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Puppe J, van Ooyen D, Neise J, Thangarajah F, Eichler C, Krämer S, Pfister R, Mallmann P, Wirtz M, Michels G. Evaluation of QTc Interval Prolongation in Breast Cancer Patients after Treatment with Epirubicin, Cyclophosphamide, and Docetaxel and the Influence of Interobserver Variation. Breast Care (Basel) 2017; 12:40-44. [PMID: 28611540 DOI: 10.1159/000455065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Chemotherapy with anthracyclines is associated with life-threatening electrocardiographic alterations including corrected QT (QTc) interval prolongation. PATIENTS AND METHODS In this study we assessed the effect of epirubicin, cyclophosphamide, and docetaxel (EC-Doc) on the QTc interval in 10 patients with early breast cancer. Cardiac toxicity was assessed with symptoms, transthoracic echocardiography, electrocardiography (ECG), and serum cardiac markers at baseline and after 4 cycles of EC and 4 cycles of docetaxel. To evaluate the influence of interobserver variation, the QTc interval was analyzed by a cardiologist, a gynecologist, and with automated ECG interpretation software. RESULTS There was a significant QTc prolongation after EC treatment independent of the investigator. In addition, a significant increase in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels was noted after EC treatment. QTc prolongation and NT-proBNP levels normalized after docetaxel treatment. Other biochemical markers were within normal ranges. No clinically relevant effect on left ventricular ejection fraction was observed. CONCLUSION This prospective study demonstrated that EC treatment increases the QTc interval and NT-proBNP levels in women with early breast cancer. This effect was reversible and independent of docetaxel administration. Moreover, the treating physician can safely perform QTc interval evaluation as part of clinical routine independent of his/her specialty. Due to the small number of patients, further conclusions are limited at this point.
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Affiliation(s)
- Julian Puppe
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Deborah van Ooyen
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Jeanne Neise
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Fabinshy Thangarajah
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | | | - Stefan Krämer
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Roman Pfister
- Department III of Internal Medicine, Heart Centre of the University of Cologne, Cologne, Germany
| | - Peter Mallmann
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Marina Wirtz
- Department of Gynaecology and Obstetrics, University Hospital Cologne, Cologne, Germany.,CIO Center for Integrated Oncology Cologne/Bonn, Bonn, Germany
| | - Guido Michels
- Department III of Internal Medicine, Heart Centre of the University of Cologne, Cologne, Germany
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Cao L, Zhu W, Wagar EA, Meng QH. Biomarkers for monitoring chemotherapy-induced cardiotoxicity. Crit Rev Clin Lab Sci 2016; 54:87-101. [PMID: 28013560 DOI: 10.1080/10408363.2016.1261270] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiotoxicity, including acute and late-onset cardiotoxicity, is a well-known adverse effect of many types of antitumor agents. Early identification of patients with cardiotoxicity is important to ensure prompt treatment and minimize toxic effects. The etiology of chemotherapy-induced cardiotoxicity is multifactorial. Traditional methods for assessment of chemotherapy-induced cardiotoxicity typically involve serial measurements of cardiac function via multi-modality imaging techniques. Typically, however, significant left ventricular dysfunction has already occurred when cardiotoxicity is detected by imaging techniques. Biomarkers, most importantly cardiac natriuretic peptides and troponins, are promising markers for identifying patients potentially at risk for clinical heart failure symptoms. This review summarizes the recent progress in clinical utilization of biomarkers for early diagnosis of acute cardiotoxicity and for prediction of late-onset cardiotoxicity. We also discuss the conflicting results of different studies and the association of results with study design.
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Affiliation(s)
- Liyun Cao
- a Department of Laboratory Medicine , Unit 37, The University of Texas MD Anderson Cancer Center , Houston , TX , USA and
| | - Wuqiang Zhu
- b Department of Biomedical Engineering , University of Alabama at Birmingham , Birmingham , AL , USA
| | - Elizabeth A Wagar
- a Department of Laboratory Medicine , Unit 37, The University of Texas MD Anderson Cancer Center , Houston , TX , USA and
| | - Qing H Meng
- a Department of Laboratory Medicine , Unit 37, The University of Texas MD Anderson Cancer Center , Houston , TX , USA and
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Jawa Z, Perez RM, Garlie L, Singh M, Qamar R, Khandheria BK, Jahangir A, Shi Y. Risk factors of trastuzumab-induced cardiotoxicity in breast cancer: A meta-analysis. Medicine (Baltimore) 2016; 95:e5195. [PMID: 27858859 PMCID: PMC5591107 DOI: 10.1097/md.0000000000005195] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Trastuzumab targets the human epidermal growth factor receptor 2 oncogene and in combination with first-line therapy results in significantly improved survival outcomes and has thus become standard of care in both adjuvant and metastatic settings. While it is estimated that 1% to 4% of patients treated with trastuzumab will develop heart failure and ∼10% will experience a reduction in left ventricular ejection fraction (LVEF), the patient risk factors associated with trastuzumab-induced cardiotoxicity (TIC) are unclear. This meta-analysis aims to consolidate previously published data to identify the risk factors most likely leading to TIC. METHODS A search of the MEDLINE literature database using the keywords trastuzumab/Herceptin, risk factors, outcomes, cardiac, cardiotoxicity, cardiomyopathy, LVEF, and chemotherapy was performed. Only prospective/retrospective human studies were included, with additional studies excluded if they reported baseline LVEF > 68%, a cohort of <50 patients, or results that were not stratified based on cardiotoxic events. Pooled odds ratio (OR) and 95% confidence interval (CI) for each potential risk factor were calculated, with heterogeneity of data and samples explored using random-effects modeling. RESULTS Data were collected from 17 articles, capturing 6527 patients. Hypertension (OR 1.61, 95% CI 1.14-2.26; P < 0.01), diabetes (OR 1.62; 95% CI 1.10-2.38; P < 0.02), previous anthracycline use (OR 2.14; 95% CI 1.17-3.92; P < 0.02), and older age (P = 0.013) were all shown to be associated with TIC. CONCLUSION Cardiac performance should be closely monitored in women treated with trastuzumab. Recognizing potential risk factors along with careful attention to symptoms/LVEF measurements could minimize the occurrence of TIC in this population.
