Immune checkpoint inhibitor-associated myocarditis: a systematic analysis of case reports

Front Immunol. 2023 Oct 9:14:1275254. doi: 10.3389/fimmu.2023.1275254. eCollection 2023.

Abstract

Background: Immune checkpoint inhibitors (ICIs) therapy can be complicated by their potential cardiovascular toxicities, including myocarditis. Nowadays, no prospective trials have focused on ICI-associated myocarditis optimized management. Available evidence only come from case reports or series. A systematic case reports analysis was conducted to collect and evaluate emerging evidence of ICI-associated myocarditis to provide more information to clinicians.

Methods: We performed a literature search for eligible case reports or series published between January 2018 and May 2023 using the PubMed database. Then, we extracted interesting information via table form. Finally, this study included 113 publications on 106 patients with ICI-associated myocarditis.

Results: Myocarditis was found to be a highly life-threatening disease, with 53.8% of cases. Over half of cases were life-threatening (G4, 23.6%) or severe (G3, 35.8%) and required glucocorticoids. Higher rates of improvement were associated with the best response to ICI for complete response/partial response (72.7% vs. 53.9%), glucocorticoid administration (30% vs. 22%), and discontinuation of ICI (58.8% vs. 32.1%). Consequently, ICI-associated G3-G4 myocarditis should be treated with a combination of discontinuation of ICIs, high-dose glucocorticoids, other drugs, chemical drugs, plasma exchange, and life support. For moderate G1 or G2 cases, discontinuation of ICIs and regular-dose glucocorticoids should be considered.

Conclusion: Once full recovery or improvement was achieved; glucocorticoids can be administered at low doses or stopped. Notably, re-challenge with ICIs appears feasible after resolution or meaningful improvement of myocarditis.

Keywords: ICI-associated myocarditis; cardiovascular toxicities; case reports and series; glucocorticoids; immune checkpoint inhibitor; immune-related adverse events.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Glucocorticoids
  • Heart
  • Humans
  • Immune Checkpoint Inhibitors* / adverse effects
  • Myocarditis* / chemically induced
  • Myocarditis* / diagnosis

Substances

  • Glucocorticoids
  • Immune Checkpoint Inhibitors

Grants and funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the Chinese Academy of Medical Sciences (2019XK320068), Beijing Municipal Science and Technology Commission (International Pharmaceutical Clinical Research and Development Platform 2015), Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (Platform Improvement of Clinical Trial Capability, 2020‐I2M‐2‐007), and the Beijing Municipal Health Commission, Beijing Demonstration Research Ward (BCRW20200303). The First Affiliated Hospital of Henan University of Science and Technology National Clinical Key Specialty Construction of Oncology 2023 Open Joint Fund Project (ZLKFJJ20230512).