Lung Cancer and Cardiovascular Disease: Shared Risks and Treatment Emergent Cardiotoxicity.

Among patients with cancer, those with lung cancer have the highest prevalence of pre‑existing cardiovascular disease (CVD) and the highest risk of cardiovascular events after diagnosis, driven by shared risk factors (notably smoking), socioeconomic determinants, and overlapping biology (inflammation/oxidative stress). As lung‑cancer survival improves, CVD increasingly affects overall outcomes.

Therapy‑related cardiotoxicity spans all modalities. Thoracic surgery carries a perioperative MACCE risk comparable to vascular surgery (~6.5% overall), with postoperative atrial fibrillation the most frequent event (≈23% after pneumonectomy; 6.6% after lobectomy; 1.4% after segmentectomy). Radiation causes endothelial injury, accelerated atherosclerosis, and myocardial/pericardial fibrosis; in NSCLC cohorts, each additional gray of mean heart dose (MHD) increased MACE risk by ~5%, and left anterior descending (LAD) dose further refines risk prediction.

Targeted and systemic therapies add heterogeneous risks: EGFR‑TKIs (osimertinib) have been linked to LV dysfunction, heart failure, atrial arrhythmias, and QT prolongation; ALK inhibitors to bradyarrhythmias, QT prolongation, hypertension, and dyslipidemia; BRAF/MEK combinations to hypertension, LV dysfunction, and thromboembolism; VEGF antibodies to hypertension and thrombotic events; and immune checkpoint inhibitors (ICIs) to myocarditis and early arterial events (MI, stroke).

Risk assessment and surveillance. The treatment start point is an opportunity to document CVD history, risk factors, ECG, and consider echocardiography based on exposure and baseline risk. Opportunistic reading of coronary artery calcium (CAC) on lung CTs used for staging/planning provides actionable CVD risk information. For potentially arrhythmogenic regimens (e.g., osimertinib, ALK‑TKIs), baseline QTc and periodic checks in high‑risk patients are advised; for ICIs, baseline ECG and troponin (with echocardiography in higher‑risk scenarios) can facilitate early recognition. Long‑term follow‑up is especially important after thoracic radiation, with society statements endorsing periodic TTE and ischemia evaluation stratified by heart dose.

Management highlights. Osimertinib‑related LV dysfunction may improve with drug interruption and guideline‑directed HF therapy; bradycardia on ALK inhibitors is often manageable with dose adjustment. In acute coronary syndromes, a primary invasive strategy is generally recommended for STEMI, while NSTEMI management should be individualized. For severe aortic stenosis in active cancer, TAVR is often favored and shows peri‑procedural outcomes similar to non‑cancer cohorts.

Takeaway for clinicians: Proactively integrate CVD risk mitigation (before, during, and after therapy), minimize cardiac radiation exposure, monitor for regimen‑specific toxicities, and apply multidisciplinary decision‑making to balance oncologic benefit with cardiovascular safety.

Editorial note: This content was developed with the support of artificial intelligence technologies to optimize the writing and structuring of the information. All material was carefully reviewed, validated, and supplemented by human experts prior to publication, ensuring scientific accuracy and adherence to good editorial practices.

#CardioOncology #LungCancer #CVD #Cardiotoxicity #RadiationTherapy #EGFRTKIs #ALKInhibitors