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Affiliation(s)
- Zeeshan Jawa
- Department of Internal Medicine, Medical College of Wisconsin
| | | | | | | | - Rubina Qamar
- Department of Medical Oncology, Aurora Health Care
| | | | - Arshad Jahangir
- Aurora Cardiovascular Services, Aurora Health Care
- Sheikh Khalifa bin Hamad Al Thani Center for Integrative Research on Cardiovascular Aging, Aurora Health Care, Milwaukee, WI
| | - Yang Shi
- Aurora Research Institute, Aurora Health Care
- Sheikh Khalifa bin Hamad Al Thani Center for Integrative Research on Cardiovascular Aging, Aurora Health Care, Milwaukee, WI
- Correspondence: Yang Shi, Aurora Research Institute, 960 N. 12th Street, Suite 4155, Milwaukee, WI 53233 (e-mail: )
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Zardavas D, Suter TM, Van Veldhuisen DJ, Steinseifer J, Noe J, Lauer S, Al-Sakaff N, Piccart-Gebhart MJ, de Azambuja E. Role of Troponins I and T and N-Terminal Prohormone of Brain Natriuretic Peptide in Monitoring Cardiac Safety of Patients With Early-Stage Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer Receiving Trastuzumab: A Herceptin Adjuvant Study Cardiac Marker Substudy. J Clin Oncol 2016; 35:878-884. [PMID: 28199174 DOI: 10.1200/jco.2015.65.7916] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Women receiving trastuzumab with chemotherapy are at risk for trastuzumab-related cardiac dysfunction (TRCD). We explored the prognostic value of cardiac markers (troponins I and T, N-terminal prohormone of brain natriuretic peptide [NT-proBNP]) to predict baseline susceptibility to develop TRCD. We examined whether development of cardiac end points or significant left ventricular ejection fraction (LVEF) drop was associated with markers' increases. Patients and Methods Cardiac marker assessments were coupled with LVEF measurements at different time points for 533 patients from the Herceptin Adjuvant (HERA) study who agreed to participate in this study. Patients with missing marker assessments were excluded, resulting in 452 evaluable patients. A primary cardiac end point was defined as symptomatic congestive heart failure of New York Heart Association class III or IV, confirmed by a cardiologist, and a significant LVEF drop, or death of definite or probable cardiac causes. A secondary cardiac end point was defined as a confirmed significant asymptomatic or mildly symptomatic LVEF drop. Results Elevated baseline troponin I (> 40 ng/L) and T (> 14 ng/L), occurring in 56 of 412 (13.6%) and 101 of 407 (24.8%) patients, respectively, were associated with an increased significant LVEF drop risk (univariate analysis: hazard ratio, 4.52; P < .001 and hazard ratio, 3.57; P < .001, respectively). Few patients had their first elevated troponin value recorded during the study (six patients for troponin I and 25 patients for troponin T). Two patients developed a primary and 31 patients a secondary cardiac end point (recovery rate of 74%, 23 of 31). For NT-proBNP, higher increases from baseline were seen in patients with significant LVEF drop. Conclusion Elevated troponin I or T before trastuzumab is associated with increased risk for TRCD. A similar conclusion for NT-proBNP could not be drawn because of the lack of a well-established elevation threshold; however, higher increases from baseline were seen in patients with TRCD compared with patients without.
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Affiliation(s)
- Dimitrios Zardavas
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Thomas M Suter
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Dirk J Van Veldhuisen
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Jutta Steinseifer
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Johannes Noe
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Sabine Lauer
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Nedal Al-Sakaff
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Martine J Piccart-Gebhart
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Evandro de Azambuja
- Dimitrios Zardavas, Breast International Group; Martine J. Piccart-Gebhart and Evandro de Azambuja, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium; Thomas M. Suter, Bern University Hospital, Bern; Jutta Steinseifer, Johannes Noe, Sabine Lauer, and Nedal Al-Sakaff, F. Hoffmann-La Roche, Basel, Switzerland; and Dirk J. Van Veldhuisen, University Medical Center Groningen, University of Groningen, The Netherlands
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Biomarkers and Cancer Therapy-Related Cardiac Dysfunction. CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0517-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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56
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Dias A, Claudino W, Sinha R, Perez C, Jain D. Human epidermal growth factor antagonists and cardiotoxicity—A short review of the problem and preventative measures. Crit Rev Oncol Hematol 2016; 104:42-51. [DOI: 10.1016/j.critrevonc.2016.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 03/09/2016] [Accepted: 04/27/2016] [Indexed: 01/21/2023] Open
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Cardiac toxicity of trastuzumab in elderly patients with breast cancer. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:355-63. [PMID: 27403145 PMCID: PMC4921548 DOI: 10.11909/j.issn.1671-5411.2016.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Breast cancer (BC) is diagnosed in ≥ 65 year old women in about half of cases. Experts currently recommend that systemic therapy is offered to elderly patients with BC, if, based on their overall conditions and life expectancy, it can be reasonably anticipated that the benefits will outweigh the risks of treatment. Like for young subjects, the monoclonal antibody against human epidermal growth factor receptor-2 (HER-2), trastuzumab, represents a valid therapeutic option when BC over-expresses this receptor. Unfortunately, administration of trastuzumab is associated with the occurrence of left ventricular dysfunction and chronic heart failure (CHF), possibly because of interference with the homeostatic functions of HER-2 in the heart. Registry-based, retrospective analyses have reported an incidence of CHF around 25% in elderly women receiving trastuzumab compared with 10%-15% in those not given any therapy for BC, and the risk of CHF has been estimated to be two-fold higher in > 60-65 year old trastuzumab users vs. non-users. Extremely advanced age and preexisting cardiac disease have been shown to predispose to trastuzumab cardiotoxicity. Therefore, selection of older patients for treatment with trastuzumab should be primarily based on their general status and the presence of comorbidities; previous chemotherapy, especially with anthracyclines, should be also taken into account. Once therapy has started, efforts should be made to ensure regular cardiac surveillance. The role of selected biomarkers, such as cardiac troponin, or new imaging techniques (three-dimension, tissue Doppler echocardiography, magnetic resonance imaging) is promising, but must be further investigated especially in the elderly. Moreover, additional studies are needed in order to better understand the mechanisms by which trastuzumab affects the old heart.
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Curigliano G, Cardinale D, Dent S, Criscitiello C, Aseyev O, Lenihan D, Cipolla CM. Cardiotoxicity of anticancer treatments: Epidemiology, detection, and management. CA Cancer J Clin 2016; 66:309-25. [PMID: 26919165 DOI: 10.3322/caac.21341] [Citation(s) in RCA: 418] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Answer questions and earn CME/CNE Cancer and heart disease are the leading causes of morbidity and mortality in the industrialized world. Modern treatment strategies have led to an improvement in the chances of surviving a diagnosis of cancer; however, these gains can come at a cost. Patients may experience adverse cardiovascular events related to their cancer treatment or as a result of an exacerbation of underlying cardiovascular disease. With longer periods of survival, late effects of cancer treatment may become clinically evident years or decades after completion of therapy. Current cancer therapy incorporates multiple agents whose deleterious cardiac effects may be additive or synergistic. Cardiac dysfunction may result from agents that can result in myocyte destruction, such as with anthracycline use, or from agents that appear to transiently affect left ventricular contractility. In addition, cancer treatment may be associated with other cardiac events, such as severe treatment-induced hypertension and vasospastic and thromboembolic ischemia, as well as rhythm disturbances, including QTc prolongation, that may be rarely life-threatening. Early and late effects of chest radiation can lead to radiation-induced heart disease, including pericardial disease, myocardial fibrosis, cardiomyopathy, coronary artery disease, valvular disease, and arrhythmias, in the setting of myocardial fibrosis. The discipline of cardio-oncology has developed in response to the combined decision making necessary to optimize the care of cancer patients, whether they are receiving active treatment or are long-term survivors. Strategies to prevent or mitigate cardiovascular damage from cancer treatment are needed to provide the best cancer care. This review will focus on the common cardiovascular issues that may arise during or after cancer therapy, the detection and monitoring of cardiovascular injury, and the best management principles to protect against or minimize cardiotoxicity during the spectrum of cancer treatment strategies. CA Cancer J Clin 2016;66:309-325. © 2016 American Cancer Society.
