Initial Assessment, Surveillance, and Management of Blood Pressure in Patients Receiving Vascular Endothelial Growth Factor Signaling Pathway Inhibitors -- Maitland et al. 102 (9): 596 -- JNCI Journal of the National Cancer Institute

Box 1. Summary recommendations

1. 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.
   
2. 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.
   
3. 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.
   
4. 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.
   
5. 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.