Highlights
- Patients with an expanded definition of heart failure (HFexp) exhibit a modest but significant increase in cancer incidence, varying by cancer type.
- Coexistence of cancer and heart failure markedly worsens prognosis, with similar contributions from cardiovascular and cancer-related mortality.
- Cardio-oncology evidence emphasizes the importance of early cardiac monitoring and vigilant management in cancer survivors and patients undergoing cardiotoxic therapies.
- Emerging therapeutic and prophylactic strategies, including antihypertensive agents and novel heart failure treatments, show potential to mitigate cardiotoxicity and improve outcomes.
Background
Cancer and heart failure (HF) are leading causes of morbidity and mortality worldwide, with increasing recognition of their overlapping patient populations. Many patients with cancer develop HF due to shared risk factors, cardiotoxic cancer therapies, or concomitant comorbidities, while patients with HF exhibit elevated cancer risk, possibly related to systemic inflammation, frailty, and impaired immune surveillance. Despite this bidirectional interplay, comprehensive data characterizing prevalence, incidence, and prognostic implications in population-based cohorts remain scarce. The recent Scottish cohort study by Iaconelli et al. (2026) addresses this gap by analyzing linked health records in people aged over 50 to elucidate these relationships within a regional healthcare setting.
Key Content
Population-Based Epidemiology of Cancer and Heart Failure in Scotland
Iaconelli et al. analyzed health records from 317,178 individuals aged >50 years. HF prevalence was 3.6%, with an additional subset identified through loop diuretic prescriptions, expanding HF definition (HFexp) to 9.6%. The annual cancer incidence was 10% higher among those with HFexp, yet varied across cancer types, underscoring heterogeneous pathophysiological links. Mortality patterns differed distinctly: individuals without cancer or HFexp had <3% annual mortality (primarily cardiovascular), while those with cancer alone had 6.3%-9.0% mortality with cancer predominating as cause of death. HFexp alone conferred 6.6%-18.4% mortality, mostly from cardiovascular causes. Importantly, patients with coexisting cancer and HFexp demonstrated substantially elevated mortality (14.5%-28.4%), with roughly equal attribution to cancer and cardiovascular disease. Notably, only around 20% died at home, highlighting potential gaps in end-of-life care settings.
Cardio-Oncology Clinical Insights on Heart Failure with Cancer
Supplementary studies elaborate on clinical characteristics and outcomes:
- Data from hospitalized patients with HF with mildly reduced EF revealed that 15.3% had concomitant malignancies, associated with increased all-cause mortality largely driven by non-cardiac causes (Morsy et al. 2026).
- Among patients receiving anticancer drugs, heart failure with preserved and reduced ejection fractions occurred at similar rates post-treatment, and mortality was more closely linked with anemia and functional status rather than EF subtype (Friday et al. 2026).
- Population-based cohorts of hematologic malignancies demonstrate elevated incidence of cardiovascular disease, including HF, venous thromboembolism, and arrhythmias, varying by cancer subtype and treatment exposures (Mackay et al. 2026).
Mechanisms and Cardioprotective Strategies
Cancer therapies, particularly anthracyclines and HER2 inhibitors, contribute significantly to cardiotoxicity and incident HF, as reported in contemporary cohorts. An umbrella review of randomized controlled trials meta-analyses supports modest cardioprotective benefits from renin-angiotensin system blockers and beta blockers in preventing chemotherapy-related cardiac dysfunction, though evidence certainty remains low (Iaconelli et al. 2026). Early identification of subclinical dysfunction via echocardiography and biomarkers improves management decisions, especially in young cancer survivors. Newer pharmacologic interventions, including sodium-glucose cotransporter-2 inhibitors, show promise in patients with concurrent cancer and diabetes to reduce mortality (Brown et al. 2026).
Prognostic Biomarkers and Risk Stratification
Inflammation, frailty, and biomarkers such as heart-type fatty acid-binding protein (H-FABP) in cardiac amyloidosis provide additive prognostic value and may inform personalized management of overlapping cancer-HF syndromes. Social determinants of health further modulate cardiovascular and cancer outcomes, underlying the need for comprehensive risk assessment models integrating clinical and socio-environmental factors (Geue et al. 2026).