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Affiliation(s)
- Giuseppe Curigliano
- Director, Division of Experimental Therapeutics, Division of Medical Oncology, European Institute of Oncology, Milan, Italy
| | - Daniela Cardinale
- Director, Division of Cardiology, Cardio-Oncology Program, International Cardio-Oncology Society (ICOS), European Institute of Oncology, Milan, Italy
| | - Susan Dent
- Associate Professor and Postdoctoral fellow, The Ottawa Hospital Cancer Center, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Carmen Criscitiello
- Director, Division of Experimental Therapeutics, Division of Medical Oncology, European Institute of Oncology, Milan, Italy
| | - Olexiy Aseyev
- Associate Professor and Postdoctoral fellow, The Ottawa Hospital Cancer Center, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Lenihan
- Director, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Carlo Maria Cipolla
- Director, Division of Cardiology, Cardio-Oncology Program, International Cardio-Oncology Society (ICOS), European Institute of Oncology, Milan, Italy
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Iakobishvili Z, Kornowski R. Can cardio-oncology deliver better care internationally? Future Oncol 2016; 11:2259-62. [PMID: 26260804 DOI: 10.2217/fon.15.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Zaza Iakobishvili
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel, 49100
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel, 49100
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Bloom MW, Hamo CE, Cardinale D, Ky B, Nohria A, Baer L, Skopicki H, Lenihan DJ, Gheorghiade M, Lyon AR, Butler J. Cancer Therapy-Related Cardiac Dysfunction and Heart Failure: Part 1: Definitions, Pathophysiology, Risk Factors, and Imaging. Circ Heart Fail 2016; 9:e002661. [PMID: 26747861 DOI: 10.1161/circheartfailure.115.002661] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Advances in cancer therapy have resulted in significant improvement in long-term survival for many types of cancer but have also resulted in untoward side effects associated with treatment. One such complication that has become increasingly recognized is the development of cardiomyopathy and heart failure. Whether a previously healthy person from a cardiovascular perspective develops cancer therapy-related cardiac dysfunction or a high-risk cardiovascular patient requires cancer therapy, the team of oncologists and cardiologists must be better equipped with an evidence-based approach to care for these patients across the spectrum. Although the toxicities associated with various cancer therapies are well recognized, limitations to our understanding of the appropriate course of action remain. In this first of a 2-part review, we discuss the epidemiologic, pathophysiologic, risk factors, and imaging aspects of cancer therapy-related cardiac dysfunction and heart failure. In a subsequent second part, we discuss the prevention and treatment aspects, concluding with a section on evidence gap and future directions. We focus on adult patients in all stages of cancer therapy from pretreatment surveillance, to ongoing therapy, and long-term follow-up.
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Affiliation(s)
- Michelle W Bloom
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Carine E Hamo
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Daniela Cardinale
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Bonnie Ky
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Anju Nohria
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Lea Baer
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Hal Skopicki
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Daniel J Lenihan
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Mihai Gheorghiade
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Alexander R Lyon
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.)
| | - Javed Butler
- From the Cardiology Division (M.W.B., C.E.H., H.S., J.B.) and Oncology Division (L.B.), Stony Brook University, NY; Oncology Division, European Institute of Oncology, Milan, Italy (D.C.); Cardiology Division, University of Pennsylvania, Philadelphia (B.K.); Cardiology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (A.N.); Cardiology Division, Vanderbilt University, Nashville, TN (D.J.L.); Cardiovascular Division, Center for Cardiovascular Innovation, Northwestern Feinberg School of Medicine, Chicago, IL (M.G.); and Cardiovascular Division, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom (A.R.L.).
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61
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Abstract
An ever-increasing array of chemotherapeutic agents is being used in the treatment of solid organ or hematologic malignancies. The success of many of these agents has led to an increasing survival of patients with cancer. However, many of these agents, particularly anthracyclines and trastuzumab, are associated with the development of cardiotoxicity. The current standard for the evaluation of chemotherapy-associated cardiotoxicity typically involves the use of serial measurements of left ventricular (LV) function by echocardiogram (Echo) and radionuclide ventriculogram (MUGA). Unfortunately, this time-honored method offers low sensitivity to the early prediction or detection of cardiac events. Frequently, by the time cardiotoxicity is detected, significant LV dysfunction has occurred and ultimately this may not respond to standard cardioprotective treatment. Cardiac biomarkers, troponin I and B-type natriuretic peptide, may allow a more accurate and timely monitoring strategy. The current data and a summarized understanding of how to utilize cardiac biomarkers for the prevention and early detection of cardiac dysfunction during chemotherapy are presented.
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Affiliation(s)
- Patrick L Stevens
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA,
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62
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Witteles RM. Biomarkers as Predictors of Cardiac Toxicity From Targeted Cancer Therapies. J Card Fail 2016; 22:459-64. [PMID: 27038641 DOI: 10.1016/j.cardfail.2016.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/24/2016] [Accepted: 03/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cardiac biomarkers have been extensively investigated as early detectors of cardiac toxicity from cancer therapies. Whereas the role of biomarkers in monitoring anthracycline toxicity is generally well understood, substantial uncertainty remains regarding their role in monitoring newer targeted cancer therapies. METHODS AND RESULTS This review article examines all major published studies using cardiac troponins and/or N-terminal pro-B-type natriuretic peptide (NT-proBNP) in monitoring for cardiac toxicity with trastuzumab, tyrosine kinase inhibitors, and mammalian target of rapamycin (mTOR) inhibitors. There is substantial variability among studies regarding biomarker assays used, sensitivity of the assays, and definitions of abnormal results. In general, troponin I predicts early but not late cardiac events when trastuzumab is administered after anthracyclines, but troponin increases likely reflect anthracycline injury rather than trastuzumab injury. NT-proBNP detects cardiac toxicity with tyrosine kinase inhibitors and mTOR inhibitors, but not independently from echocardiography. CONCLUSIONS Troponin I can serve as a marker for susceptibility to cardiac toxicity during early trastuzumab treatment in patients who have received recent anthracyclines. NT-proBNP can serve as a useful marker of cardiac toxicity in patients treated with tyrosine kinase inhibitors or mTOR inhibitors if echocardiographic screening is not being used.
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Affiliation(s)
- Ronald M Witteles
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
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63
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Yu AF, Manrique C, Pun S, Liu JE, Mara E, Fleisher M, Patil S, Jones LW, Steingart RM, Hudis CA, Dang CT. Cardiac Safety of Paclitaxel Plus Trastuzumab and Pertuzumab in Patients With HER2-Positive Metastatic Breast Cancer. Oncologist 2016; 21:418-24. [PMID: 26984450 PMCID: PMC4828117 DOI: 10.1634/theoncologist.2015-0321] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/04/2016] [Indexed: 01/03/2023] Open
Abstract
The results of a preplanned cardiac safety analysis of global longitudinal strain (GLS), and troponin-I (TnI) and brain natriuretic peptide (BNP) levels in the phase II study of paclitaxel, trastuzumab, and pertuzumab (THP) for metastatic HER2-positive breast cancer are reported. There were no statistically significant changes in GLS, and TnI and BNP levels. The finding supports the cardiac safety of THP in this group of patients. Introduction. Myocardial strain imaging and blood biomarkers have been proposed as adjuncts to left ventricular ejection fraction (LVEF) monitoring for the early detection of cardiotoxicity during cancer therapy. We report the results of a preplanned cardiac safety analysis of global longitudinal strain (GLS), and troponin-I (TnI) and brain natriuretic peptide (BNP) levels in the phase II study of paclitaxel, trastuzumab, and pertuzumab (THP) for metastatic HER2-positive breast cancer. Patients and Methods. Patients with 0–1 lines of prior therapy were treated with weekly paclitaxel (80 mg/m2) plus trastuzumab (8 mg/kg loading dose followed by 6 mg/kg) and pertuzumab (840 mg loading dose followed by 420 mg) every 3 weeks. Exploratory endpoints were GLS measured with speckle-tracking echocardiography every 3 months and TnI and BNP levels measured every 6 weeks (immediately pre- and postchemotherapy infusion) at 6 time points. Results. Sixty-seven of 69 enrolled patients were treated with THP: 19 (28%) had hypertension, 8 (12%) had diabetes, 11 (16%) had hyperlipidemia, and 26 (38%) had smoking history. After a median follow-up of 21 months (range: 3–38 months), no patients developed symptomatic heart failure. Two patients (3.0%) experienced asymptomatic LVEF decline (grade 2). The mean GLS (±SD) was 19% ± 2% (baseline), 19% ± 2% (month 6), and 19% ± 3% (month 12). Detectable TnI (>0.06 ng/mL) and elevated BNP (>100 pg/mL) levels were observed in 3 (4.3%) and 2 (3.0%) patients, respectively, but were not associated with LVEF decline. Conclusion. The absence of any significant changes in GLS and cardiac biomarkers (TnI and BNP) further support the cardiac safety of THP in patients with metastatic HER2-positive breast cancer. Implications for Practice: Dual anti-HER2 therapy with trastuzumab and pertuzumab in combination with taxane-based chemotherapy improves overall survival in patients with metastatic HER2-positive breast cancer. There is a critical need to investigate the potential cardiotoxicity of dual anti-HER2 blockade, given the importance of HER2 signaling in cardiac homeostasis and stress response. Global longitudinal strain and cardiac biomarkers have been proposed as adjuncts to left ventricular ejection fraction for the early detection of cardiotoxicity. In this phase II study of combination trastuzumab and pertuzumab with paclitaxel, no clinically significant change was observed in global longitudinal strain or cardiac biomarkers. These results further support the cardiac safety of dual anti-HER2 blockade previously reported in the CLEOPATRA study. The findings in the current study also call into question the role of intensive cardiac monitoring among patients treated with anti-HER2 therapy in the absence of anthracyclines. Less frequent cardiac assessments could lead to a reduction in unnecessary treatment interruption and is an important consideration given the rise in medical expenditures, but this requires further investigation.
