Management of Immune Checkpoint Inhibitor (ICI) Induced Cardiotoxicity Problem - Immune checkpoint inhibitors (ICIs) are associated with cardiotoxicity. ✖ Cardiotoxicity with ICIs range from myocarditis and heart failure to potentially serious arrhythmias, pericarditis and vasculitis. ✖ Current guideline recommendations lack key prognostic factors, strategies for prevention and a data-driven suggestion for frequency of monitoring. ✖ The mechanisms of ICI-related cardiovascular events are not well-known. Solution: ✔ With either suspicion or confirmation of ICI-associated cardiotoxicity, discontinuation of the offending agent and initiation of steroids should be initiated promptly. ✔ Other conditions including ischemia must be ruled out. ✔ Corticosteroids should be continued until resolution of symptoms and normalization of troponin, left ventricular systolic function and conduction abnormalities. ✔ Consider abatacept for the treatment of severe ICI myocarditis. Severity Grading: G1: Mildly abnormal screening tests, no symptoms G2: Abnormal screening tests with mild symptoms G3 - Severe: Moderately abnormal screening tests (arrythmia, cardiac biomarker > upper limit of normal, significant echocardiogram findings), symptoms with mild activity G4 - Life-Threatening: Moderate to severe decompensation, hemodynamic instability, cardiac biomarker >3x upper limit of normal, requiring intravenous medications or interventions MANAGEMENT: G1 toxicity: - Hold ICI - Monitor and trend electrocardiogram and cardiac biomarkers - Rule out other potential causes - Resume ICI under close monitoring if no worsening G2-G3 toxicity: - Permanently discontinue ICI - Mild symptoms: Oral prednisone 1-2 mg/kg/day - Severe symptoms: Methylprednisolone intravenously 1 g/day for 3-5 days - Continue steroid until cardiac function returns to baseline, then taper 4-6 weeks G4 toxicity: - Permanently discontinue ICI - Methylprednisolone intravenously 1 g/day for 3-5 days - Consider initiating abatacept or other immunosuppressive therapies (antithymocyte globulin, infliximab, or mycophenolate mofetil) - Continue steroid until cardiac function returns to baseline, then taper 4-6 weeks - Initiate advanced heart failure management, including hemodynamic support with ventricular assist devices, as indicated #Checkpoint #Inhibitor #ICI #Cardiotoxicity #cardiology #oncology #management #treatment
