Cardiovascular toxicities represent one of the most severe immunotherapy complications. While less than 1% of patients experience cardiac toxicity, 50% of patients who experience a cardiac event discontinue immunotherapy due to the high mortality rate. This risk for cardiac toxicity increases with both combination immunotherapy and in patients who received prior chemotherapy or targeted therapy. Current literature suggests subclinical cardiovascular damage from cardiac antigen exposure during prior lines of therapy may be amplified with subsequent immunotherapy resulting in cardiac toxicity. ICI therapy has been shown to affect the heart in both an inflammatory (myocarditis, perimyocarditis, ventricular dysfunction) and non-inflammatory (asymptomatic non-inflammatory left ventricular dysfunction, arrhythmias, myocardial infarction) manner. Non-specific symptoms including fatigue, chest pain and overall body weakness present in the first 2 months of initiating immunotherapy. A full cardiac history prior to initiation of immunotherapy is essential due to the high mortality rate and rapid clinical deterioration that can lead to heart failure if not diagnosed and treated early. Clinical assessment includes serum testing, diagnostic imaging (ie, ECG and cardiac MRI to assess inflammation), cardiologist consultation, and in instances involving suspected myocarditis a cardiac biopsy is necessary.
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