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Affiliation(s)
- Anthony F Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carlos Manrique
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Shawn Pun
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer E Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elton Mara
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Martin Fleisher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sujata Patil
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard M Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Clifford A Hudis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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64
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Chaudry M, Banchs J, Chavez-MacGregor M. Anthracycline or trastuzumab-related cardiotoxicity: do we have a predictive biomarker? Biomark Med 2016; 10:315-28. [DOI: 10.2217/bmm.15.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Chemotherapy-induced cardiotoxicity, is a well-known and potentially serious complication strongly impacting the quality of life and overall survival of breast cancer patients. The current diagnostic approach to detect cardiac damage is the estimation of left ventricular ejection fraction by echocardiography. However, this approach exhibits less sensitivity toward early prediction of cardiomyopathy, not allowing for preventive strategies. Measurement of serum cardiac-specific biomarkers can be a valid diagnostic tool for identifying patients prone to developing cardiotoxocity and in whom closer cardiac monitoring and preventive strategies are pivotal. In this article, we review work done on biomarkers in recent years, with an emphasis on troponin and B-type natriuretic peptide, which are currently the most studied in this field. We also briefly discuss current and emerging imaging techniques for early detection of cardiomyopathy.
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Affiliation(s)
- Misbat Chaudry
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-3721, USA
| | - Jose Banchs
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-3721, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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65
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Affiliation(s)
- Ronald M Witteles
- From Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (R.M.W.); Cardiology Department, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain (X.B.); and Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Spain (X.B.)
| | - Xavier Bosch
- From Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (R.M.W.); Cardiology Department, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain (X.B.); and Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Spain (X.B.).
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66
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Singh D, Thakur A, Tang WHW. Utilizing cardiac biomarkers to detect and prevent chemotherapy-induced cardiomyopathy. Curr Heart Fail Rep 2016; 12:255-62. [PMID: 25869733 DOI: 10.1007/s11897-015-0258-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The success achieved in advances in cancer therapy has been marred by development of cardiotoxicity, which causes significant morbidity and mortality. This has led to the development of surveillance protocols for cardiotoxicity utilizing multimodality imaging techniques and investigation of various drugs to treat and prevent cardiotoxicity in this subset of patients. Cardiac biomarkers hold important diagnostic and prognostic value in various cardiac diseases. In this review, we discuss the use of biomarkers in patients receiving chemotherapy, highlighting data behind the use of troponin, B-type natriuretic peptide, and myeloperoxidase. We also discuss the use of dexrazoxane, angiotensin-converting enzyme inhibitors, and beta blockers in the treatment and prevention of chemotherapy-induced cardiotoxicity. Cardiac biomarkers may serve an important role in selecting patients that are at high risk of cardiotoxicity and can potentially be used to guide the administration of drugs to treat and prevent cardiotoxicity.
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Affiliation(s)
- Dhssraj Singh
- Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J3-4, Cleveland, OH, 44195, USA
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67
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Eryilmaz U, Demirci B, Aksun S, Boyacioglu M, Akgullu C, Ilgenli TF, Yalinkilinc HS, Bilgen M. S100A1 as a Potential Diagnostic Biomarker for Assessing Cardiotoxicity and Implications for the Chemotherapy of Certain Cancers. PLoS One 2015; 10:e0145418. [PMID: 26682543 PMCID: PMC4687715 DOI: 10.1371/journal.pone.0145418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/03/2015] [Indexed: 01/02/2023] Open
Abstract
This study examined the value of blood marker S100A1 in detecting cardiotoxicity induced by chemotherapy agents; trastuzumab and lapatinib, in normal rat heart. The rats were divided into three groups: control (n = 8, no treatment), T (n = 8, one time ip treatment with 10 mg/kg trastuzumab) and L (n = 8, oral treatment with 100 mg/kg/day lapatinib for 7 days). The activities of oxidative stress parameters Malondialdehyde (MDA), Superoxide dismutase (SOD), Catalase (CAT) and Glutathione (GSH) were measured from the extracted cardiac tissues. The levels of troponinI and S100A1 expressions were measured from blood samples. All biomarkers responded to the treatments as they exhibited alterations from their normative values, validating the chemically induced cardiotoxicity. S100A1 expression attenuated significantly (75%), which made the sensitive detection of cardiotoxicity feasible. Assessment of cardiotoxicity with S100A1 may be a valuable alternative in clinical oncology of cancers in some organs such as breast and prostate, as they do not overexpress it to compete against.
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Affiliation(s)
- Ufuk Eryilmaz
- Department of Cardiology, Medical Faculty, Adnan Menderes University, Aydin, Turkey
- * E-mail:
| | - Buket Demirci
- Department of Medical Pharmacology, Medical Faculty, Adnan Menderes University, Aydin, Turkey
| | - Saliha Aksun
- Department of Medical Biochemistry, Medical Faculty, Katip Celebi University, Izmir, Turkey
| | - Murat Boyacioglu
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Adnan Menderes University, Aydin, Turkey
| | - Cagdas Akgullu
- Department of Cardiology, Medical Faculty, Adnan Menderes University, Aydin, Turkey
| | | | - Hande Sultan Yalinkilinc
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Adnan Menderes University, Aydin, Turkey
| | - Mehmet Bilgen
- Department of Biophysics, Medical Faculty, Adnan Menderes University, Aydin, Turkey
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68
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Yu AF, Ky B. Roadmap for biomarkers of cancer therapy cardiotoxicity. Heart 2015; 102:425-30. [PMID: 26674989 DOI: 10.1136/heartjnl-2015-307894] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/17/2015] [Indexed: 01/07/2023] Open
Abstract
Contemporary cancer treatment uses multiple modalities such as chemotherapy, targeted therapy and radiotherapy. These therapies, often used in combination, are associated with an increased risk of cardiotoxicity, specifically cardiomyopathy and heart failure. Cardiologists and oncologists are faced with the challenge of maximising the clinical benefit from cancer therapy while minimising the risk of early and late-onset cardiotoxicity. The current paradigm for cardiotoxicity detection and management relies primarily upon the assessment of left ventricular ejection fraction (LVEF). However, LVEF alone is limited in both diagnostic and prognostic ability. There is growing enthusiasm over the identification of newer biomarkers of cardiotoxicity that can detect cardiac injury at earlier stages of disease and could be used as an adjunctive prognostic measure to routine LVEF assessment. Thus, imaging and circulating biomarkers are currently under active investigation for use throughout the continuum of cancer care-for risk stratification of cardiotoxicity prior to treatment, detection of early cardiotoxicity during treatment and diagnosis of late cardiotoxicity in survivorship. Myocardial strain, cardiac troponin and brain natriuretic peptide are the most prominent biomarkers currently being studied, although data on novel circulating biomarkers are emerging.
