Cardiovascular toxicities of immune therapies for cancer - a scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Council of Cardio-Oncology.

The advent of immunological therapies has revolutionized the treatment of solid and haematological cancers over the last decade. Licensed therapies which activate the immune system to target cancer cells can be broadly divided into two classes. The first class are antibodies that inhibit immune checkpoint signalling, known as immune checkpoint inhibitors (ICIs). The second class are cell-based immune therapies including chimeric antigen receptor T lymphocyte (CAR-T) cell therapies, natural killer (NK) cell therapies, and tumour infiltrating lymphocyte (TIL) therapies. The clinical efficacy of all these treatments generally outweighs the risks, but there is a high rate of immune-related adverse events (irAEs), which are often unpredictable in timing with clinical sequalae ranging from mild (e.g. rash) to severe or even fatal (e.g. myocarditis, cytokine release syndrome) and reversible to permanent (e.g. endocrinopathies).The mechanisms underpinning irAE pathology vary across different irAE complications and syndromes, reflecting the broad clinical phenotypes observed and the variability of different individual immune responses, and are poorly understood overall. Immune-related cardiovascular toxicities have emerged, and our understanding has evolved from focussing initially on rare but fatal ICI-related myocarditis with cardiogenic shock to more common complications including less severe ICI-related myocarditis, pericarditis, arrhythmias, including conduction system disease and heart block, non-inflammatory heart failure, takotsubo syndrome and coronary artery disease. In this scientific statement on the cardiovascular toxicities of immune therapies for cancer, we summarize the pathophysiology, epidemiology, diagnosis, and management of ICI, CAR-T, NK, and TIL therapies. We also highlight gaps in the literature and where future research should focus.

Trends and outcomes of cardiovascular disease admissions in Lagos, Nigeria: a 16-year review.

BACKGROUND: Cardiovascular disease (CVD)-related admissions are on the increase in Nigeria and the rest of Africa. This study was carried out to highlight the burden, patterns and outcomes of CVD admissions in a tertiary hospital over a 16-year period in Lagos, Nigeria. METHODS: Admissions records of patients admitted into the medical wards within the study period (January 2002 to December 2017) were reviewed and relevant information pertaining to the study objectives was retrieved for analysis. RESULTS: There were a total of 21 369 medical admissions and 4 456 (20.8%) CVD-related admissions. A total of 3 582 medical deaths were recorded and 1 090 (30.4%) CVD-related deaths. The median age of the patients was 56.6 (46.0-68.0) years and 51.4% of these were males. Stroke, heart failure, hypertensive disease and acute coronary syndrome constituted 51.2, 36.2, 11.3 and 1.6% of all CVD admissions, respectively. There was a cumulative increase in the number of CVD admissions and deaths (p < 0.001, respectively) during the period under review. CONCLUSIONS: CVD admissions are not only common in Nigeria, but there was also a temporal exponential increase in both the admission and death rates, most likely reflecting the epidemiological transition in Nigeria.

Prevalence, patterns and predictors of metabolic abnormalities in Nigerian hypertensives with hypertriglyceridemic waist phenotype: A cross sectional study.

BACKGROUND: Simultaneous presence of elevated waist circumference and hypertriglyceridemia (HTGW) is a simple and low-cost measure of visceral obesity, and it is associated with a plethora of cardio-metabolic abnormalities that can increase the risk of cardiovascular diseases and incident Type 2 diabetes mellitus. We decided to study the prevalence, patterns, and predictors of metabolic abnormalities in Nigerian hypertensives with the HTGW phenotype. METHODS: The medical records of 582 hypertensives with complete data of interest were retrieved and analyzed for the study. Their socio-demographic data, anthropometric data, and booking blood pressure values were retrieved. The results of their fasting plasma glucose, lipid profile, uric acid and serum creatinine were also retrieved for analysis. RESULTS: The mean age of the study population was 56.2 ±13.6, with 53.1% being males. The prevalence of smoking and use of alcohol was 4.3% and 26.5% respectively. The prevalence of the HTGW phenotype was 23.4% and were predominantly males (61%). Subjects with the HTGW phenotype were more obese assessed by waist circumference (WC) and body mass index (BMI). Mean serum total cholesterol, triglyceride, very low-density lipoprotein, uric acid, and creatinine were significantly higher in the HTGW phenotype (p = 0.003; <0.001; <0.001; 0.002 and <0.001 respectively). The prevalence of newly diagnosed Type 2 diabetes was 28.7%. There was also a preponderance of cardio-metabolic abnormalities (obesity, dyslipidaemia, hyperuricemia) in the HTGW phenotype. In both males and females, the HGTW phenotype was significantly associated with elevated Tc, TG, VLDL, hyperuricemia and atherogenic index of plasma. CONCLUSION: The HTGW phenotype is common amongst Nigerian hypertensives, and it is associated with metabolic abnormalities.

Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria.

AIMS: The prospective, multicentre Peripartum Cardiomyopathy in Nigeria (PEACE) registry originally demonstrated a high prevalence of peripartum cardiomyopathy (PPCM) among patients originating from Kano, North-West Nigeria. In a post hoc analysis, we sought to determine if this phenomenon was characterized by a differential case profile and outcome among PPCM cases originating elsewhere. METHODS AND RESULTS: Overall, 199 (81.6%) of a total 244 PPCM patients were recruited from three sites in Kano, compared with 45 patients (18.4%) from 11 widely dispersed centres across Nigeria. Presence and extent of ventricular myocardial remodelling during follow-up, relative to baseline status, were assessed by echocardiography. During median 17 months follow-up, Kano patients demonstrated significantly better myocardial reverse remodelling than patients from other sites. Overall, 50.6% of patients from Kano versus 28.6% from other regions were asymptomatic (P = 0.029) at study completion, with an accompanying difference in all-cause mortality (17.6% vs. 22.2% respectively, P = 0.523) not reaching statistical significance. Alternatively, 135/191 (84.9%) of Kano patients had selenium deficiency (<70 µg/L), and 46/135 (34.1%) of them received oral selenium supplementation. Critically, those that received selenium supplementation demonstrated better survival (6.5% vs. 21.2%; P = 0.025), but the supplement did not have significant impact on myocardial remodelling. CONCLUSIONS: This study has shown important non-racial regional disparities in the clinical features and outcomes of PPCM patients in Nigeria, that might partly be explained by selenium supplementation.

SARS-CoV 2 Infection (Covid-19) and Cardiovascular Disease in Africa: Health Care and Socio-Economic Implications.

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones. This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region.

Electrocardiographic features and their echocardiographic correlates in peripartum cardiomyopathy: results from the ESC EORP PPCM registry.

AIMS: In peripartum cardiomyopathy (PPCM), electrocardiography (ECG) and its relationship to echocardiography have not yet been investigated in large multi-centre and multi-ethnic studies. We aimed to identify ECG abnormalities associated with PPCM, including regional and ethnic differences, and their correlation with echocardiographic features. METHODS AND RESULTS: We studied 411 patients from the EURObservational PPCM registry. Baseline demographic, clinical, and echocardiographic data were collected. ECGs were analysed for rate, rhythm, QRS width and morphology, and QTc interval. The median age was 31 [interquartile range (IQR) 26-35] years. The ECG was abnormal in > 95% of PPCM patients. Sinus tachycardia (heart rate > 100 b.p.m.) was common (51%), but atrial fibrillation was rare (2.27%). Median QRS width was 82 ms [IQR 80-97]. Left bundle branch block (LBBB) was reported in 9.30%. Left ventricular (LV) hypertrophy (LVH), as per ECG criteria, was more prevalent amongst Africans (59.62%) and Asians (23.17%) than Caucasians (7.63%, P < 0.001) but did not correlate with LVH on echocardiography. Median LV end-diastolic diameter (LVEDD) was 60 mm [IQR 55-65] and LV ejection fraction (LVEF) 32.5% [IQR 25-39], with no significant regional or ethnic differences. Sinus tachycardia was associated with an LVEF < 35% (OR 1.85 [95% CI 1.20-2.85], P = 0.006). ECG features that predicted an LVEDD > 55 mm included a QRS complex > 120 ms (OR 11.32 [95% CI 1.52-84.84], P = 0.018), LBBB (OR 4.35 [95% CI 1.30-14.53], P = 0.017), and LVH (OR 2.03 [95% CI 1.13-3.64], P = 0.017). CONCLUSIONS: PPCM patients often have ECG abnormalities. Sinus tachycardia predicted poor systolic function, whereas wide QRS, LBBB, and LVH were associated with LV dilatation.

