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Review Article Volume 19 Issue 4
Expanding spectrum of immune checkpoint inhibitor–associated cardiovascular toxicity: beyond myocarditis
Berkant Bebek, Muharrem Özden, Abdullah Sarıhan, Mehmet Murat Şahin, Mehmet Mustafa Yılmaz, Muhammet Cihat Çelik, Mucahit Yetim, Macit Kalçık, Lütfü Bekar, Yusuf Karavelioğlu
Received: September 07, 2026 | Published: October 1, 2026
Citation: Bebek B, Özde M, Sarıhan A, et al. Expanding spectrum of immune checkpoint inhibitor–associated cardiovascular toxicity: beyond myocarditis. J Cardiol Curr Res. 2026;19(4):115-125. DOI: 10.15406/jccr.2026.19.00652
Abstract
Immune checkpoint inhibitors (ICIs) have transformed the treatment of multiple malignancies but are increasingly recognized as a cause of cardiovascular toxicity. Although ICI-associated myocarditis has traditionally received the greatest attention because of its potentially fulminant course and high risk of adverse outcomes, accumulating evidence indicates that the cardiovascular effects of checkpoint inhibition extend substantially beyond myocarditis. The expanding clinical spectrum includes accelerated atherosclerosis and acute coronary syndromes, pericardial disease, arrhythmias and conduction disturbances, heart failure and non-inflammatory ventricular dysfunction, as well as vascular and thromboembolic complications. These manifestations appear to arise through heterogeneous mechanisms, including disruption of myocardial immune tolerance, T-cell–mediated tissue injury, endothelial activation, vascular inflammation, and acceleration or destabilization of pre-existing cardiovascular disease. This broader spectrum creates important diagnostic challenges because cardiovascular events occurring during ICI therapy may reflect direct immune-mediated toxicity, progression of underlying cardiovascular disease, cancer-associated complications, or effects of concomitant therapies. Accordingly, cardiovascular assessment should extend beyond surveillance for myocarditis and incorporate baseline risk characterization, optimization of modifiable cardiovascular risk factors, and phenotype-directed use of biomarkers and multimodality imaging. Management should similarly be tailored to the specific cardiovascular phenotype and severity, balancing prompt treatment of potentially life-threatening immune-mediated toxicity against unnecessary interruption of effective anticancer therapy. Emerging biomarkers, clonal hematopoiesis, advanced cardiovascular imaging, immune profiling, and multi-omics approaches may enable more individualized risk prediction in the future. This review summarizes the mechanisms, clinical manifestations, diagnosis, surveillance, and management of the expanding spectrum of ICI-associated cardiovascular toxicity, with particular emphasis on cardiovascular complications beyond myocarditis.
Keywords: immune checkpoint inhibitors, cardiovascular toxicity, cardio-oncology, myocarditis, atherosclerosis, immune-related adverse events
©2026 Bebek, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.