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Affiliation(s)
- Anthony F Yu
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Bonnie Ky
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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69
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70
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De Iuliis F, Salerno G, Taglieri L, De Biase L, Lanza R, Cardelli P, Scarpa S. Serum biomarkers evaluation to predict chemotherapy-induced cardiotoxicity in breast cancer patients. Tumour Biol 2015; 37:3379-87. [PMID: 26449821 DOI: 10.1007/s13277-015-4183-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/01/2015] [Indexed: 01/20/2023] Open
Abstract
Anti-neoplastic chemotherapy can determine various side effects, including cardiotoxicity, and no real guidelines for its early detection and management have been developed. The aim of this study is to find some plasmatic markers able to identify breast cancer patients that are at greater risk of developing cardiovascular complications during chemotherapy, in particular heart failure. A prospective study on 100 breast cancer patients with mean age of 66 years in adjuvant treatment with anthracyclines, taxanes, and trastuzumab was performed. Patients underwent cardiological examination before starting treatment (T0) and at 3 months (T1), 6 months (T2), and 1 year (T3) after treatment. Evaluation of serum cardiac markers and N-terminal pro-brain natriuretic peptide (NT-proBNP) was performed at T0, T1, T2, and T3, simultaneously to electrocardiogram and echocardiogram, showing a significant increase in NT-proBNP concentration (p > 0.0001) at T1, T2, and T3, before left ventricular ejection fraction decrease became evident. Human epidermal growth factor receptor 2 (HER2)-negative patients were more susceptible to mild hematological cardiotoxicity, while HER2-positive patients were more susceptible to severe cardiotoxicity. A significant correlation between NT-proBNP increased values after chemotherapy and prediction of mortality at 1 year was evidenced. From our experience, serum biomarker detection was able to support an early diagnosis of cardiac damage, also in the absence of left ventricular ejection fraction decrease. Therefore, the evaluation of specific plasmatic markers for cardiac damage is more sensitive than echocardiography in the early diagnosis of chemotherapy-related cardiotoxicity; furthermore, it can also add a prognostic value on outcome.
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Affiliation(s)
- Francesca De Iuliis
- Experimental Medicine Department, University of Rome Sapienza, Viale Regina Elena 324, 00161, Rome, Italy
| | - Gerardo Salerno
- Laboratory of Diagnostics, Department of Clinical and Molecular Medicine, University of Rome Sapienza, 00161, Rome, Italy
| | - Ludovica Taglieri
- Experimental Medicine Department, University of Rome Sapienza, Viale Regina Elena 324, 00161, Rome, Italy
| | - Luciano De Biase
- Cardiology Center, Department of Clinical and Molecular Medicine, University of Rome Sapienza, 00161, Rome, Italy
| | - Rosina Lanza
- Ginecology, Obstetrics and Urology Department, University of Rome Sapienza, 00161, Rome, Italy
| | - Patrizia Cardelli
- Laboratory of Diagnostics, Department of Clinical and Molecular Medicine, University of Rome Sapienza, 00161, Rome, Italy
| | - Susanna Scarpa
- Experimental Medicine Department, University of Rome Sapienza, Viale Regina Elena 324, 00161, Rome, Italy.
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71
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Lyons TG, Morris PG. How can clinical research help our understanding of trastuzumab-related cardiotoxicity? EBioMedicine 2015; 2:802-3. [PMID: 26425684 PMCID: PMC4563129 DOI: 10.1016/j.ebiom.2015.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 11/27/2022] Open
Affiliation(s)
- Tomás G Lyons
- Cancer Clinical Trials and Research Unit, Beaumont Hospital, Dublin 9, Ireland
| | - Patrick G Morris
- Cancer Clinical Trials and Research Unit, Beaumont Hospital, Dublin 9, Ireland
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72
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Khouri MG, Klein MR, Velazquez EJ, Jones LW. Current and emerging modalities for detection of cardiotoxicity in cardio-oncology. Future Cardiol 2015; 11:471-84. [PMID: 26235924 DOI: 10.2217/fca.15.16] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Advancements in diagnostic tools and curative-intent therapies have improved cancer-specific survival. With prolonged survival, patients are now subject to increased aging and development of cardiovascular risk factors such that further improvements in cancer-specific mortality are at risk of being offset by increased cardiovascular mortality. Moreover, established and novel adjuvant therapies used in cancer treatment are associated with unique and varying degrees of direct as well as indirect myocardial and cardiovascular injury (i.e., cardiotoxicity). Current approaches for evaluating anticancer therapy-induced injury have limitations, particularly lack of sensitivity for early detection of subclinical cardiac and cardiovascular dysfunction. With emerging evidence suggesting early prevention and treatment can mitigate the degree of cardiotoxicity and limit interruption of life-saving cancer therapy, the importance of early detection is increasingly paramount. Newer imaging modalities, functional capacity testing and blood biomarkers have the potential to improve early detection of cardiotoxicity and reduce cardiovascular morbidity and mortality.
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Affiliation(s)
- Michel G Khouri
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Michael R Klein
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Eric J Velazquez
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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73
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Piper SE, McDonagh TA. Chemotherapy-related Cardiomyopathy. Eur Cardiol 2015; 10:19-24. [PMID: 30310418 PMCID: PMC6159418 DOI: 10.15420/ecr.2015.10.01.19] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 07/23/2015] [Indexed: 11/04/2022] Open
Abstract
Advances in chemotherapeutic agents have resulted in significantly improved cancer survival rates. Cardiac toxicity, however, has emerged as a leading cause of morbidity, both during and years after treatment. One of the most common manifestations of cardiotoxicity is that of heart failure and left ventricular systolic dysfunction. In this review, current opinions and guidelines in this field are discussed, with particular focus on the most common culprits, the anthracyclines, and the monoclonal antibody, trastuzumab.
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Affiliation(s)
- Susan E Piper
- King's College London, The James Black Centre, London, UK; Kings College Hospital NHS Foundation Trust, London, UK
| | - Theresa A McDonagh
- King's College London, The James Black Centre, London, UK; Kings College Hospital NHS Foundation Trust, London, UK
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74
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Abstract
Improvements in therapies have significantly changed survival of cancer patients. However, the clinical history and oncologic treatment put cancer patients at higher risk for developing cardiovascular problems. Anthracyclines, but also the targeted therapy and angiogenesis inhibitors, are all treatments associated with cardiotoxicity. The most common adverse event is a reduction in left ventricular ejection fraction that may progress to overt heart failure. Recognition of a cardiac impairment during or after a potential cardiotoxic treatment requires a stringent assessment of clinical symptoms and signs of heart failure associated with an evaluation of the left ventricular ejection fraction, which, however, detects the damage already installed. Circulating cardiac biomarkers are promising in detecting cardiotoxicity and will likely change the approach for identifying patients at risk.