Clinical Features and Outcomes of Peripartum Cardiomyopathy in Nigeria.

BACKGROUND: Nigeria has the highest incidence of peripartum cardiomyopathy (PPCM) in the world. However, data on PPCM-related outcomes are limited. OBJECTIVES: The purpose of this study was to examine the clinical profile, myocardial remodeling, and survival of patients with PPCM in Nigeria. METHODS: This study consecutively recruited 244 PPCM patients (median 7 months postpartum) at 14 sites in Nigeria and applied structured follow-up for a median of 17 months (interquartile range: 14 to 20 months). Left ventricular reverse remodeling (LVRR) was defined as the composite of left ventricular (LV) end-diastolic dimension <33 mm/m2 and absolute increase in left ventricular ejection fraction (LVEF) ≥10%. LV full recovery was defined as LVEF ≥55%. RESULTS: Overall, 45 (18.7%) patients died during follow-up. Maternal age <20 years (hazard ratio [HR]: 2.40; 95% confidence interval (CI): 1.27 to 4.54), hypotension (HR: 1.87; 95% CI: 1.02 to 3.43), tachycardia (HR: 2.38; 95% CI: 1.05 to 5.43), and LVEF <25% at baseline (HR: 2.11; 95% CI: 1.12 to 3.95) independently predicted mortality. Obesity (HR: 0.16; 95% CI: 0.04 to 0.55) and regular use of beta-blockers at 6-month follow-up (HR: 0.20; 95% CI: 0.09 to 0.41) were independently associated with reduced risk for mortality. In total, 48 patients (24.1%) achieved LVRR and 45 (22.6%) achieved LV full recovery. LVEF <25% at baseline (HR: 0.66; 95% CI: 0.47 to 0.92) and regular use of beta-blockers at 6-month follow-up (HR: 1.62; 95% CI: 1.17 to 2.25) independently determined the risk for LV full recovery. Progressive reverse remodeling of all cardiac chambers was observed. In total, 18 patients (7.4%) were hospitalized during the study. CONCLUSIONS: This is the largest study of PPCM in Africa. Consistent with late presentations, the mortality rate was high, whereas frequencies of LVRR and LV full recovery were low. Several variables predicted poor outcomes, and regular use of beta-blockers correlated with late survival and LV functional recovery.

Correction to: Knowledge of cardiovascular disease risk factors and practice of primary prevention of cardiovascular disease by Community Pharmacists in Nigeria: a cross-sectional study.

The article Knowledge of cardiovascular disease risk factors and practice of primary prevention of cardiovascular disease by Community Pharmacists in Nigeria: a cross-sectional study.

Prevalence of positive chronic kidney Disease screening in professional male long haul drivers at risk of cardiovascular Disease in Lagos, Nigeria: a cross-section study.