Expert Commentary
This synthesized evidence highlights a complex and bidirectional relationship between cancer and heart failure with important epidemiological and clinical implications. The Scottish cohort elucidates population-level patterns, emphasizing that an expanded HF definition incorporating pharmacological markers can capture patients at elevated risk for cancer and adverse outcomes. Integration of cardio-oncology principles is essential in routine care, including vigilant cardiac monitoring before, during, and after cancer therapy, as underscored by varying echocardiography utilization rates.
While the current evidence supports pharmacological prophylaxis to mitigate chemotherapy-induced cardiotoxicity, limitations in trial design and evidence quality necessitate further robust randomized controlled trials. Multidisciplinary collaboration approaches are critical to optimize cancer treatment continuation and cardiovascular management, especially given the comparable mortality burden from cardiovascular disease and cancer in co-morbid patients. Differences in oncology treatment modalities, cancer types, HF subtypes, and patient demographic factors require consideration in individualized risk stratification and tailored surveillance.
Additionally, nontraditional aspects including psychological factors, social vulnerability, and end-of-life care preferences emerge as underappreciated domains influencing outcomes in this population. Future research must address mechanistic pathways linking cancer pathobiology and heart failure progression, enabling novel therapeutic targets and integrated care models.
Conclusion
The intersection of cancer and heart failure presents an increasing clinical challenge, with patients exhibiting concomitant diagnoses facing significantly elevated mortality largely driven by dual disease processes. Population-level data from Scotland and supporting evidence outline the modestly increased cancer incidence in heart failure patients and highlight the bidirectional prognosis implications.
Enhanced surveillance for cardiovascular complications in cancer patients and for cancer in heart failure patients, accompanied by evidence-based prophylactic interventions, are paramount. Multidisciplinary cardio-oncology care, refined by biomarker-guided risk stratification and addressing patient psychosocial needs, holds promise to improve outcomes. Ongoing research must define definitive preventive strategies, elucidate mechanistic underpinnings, and develop comprehensive models accounting for clinical and social determinants.
References
- Iaconelli A, Morsy MI, Friday JM, et al. Cancer and heart failure: prevalence, incidence, and prognosis in Scotland. Eur Heart J. 2026 Jun 23;47(24):3152-3169. PMID: 42068332.
- Morsy MI, Pellicori P, Elyan BMP, et al. Cardio-Oncologic Considerations in Heart Failure With Mildly Reduced Ejection Fraction: Prevalence and Prognostic Impact of Malignancies. J Am Heart Assoc. 2026 Jun 16;15(12):e047798. PMID: 42261985.
- Friday JM, Pellicori P, Elyan BMP, et al. Clinical Characteristics and Outcomes of Heart Failure with Preserved Ejection Fraction Versus Reduced Ejection Fraction in Patients Receiving Anticancer Drugs. Cardiovasc Toxicol. 2026 May 26;26(6):60. PMID: 42189435.
- Brown D, Ho FK, Hastie CE, et al. Safety and Efficacy of Sodium Glucose Cotransporter-2 Inhibitors in Patients With Cancer and Diabetes. J Am Heart Assoc. 2026 Mar 17;15(6):e042404. PMID: 41804881.
- Iaconelli A, et al. Cardioprotective role of antihypertensive treatment in chemotherapy-induced cardiotoxicity: umbrella review of meta-analyses of randomised controlled trials. Open Heart. 2026 Jun 18;13(1):e004062. PMID: 42315195.
- Mackay DF, Pell JP, Lewsey J, et al. Cardiovascular Disease Risk in Adults With Hematological Malignancies: A Population-Based Cohort Study Using Linked Databases. J Am Coll Cardiol. 2026 May 26;87(20):2907-2921. PMID: 41949515.
- Geue CE, Stevenson A, du Toit C, et al. Impact of Documented Social Vulnerability on Clinical Outcomes in Metabolic Dysfunction-Associated Steatotic Liver Disease. Liver Int. 2026 Apr;46(4):e70550. PMID: 41749065.