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Affiliation(s)
- Michela Salvatici
- Division of Laboratory Medicine, European Institute of Oncology, via Ripamonti, 435, 20141 Milan, Italy
| | - Maria T Sandri
- Division of Laboratory Medicine, European Institute of Oncology, via Ripamonti, 435, 20141 Milan, Italy
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75
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Mulrooney DA, A Duprez D. Caring for cancer survivors: more than just checking the blood pressure and measuring the ejection fraction. Future Cardiol 2015; 11:371-5. [DOI: 10.2217/fca.15.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Daniel A Mulrooney
- St. Jude Children's Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105, USA
- University of Tennessee Health Science Center, 920 Court Avenue, Memphis, TN 38163, USA
| | - Daniel A Duprez
- University of Minnesota, MMC 508, 420 Delaware St. SE, Minneapolis, MN 55455, USA
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76
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Abstract
Advances in chemotherapeutic agents over the past two decades have resulted in significantly improved cancer survival rates. Cardiac toxicity, however, has emerged as a leading cause of morbidity, both during and years after treatment. One of the most common manifestations of cardiotoxicity is that of heart failure and left ventricular systolic dysfunction. Consequently, the field of cardio-oncology is a rapidly emerging field of sub-specialty, with growing research interests in all aspects of management. In this review, current opinions and guidelines in this field are discussed, with particular focus on the most common culprits, the anthracyclines and the monoclonal antibody, trastuzumab.
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Affiliation(s)
- Susan Piper
- Department of Cardiovascular Research, King's College London, The James Black Center, 125 Coldharbour Lane, London SE5 9NU, UK
- Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Theresa McDonagh
- Department of Cardiovascular Research, King's College London, The James Black Center, 125 Coldharbour Lane, London SE5 9NU, UK
- Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
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77
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Reijers JAA, Burggraaf J. Trastuzumab Induces an Immediate, Transient Volume Increase in Humans: A Randomised Placebo-Controlled Trial. EBioMedicine 2015; 2:953-9. [PMID: 26425703 PMCID: PMC4563119 DOI: 10.1016/j.ebiom.2015.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/25/2015] [Accepted: 05/06/2015] [Indexed: 02/03/2023] Open
Abstract
Background The exact extent of and the mechanism by which trastuzumab causes cardiac side effects are not completely unravelled. We investigated the (cardiotoxic) side effects of trastuzumab in a relatively large homogeneous population. Methods Healthy male volunteers (n = 54) with a left ventricle ejection fraction (LVEF) > 55% were administered 6 mg/kg trastuzumab (n = 46) IV in 90 min in a placebo-controlled, parallel study. Placebo consisted of 0 · 9% NaCl (n = 8). Assessments included body weight, routine and cardiac laboratory markers and serial echocardiographic examinations (8 placebo and 9 trastuzumab treated participants) up to 63 days after dosing. Statistical analysis was done using repeated measurements of variance. Findings Following trastuzumab infusion, fluid retention was observed: mean body weight increased over the first 4 days post-administration with 0 · 4 kg (95%-confidence interval: − 0 · 2, 0 · 9, p = 0 · 2261) compared to placebo, mean haemoglobin concentration decreased with 0 · 3 mM (− 0 · 6, − 0 · 1; p = 0 · 0043), as did haematocrit (− 0 · 013 L/L [− 0 · 024, − 0 · 002], p = 0 · 0216), and protein (− 2 g/L [− 4, − 0], p = 0 · 0443) and albumin (− 2 g/L [− 3, − 1], p < 0 · 0001) concentrations. Elevations in NT-proBNP levels, parallel to the weight increase, were observed in individual cases, but not on a group level. Troponin-T concentrations did not increase. The only echocardiographic parameter that changed significantly at all studied dose levels was E/A-ratio, a load-dependent parameter: from 1 · 81 (SD 0 · 42) to 1 · 98 (0 · 31) 3–5 days after administration, contrast to placebo of 0 · 57 (90%-CI: 0 · 21–0 · 93, p = 0 · 0034). Ejection fraction and pulsed-wave Doppler recorded parameters remained unchanged. Interpretation Single dose administration of trastuzumab in humans is associated with an immediate, transient extracellular volume increase, either as a primary or secondary (compensatory) response, which can be detected easily using routine clinical assessments. Echocardiographic changes, both short and long term, could not be found after single dose administration to drug-naive patients. If and how trastuzumab causes cardiotoxicity remains unknown. We investigated trastuzumab in a large cohort of healthy volunteers. Trastuzumab is associated with an immediate, transient volume increase. This response can be detected easily using routine clinical assessments. Echocardiographic changes, both short and long term, were not found.
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Abstract
Cancer survivorship should be defined starting not from completion of treatment, but from the time of diagnosis. Assessing and controlling the cancer patient's cardiovascular risk before, during, and after treatment is crucial to improving their overall outcome. There are many cancer therapies, including but not limited to anthracyclines, radiation, and vascular signaling pathway inhibitors which should be considered nontraditional cardiovascular risk factors with significant morbidity. Monitoring novel populations, such as a younger age group, for ischemic coronary disease or congestive heart failure (CHF) is not intuitive to many clinicians. Symptoms of CHF and coronary artery disease overlap with common side effects of cancer and cancer treatment. Cancer survivors may also have fewer typical symptoms of cardiovascular disease. Increased surveillance and aggressive control of cardiovascular disease is important in cancer patients both while undergoing active treatment and in the long term. Despite the increasing interest in cardio-oncology, data-driven guidelines are lacking due to small study sizes and low event rates over a short period of time. Most practice guidelines have been based on clinical practice and expert opinion. The list of cardiotoxic cancer therapies continues to grow each year. This review is not intended to be a comprehensive review of all cancer therapy toxicity, but will focus on recent literature regarding prevention of CHF and coronary artery disease (CAD) during active cancer therapy as well as current screening guidelines for long-term survivors.
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79
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Christenson ES, James T, Agrawal V, Park BH. Use of biomarkers for the assessment of chemotherapy-induced cardiac toxicity. Clin Biochem 2014; 48:223-35. [PMID: 25445234 DOI: 10.1016/j.clinbiochem.2014.10.013] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 10/25/2014] [Accepted: 10/28/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To review the evidence for the use of various biomarkers in the detection of chemotherapy associated cardiac damage. DESIGN AND METHODS Pubmed.gov was queried using the search words chemotherapy and cardiac biomarkers with the filters of past 10years, humans, and English language. An emphasis was placed on obtaining primary research articles looking at the utility of biomarkers for the detection of chemotherapy-mediated cardiac injury. RESULTS Biomarkers may help identify patients undergoing treatment who are at high risk for cardiotoxicity and may assist in identification of a low risk cohort that does not necessitate continued intensive screening. cTn assays are the best studied biomarkers in this context and may represent a promising and potentially valuable modality for detecting cardiac toxicity in patients undergoing chemotherapy. Monitoring cTnI levels may provide information regarding the development of cardiac toxicity before left ventricular dysfunction becomes apparent on echocardiography or via clinical symptoms. A host of other biomarkers have been evaluated for their utility in the field of chemotherapy related cardiac toxicity with intermittent success; further trials are necessary to determine what role they may end up playing for prediction and prognostication in this setting. CONCLUSIONS Biomarkers represent an exciting potential complement or replacement for echocardiographic monitoring of chemotherapy related cardiac toxicity which may allow for earlier realization of the degree of cardiac damage occurring during treatment, creating the opportunity for more timely modulation of therapy.