BACKGROUND: Professional drivers are known to be at high risk for cardiovascular disease (CVD) on account of the higher prevalence co-occurring risk factors they harbour. Chronic kidney disease (CKD) and CVD share similar risk factors. Both impact each other adversely. The renal profile of professional drivers in Nigeria is not well characterised. We decided to study the prevalence of positive CKD screening amongst professional male long distance drivers in Lagos, Southwest Nigeria so as to quantify the burden and its predictors. METHODS: Two hundred and ninety-three drivers were recruited. Details of their socio-demographic characteristics were obtained. Their anthropometric indices, blood pressure, fasting plasma blood glucose and lipid profile were measured. Serum creatinine was measured and estimated glomerular filtration rate, eGFR, was calculated with Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Urinary Albumin Creatinine Ratio (UACR) was determined. A 10 year CVD risk of the subjects was calculated with the Framingham Risk Score (FRS). RESULTS: Mean age of the study population was 44.8 + 9.7 years. The prevalence of alcohol use and smoking were 71.0 and 19.5% respectively. One hundred and twenty-one (62.8%) of the subjects were either overweight or obese while 70(24.1%) had abdominal obesity. The prevalence of hypertension and diabetes were 39.7 and 13.9% respectively. Prevalence of CKD by eGFR< 60 ml/min/1.73m2 or UACR > 30 mg/g was 51.7% (95% CI; 46.0-57.5). The odds for CKD increased with lower HDL-c levels; OR 3.5 (95% CI, 1.1-11.2; p = 0.03) and longer duration of professional driving > 20 years; OR 2.4(95% CI, 1.5-4.0). CONCLUSION: Professional male long distance drivers in addition to having very high prevalence of clustering of both CVD and CKD risk factors have a significant burden of asymptomatic CKD. UACR appears to be an earlier marker of CKD in this population. Health awareness promotion and aggressive risk factor reduction are advocated as ways to reduce this burden.

Knowledge of cardiovascular disease risk factors and practice of primary prevention of cardiovascular disease by Community Pharmacists in Nigeria: a cross-sectional study.

Background Studies in international literature have shown that Community Pharmacists can make considerable impact in controlling cardiovascular disease risk factors, especially hypertension. In Nigeria, there are no studies on the knowledge of CVD risk factors by Community Pharmacists and their practice of primary prevention. Objective To assess the knowledge of CVD risk factors and practice of primary prevention of CVD amongst Nigerian community pharmacists. Setting Community Pharmacists in Lagos, Nigeria. Methods This cross-sectional study involved 168 Community Pharmacists. Their knowledge of CVD risk factors was assessed with the Heart Disease Fact Questionnaire. Their opportunistic screening practices for CVD risk factors (primary prevention) were also assessed. Main outcome measures Knowledge of CVD risk factors and practice of primary CVD prevention. Results The mean age of the participating pharmacists was 41.7 (± 11.2) years and 87 (51.8%) of them were males. The median number of years of practice was 9.0 (3-15) years. Mean knowledge score was 22.1 (± 3.0) with 154 (91.7%) of the subjects scoring above 70%. An average of 95.5% of the participants correctly identified hypertension, smoking, dyslipidaemia, obesity, physical inactivity and diabetes as CVD risk factors. Eighty-one (48.2%) had good practice of primary CVD prevention. Conclusion: This study shows that Community Pharmacists in Nigeria have very good knowledge level of CVD risk factors and almost 50% of them practised primary prevention of CVD.

Prevalence of cardiometabolic risk factors among professional male long-distance bus drivers in Lagos, south-west Nigeria: a cross-sectional study.

BACKGROUND: Professional drivers are known to be at high risk of cardiovascular disease (CVD). This study was carried out to highlight these risk factors and their predictors among male long-distance professional bus drivers in Lagos, south-west Nigeria, with a view to improving health awareness in this group. METHOD: Socio-demographic data, anthropometric indices, blood pressure, fasting plasma blood glucose levels and lipid and physical activity profiles of 293 drivers were measured. RESULTS: Mean age of the study population was 48 ± 9.7 years; 71.0 and 19.5% of the drivers used alcohol and were smokers, respectively; and 50.9% were physically inactive. The prevalence of overweight and obesity was 41.7 and 21.1%, respectively, while 39.7 and 13.9% were hypertensive and diabetic, respectively. Ninety (31.3%) subjects had impaired fasting glucose levels while 56.3% had dyslipidaemia. Predictors of hypertension were age and body mass index (BMI). BMI only was a predictor of abnormal glucose profile. CONCLUSION: Professional male long-distance bus drivers in this study showed a high prevalence of a cluster of risk factors for CVD.