64
Treatment
Table 9. Cardiovascular Toxicities
Qualifying Statement: Treatment recommendations are based on anecdotal evidence
and the life-threatening nature of cardiovascular complications. Holding checkpoint
inhibitor therapy is recommended for all grades of complications. The appropriateness of
rechallenging remains unknown. Note that infliximab has been associated with heart
failure and is contraindicated at high doses (i.e., >5 mg/kg) in patients with moderate-
severe heart failure.
*
According to CTCAE v5.0, G1 elevated troponin is defined as levels above the upper limit of
normal and below the level of myocardial infarction as defined by the manufacturer.
9.2 Venous thromboembolism
Workup/Evaluation:
• Evaluation of signs and symptoms of pulmonary embolism (PE) or DVT may
include:
▶ Clinical prediction rule to stratify patients with suspected VTE.
▶ Venous US for suspected DVT.
▶ CTPA for suspected PE.
▶ Can also consider D-dimer for low-risk patients based on risk stratification by clinical
prediction rule for DVT/PE when CT or Doppler not available or appropriate.
▶ V/Q scan is also an option when CTPA is not appropriate.
▶ Consider other testing, including ECG, chest radiography, BNP and troponin
levels, and ABG.
Grading Management
G1: Venous thrombosis (e.g.,
superficial thrombosis).
• Continue ICPi.
• Warm compress.
• Clinical surveillance.
G2: Venous thrombosis
(e.g., uncomplicated deep
vein thrombosis), medical
intervention indicated.
• Continue ICPi.
• Management according to CHEST, ACC, and/
or AHA guidelines and consider consult from
cardiolog y or other relevant specialties.
• Low-molecular-weight heparin (LMWH),
vitamin K agonist (VKA), dabigatran,
rivaroxaban, apixaban, or edoxaban for
initial anticoagulation treatment. For long-
term anticoagulation, LMWH, edoxaban,
rivaroxaban, or apixaban for at least 6 months
are preferred over VKAs because of improved
efficacy.
• IV heparin is an acceptable alternative for initial
use and oral anticoagulants are acceptable for the
long term.
G3: Venous thrombosis (e.g.,
uncomplicated pulmonary
embolism), urgent medical
intervention indicated.
• Hold ICPi and may reintroduce after risk/
benefit are considered.
• Follow G2 anticoagulation recommendations.
(cont'd)