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Affiliation(s)
- Eric S Christenson
- Johns Hopkins University, Department of Medicine, Baltimore, MD 21287, USA.
| | - Theodore James
- Johns Hopkins University, Department of Medicine, Baltimore, MD 21287, USA
| | - Vineet Agrawal
- Johns Hopkins University, Department of Medicine, Baltimore, MD 21287, USA
| | - Ben H Park
- Johns Hopkins University, Department of Oncology, Baltimore, MD 21287, USA
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80
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Stachowiak P, Kornacewicz-Jach Z, Safranow K. Prognostic role of troponin and natriuretic peptides as biomarkers for deterioration of left ventricular ejection fraction after chemotherapy. Arch Med Sci 2014; 10:1007-18. [PMID: 25395954 PMCID: PMC4223124 DOI: 10.5114/aoms.2013.34987] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 11/12/2012] [Accepted: 12/22/2012] [Indexed: 11/24/2022] Open
Abstract
Cardiotoxicity due to anthracyclines, trastuzumab and other potential cardiotoxic drugs is still a problem of modern chemotherapy. For years researchers have tried to find biological markers that can predict changes in the heart. The most thoroughly tested markers are troponin and natriuretic peptides. Some studies have proven that these markers can indeed be useful. In studies which have shown the predictive role of troponin I the assessment of this marker was performed very frequently. It is not possible to carry out such serial measurements in many centers because of typical 1-day hospital stay times. The predictive role of natriuretic peptides still needs further investigation. This review considers the newest research from recent years.
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Affiliation(s)
- Paweł Stachowiak
- Department of Cardiology, Pomeranian Medical University, Szczecin, Poland
| | | | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland
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81
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Tian S, Hirshfield KM, Jabbour SK, Toppmeyer D, Haffty BG, Khan AJ, Goyal S. Serum biomarkers for the detection of cardiac toxicity after chemotherapy and radiation therapy in breast cancer patients. Front Oncol 2014; 4:277. [PMID: 25346912 PMCID: PMC4191171 DOI: 10.3389/fonc.2014.00277] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/23/2014] [Indexed: 12/31/2022] Open
Abstract
Multi-modality cancer treatments that include chemotherapy, radiation therapy, and targeted agents are highly effective therapies. Their use, especially in combination, is limited by the risk of significant cardiac toxicity. The current paradigm for minimizing cardiac morbidity, based on serial cardiac function monitoring, is suboptimal. An alternative approach based on biomarker testing, has emerged as a promising adjunct and a potential substitute to routine echocardiography. Biomarkers, most prominently cardiac troponins and natriuretic peptides, have been evaluated for their ability to describe the risk of potential cardiac dysfunction in clinically asymptomatic patients. Early rises in cardiac troponin concentrations have consistently predicted the risk and severity of significant cardiac events in patients treated with anthracycline-based chemotherapy. Biomarkers represent a novel, efficient, and robust clinical decision tool for the management of cancer therapy-induced cardiotoxicity. This article aims to review the clinical evidence that supports the use of established biomarkers such as cardiac troponins and natriuretic peptides, as well as emerging data on proposed biomarkers.
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Affiliation(s)
- Sibo Tian
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Kim M Hirshfield
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Deborah Toppmeyer
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
| | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School , New Brunswick, NJ , USA
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82
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Plana JC, Galderisi M, Barac A, Ewer MS, Ky B, Scherrer-Crosbie M, Ganame J, Sebag IA, Agler DA, Badano LP, Banchs J, Cardinale D, Carver J, Cerqueira M, DeCara JM, Edvardsen T, Flamm SD, Force T, Griffin BP, Jerusalem G, Liu JE, Magalhães A, Marwick T, Sanchez LY, Sicari R, Villarraga HR, Lancellotti P. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2014; 15:1063-93. [PMID: 25239940 PMCID: PMC4402366 DOI: 10.1093/ehjci/jeu192] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Ana Barac
- Medstar Washington Hospital Center, Washington, District of Columbia
| | - Michael S Ewer
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Igal A Sebag
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | | | | | - Jose Banchs
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | | | - Joseph Carver
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Thor Edvardsen
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | | | | | | | - Jennifer E Liu
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | - Liza Y Sanchez
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Rosa Sicari
- CNR Institute of Clinical Physiology, Pisa, Italy
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83
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Herrmann J, Lerman A. An update on cardio-oncology. Trends Cardiovasc Med 2014; 24:285-95. [PMID: 25153017 PMCID: PMC4258878 DOI: 10.1016/j.tcm.2014.07.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 12/22/2022]
Abstract
Over the past decades, there have been great advancements in the survival outcome of patients with cancer. As a consequence, treatment regimens are being extended to patient populations that would not have qualified in the past based on comorbidities and age. Furthermore, the anti-cancer regimens, which have been and are being used, can cause considerable morbidity and even mortality. In fact, new drugs such as tyrosine kinase inhibitors have yielded unanticipated side effects in frequency and severity. The cardiovascular disease spectrum is an important element in all of these. In order to optimize the outcome of cancer patients with cardiovascular diseases existing prior to cancer treatment or developing as a consequence of it, a new discipline called "cardio-oncology" has evolved over the past few years. Herein, we review the latest developments in this field including cardiotoxicities, vascular toxicities, and arrhythmias. This field is taking on more shape as cardiologists, oncologists, and hematologists are forming alliances, programs, and clinics, supported by the development of expert consensus statements on best management approaches and care of the cancer patient with cardiovascular diseases.
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Affiliation(s)
- Joerg Herrmann
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Amir Lerman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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84
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Preemptive Cardioprotective Strategies in Patients Receiving Chemotherapy. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0406-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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85
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[Towards an integrated approach to cardiovascular toxicities related to the treatments of breast cancer]. Bull Cancer 2014; 101:730-40. [PMID: 25091656 DOI: 10.1684/bdc.2014.1926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is an increasing number of therapeutic options in breast cancer management. While prognosis improves, the cardiac toxicity related to treatments remains a significant issue. This toxicity has several clinical presentations and can be explained by complex and diverse molecular mechanisms. Systemic treatments (anthracyclines, inhibitors of HER2 signaling pathway, hormone therapy, antiangiogenic agents) and radiotherapy have their own cardiac toxicity. However, the toxicities associated with these treatments may potentiate together and the existence of pre-existing cardiovascular risk factors should be taken into account. The assessment of cardiac hazard evolves toward a multifactorial approach. Several possibilities exist to minimize the incidence of cardiac complications. Those include pharmacological and technological innovations, but also a more accurate selection of patients and a growing involvement of practitioners in the field of cardiac toxicity, which is prerequisite for an early management of cardiac events.
