromise.
• Hold ICPi for G1 elevated troponin* and
recheck troponin 6 hours later. May consider
resuming once normalized or if believed not to
be related to ICPi.
• Hold ICPi and discontinue for ≥G2.
• For patients with Grade ≥2, early (i.e., within
24 hours) initiation of high-dose corticosteroids
(1–2 mg/kg/day of prednisone, oral or IV
depending on symptoms) should be considered as
it is likely to be beneficial without adverse effects.
• Admit patient, cardiolog y consultation.
• Management of cardiac symptoms according to
ACC/AHA guidelines and with guidance from
cardiolog y.
• Immediate transfer to a coronary care unit should
be considered for patients with elevated troponin
or conduction abnormalities.
• For new conduction delay, consider a pacemaker.
• In patients without an immediate response
to high-dose corticosteroids, consider early
institution of cardiac transplant rejection doses
of corticosteroids (methylprednisolone 1 g every
day) and the addition of either mycophenolate,
infliximab, or anti-thymocyte globulin. Consider
abatacept (costimulatory molecule blockade) or
alemtuzumab (CD52 blockade) as additional
immunosuppression in life threatening cases.
G2: Abnormal cardiac biomarker
testing with mild symptoms or
new ECG abnormalities without
conduction delay.
G3: Abnormal cardiac biomarker
testing with either moderate
symptoms or new conduction
delay.
G4: Moderate to severe
decompensation, intravenous
medication or intervention
required, life threatening
conditions.
