Androgen receptor pathway inhibitors (ARPIs) have drastically improved survival outcomes in prostate cancer and are now available for use in combination with androgen deprivation therapy across multiple stages of disease. While their efficacy in managing disease is well documented, there is growing concern regarding potential cardiovascular (CV) toxicity, causing adverse events such as ischaemic heart disease, congestive cardiac failure, cerebrovascular disease, and atrial fibrillation. To this end, the importance of cardio-oncology and appropriate pre-commencement workup is of increasingly recognised importance. We aimed to investigate the extent of pre-commencement CV workup, as well as occurrence of CV events in the setting of ARPIs at a large tertiary urology department.

Ethics approval was acquired from the Monash Health Human Research Ethics Committee. All patients prescribed either apalutamide, darolutamide or enzalutamide for prostate cancer between 1st Jan 2021 to 1st June 2024 were identified for analysis. Data extracted included patient and disease characteristics; CV history and risk factors including diabetes mellitus and hypercholesterolaemia, pre-commencement CV counselling and testing; and subsequent CV events up until 1st February 2025 (6 months after final inclusion).

Out of 138 patients, median age at commencement was 74.5 (67 - 81). Indication for ARPIs included metastatic castrate sensitive prostate cancer (49.3%), M0 castrate resistant prostate cancer (20.3%) , and metastatic castrate resistant prostate cancer (29.7%). A total of 60.9%, 37.5%, 44.2%, 5.1% and 15.9% of patients reported histories of hypertension, diabetes mellitus, hypercholesterolaemia, obstructive sleep apnoea and obesity respectively. Similarly, 27.5%, 15.9%, 7.3% and 6.5% of patients had histories of ischaemic heart disease, arrhythmias, heart failure and cerebrovascular disease. Median follow up was 539.5 days, and 24 patients (17.4%) developed significant CV events including ischaemic heart disease (n=9), heart failure (n=8) and arrythmias (n=3). Four patients died secondary to CV complications. Median time to event was 448.5 days. Only 18.1%, 23.9%, 2.9% and 9.4% patients underwent lipid studies, Hba1c, nutrition counselling, and echocardiograms respectively prior to ARPI commencement, and only 8.0% underwent prior cardiology review.

Our study highlights a significant prevalence of CV comorbidities and adverse events among patients receiving ARPIs. Despite growing recognition of cardio-oncology, pre-commencement CV assessments remain insufficient. Given the observed risks, our findings underscore the need for improved CV risk stratification and proactive management, including standardized screening and preventative strategies, to mitigate potential cardiotoxic effects.