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"Inhibiting angiogenesis is an effective approach to cancer therapy, but it has been associated with cardiovascular toxic effects. At times, adverse events such as hypertension and heart failure have led to treatment cessation and even life-threatening consequences. Cancer patients have often been excluded from studies of cardiovascular disease, and patients with clinically significant cardiovascular disease have been excluded from studies of new cancer therapies. Consequently, the capacity for determining the incidence or prevalence of cardiovascular toxic effects of anticancer agents and to determine their optimal management has been limited. Oncologists and cardiovascular medicine specialists have increasingly recognized that the prevention and management of these toxic effects is important for these potentially life-sustaining anticancer agents to benefit the greatest possible number of patients."
Box 1. Summary recommendations
- Conduct and document a formal risk assessment for
potential cardiovascular complications before vascular
endothelial growth factor signaling pathway (VSP) inhibitor
treatment. The assessment should include standardized blood
pressure measurements (two separate sessions are suggested)
and thorough history and examination to assess specific
cardiovascular risk factors, and directed laboratory studies
as indicated. (Table
2 summarizes the risk factors.) The purpose of this
evaluation is to guide the physician and patient in
determining the appropriate intensity of monitoring and
control of blood pressure elevations. This provides an important opportunity
to address comorbidities that through more attentive management
could help prolong the patient's life and support more
aggressive anticancer therapy.
- Recognize that preexisting hypertension will be
common in cancer patients and should be identified and
addressed before initiation of VSP inhibitor therapy. Given
the suspected importance of pretreatment intervention in the
management of VSP inhibitor–induced blood pressure elevations,
properly collected, objective, office measurements or more
thorough evaluations for isolated office hypertension (also
known as "white coat hypertension") should guide the risk assessment
rather than patient and/or physician speculation and
dismissal.
- Actively monitor blood pressure throughout treatment with
more frequent assessments during the first cycle of treatment. The
first cycle is typically when the bulk of the blood pressure elevation
is expected to occur and when most patients unexpectedly present
with elevations warranting treatment even in the absence of
preexisting cardiovascular risk factors.
- The goal for hypertension control in patients
receiving VSP inhibitor therapy is a maximum blood pressure
of 140/90 mmHg, and efforts to reach this goal should begin
before initiation of VSP inhibitor therapy. The recommendation
for a goal of maintaining blood pressure less than 140/90
mmHg is based on prudence and consistency with general guidelines.
As per the risk stratification considerations, targets should
be adjusted lower for patients with multiple preexisting risk
factors for adverse consequences of high blood pressure. For
example, for patients with diabetes and/or chronic kidney disease,
a goal blood pressure of less than 130/80 mmHg is the current
public health recommendation.
- Manage blood pressure elevations aggressively to
avoid the development of complications associated with
excessive/prolonged elevations. Management requires attention
to proper agent selection, dosing, and scheduling of
follow-up to ensure efficacy and to control adverse effects of
the antihypertensive agent. The panel suggests that at any time,
if the oncologist or responsible medical team member has any
difficulty in helping the patient progress to the goal blood pressure
of 140/90 mmHg, consultation with the local hypertension specialist
(cardiologist, nephrologist, endocrinologist, or certified
hypertension specialist) should be obtained promptly.
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