Immune checkpoint inhibitors

(e.g., nivolumab, pembrolizumab, cemiplimab, avelumab, atezolizumab, durvalumab, ipilimumab, tremelimumab)

ECG, Troponin*, Natriuretic peptides

before cancer treatment begins

Consider one of the two strategies according to local skills ans resources

Strategy 1 (preferred)

ECG AND Troponin*

within 48h before each administration AND

Check (by the oncologist)

for new CV symptoms/signs

before each administration

 

ECG, troponin,* Natriuretic peptides 

if new CV symptoms/signs OR

if other irAEs occur

Strategy 2 (alternatively)

Check (by the oncologist)

for new CV symptoms/signs

before each administration

 

ECG, troponin,* Natriuretic peptides 

if new CV symptoms/signs OR

if other irAEs occur

New cardiovascular symptoms/signs OR

Troponin+* OR

ECG abnormality

Suspect myocarditis

Withhold immunotherapy

Refer to a cardio-oncology unit (preferably) or cardiology department for monitoring and diagnostic work-up

*For monitoring, troponin testing should be carried out by the same laboratory (same type of troponin, same method of measurement). Troponin testing is considered as positive if troponin I or T >99th percentile of the upper reference limit. Concomitant myositis may result in significant elevations of CK, CK isoforms, and even troponin T. Thus, troponin I would be the most specific option for myocardial injury. CK-MB should be used if troponin I measurement is not available. In patients with pretherapeutic troponin elevation, a 50% increase of the level may be used as a cutoff, but no evidence currently supports this recommendation.

irAEs=immune-related adverse events

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Centre Méditerranéen Hospitalo-Universitaire de Cardio-Oncologie

​Hôpital Nord, chemin des Bourrely, 13015 Marseille, France

Aix-Marseille Université

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