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86
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Plana JC, Galderisi M, Barac A, Ewer MS, Ky B, Scherrer-Crosbie M, Ganame J, Sebag IA, Agler DA, Badano LP, Banchs J, Cardinale D, Carver J, Cerqueira M, DeCara JM, Edvardsen T, Flamm SD, Force T, Griffin BP, Jerusalem G, Liu JE, Magalhães A, Marwick T, Sanchez LY, Sicari R, Villarraga HR, Lancellotti P. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2014; 27:911-39. [PMID: 25172399 DOI: 10.1016/j.echo.2014.07.012] [Citation(s) in RCA: 874] [Impact Index Per Article: 87.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Ana Barac
- Medstar Washington Hospital Center, Washington, District of Columbia
| | - Michael S Ewer
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Igal A Sebag
- Jewish General Hospital and McGill University, Montreal, Quebec, Canada
| | | | | | - Jose Banchs
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | | | - Joseph Carver
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Thor Edvardsen
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | | | | | | | - Jennifer E Liu
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | - Liza Y Sanchez
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Rosa Sicari
- CNR Institute of Clinical Physiology, Pisa, Italy
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87
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Colombo A, Sandri MT, Salvatici M, Cipolla CM, Cardinale D. Cardiac complications of chemotherapy: role of biomarkers. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:313. [PMID: 24771223 DOI: 10.1007/s11936-014-0313-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Both conventional and novel antineoplastic drugs may cause damage to the heart, ultimately affecting patients' survival and quality of life. In fact, the most frequent and typical clinical manifestation of cardiotoxicity, asymptomatic or symptomatic left ventricular dysfunction, may be induced not only by conventional cancer therapy, like anthracyclines, but also by new antitumoral targeted therapy such as trastuzumab. At present, left ventricular ejection fraction assessment represents the main standard practice for cardiac monitoring during cancer therapy, but it detects myocardial damage only when a functional impairment has already occurred, not allowing for early preventive strategies. In the last decade, a newer approach based on the measurement of cardiospecific biomarkers has been proposed, proving to have higher prognostic value than imaging modalities. In particular, cardiac troponin elevation during chemotherapy allows us to identify patients who are more prone to develop myocardial dysfunction and cardiac events during follow up. In these patients, the use of an angiotensin-converting enzyme inhibitor, such as enalapril, has shown to be effective in improving clinical outcome, giving the chance for a cardioprotective strategy in a selected population.
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Affiliation(s)
- Alessandro Colombo
- Cardiology Division, European Institute of Oncology, I.R.C.C.S., Via Ripamonti 435, 20141, Milan, Italy,
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88
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Greene J, Hennessy B. The role of anthracyclines in the treatment of early breast cancer. J Oncol Pharm Pract 2014; 21:201-12. [DOI: 10.1177/1078155214531513] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We review the use of anthracyclines, their associated cardiotoxicity, and the role of taxanes in the treatment of early breast cancer. The efficacy of anthracyclines has been proven in multiple large cohort trials and meta-analyses. The addition of a taxane to an anthracycline-based regimen in the adjuvant setting has improved the disease-free survival and overall survival in patients with early breast cancer. The use of the monoclonal antibody trastuzumab combined with an anthracycline and taxane regimen has had significant benefit both in disease-free survival and overall survival in patients with human epidermal growth factor receptor 2(HER2)–positive disease. However, the development of significant cardiotoxicity related to anthracyclines and the emergence of newer agents that appear to limit the cardiotoxicity but with similar anticancer efficacy have called the role of anthracyclines into doubt. Taxane/trastuzumab-based chemotherapy without anthracyclines is now a widely accepted adjuvant regimen in patients with HER2–positive early breast cancer. Indeed, the use of taxanes in early breast cancer has overtaken the use of anthracyclines, particularly in women with HER2–positive breast cancer. Concerns regarding anthracycline cardiotoxicity and positive data from taxane-based regimens likely have contributed to this change in practice. Ongoing trials will determine whether taxane-based chemotherapy has equivalent efficacy to anthracycline-based regimens in adjuvant therapy of HER2–negative early breast cancer. Moving forward, the use of anthracyclines as initial chemotherapy in early breast cancer may continue to be replaced by taxane-based and novel regimens in the future.
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89
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Evaluation of ultrasensitive cardiac Troponin I levels in patients with breast cancer during chemotherapy. Clin Chim Acta 2014; 428:70-1. [DOI: 10.1016/j.cca.2013.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/30/2013] [Accepted: 11/04/2013] [Indexed: 11/22/2022]
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90
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Steingart RM, Yadav N, Manrique C, Carver JR, Liu J. Cancer Survivorship: Cardiotoxic Therapy in the Adult Cancer Patient; Cardiac Outcomes With Recommendations for Patient Management. Semin Oncol 2013; 40:690-708. [DOI: 10.1053/j.seminoncol.2013.09.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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91
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Bosch X, Sitges M, Rovira M, Ortiz-Pérez JT, Esteve J. Reply. J Am Coll Cardiol 2013; 62:2452. [DOI: 10.1016/j.jacc.2013.08.712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/01/2013] [Accepted: 08/06/2013] [Indexed: 11/26/2022]
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92
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Early increases in multiple biomarkers predict subsequent cardiotoxicity in patients with breast cancer treated with doxorubicin, taxanes, and trastuzumab. J Am Coll Cardiol 2013; 63:809-16. [PMID: 24291281 DOI: 10.1016/j.jacc.2013.10.061] [Citation(s) in RCA: 362] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 10/11/2013] [Accepted: 10/22/2013] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The aim of this study was to determine if individual or multiple biomarkers are associated with cardiotoxicity in patients with breast cancer undergoing cancer therapy. BACKGROUND Current methods to identify patients at risk for cardiotoxicity from cancer therapy are inadequate. METHODS We measured 8 biomarkers in a multicenter cohort of 78 patients with breast cancer undergoing doxorubicin and trastuzumab therapy: ultrasensitive troponin I (TnI), high-sensitivity C-reactive protein (CRP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), growth differentiation factor (GDF)-15, myeloperoxidase (MPO), placental growth factor (PlGF), soluble fms-like tyrosine kinase receptor (sFlt)-1, and galectin (gal)-3. Cardiotoxicity, defined by the Cardiac Review and Evaluation Committee criteria, was assessed every 3 months for up to 15 months. Hazard ratios (HRs) of cardiotoxicity risk were assessed for each biomarker at baseline, at visit 2 (3 months), and as a function of the difference between visit 2 and baseline. Joint models were assessed for the most promising biomarkers. RESULTS TnI, CRP, GDF-15, MPO, PlGF, and sFlt-1 levels increased from baseline to visit 2 (p < 0.05). A greater risk of cardiotoxicity was associated with interval changes in TnI (HR: 1.38 per SD; 95% confidence interval: 1.05 to 1.81; p = 0.02) and MPO (HR: 1.34 per SD; 95% confidence interval: 1.00 to 1.80; p = 0.048) and in models combining both markers (p = 0.007 and p = 0.03, respectively). The risk of cardiotoxicity was 46.5% in patients with the largest changes in both markers (ΔTnI >121.8 μg/l; ΔMPO >422.6 pmol/l). CONCLUSIONS Early increases in TnI and MPO levels offer additive information about the risk of cardiotoxicity in patients undergoing doxorubicin and trastuzumab therapy. Independent validation of these findings is necessary before application to clinical practice.
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93
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Abstract
Modern cancer therapies are highly effective in the treatment of various malignancies, but their use is limited by the potential for cardiotoxicity. The most frequent and typical clinical manifestation of cardiotoxicity is left ventricular dysfunction, induced not only by cytotoxic conventional cancer therapy like anthracyclines, but also by new antitumor targeted therapy such as trastuzumab. The current standard for monitoring cardiac function, based on periodic assessment of left ventricular ejection fraction detects cardiotoxicity only when a functional impairment has already occurred, precluding any chance of preventing its development. A novel approach, based on the use of cardiac biomarkers has emerged in the last decade, resulting in a cost-effective diagnostic tool for early, real-time identification, assessment and monitoring of cardiotoxicity. In particular, prophylactic treatment with enalapril in patients with an early increase in troponin after chemotherapy has been shown to be very effective in preventing left ventricular dysfunction and associated cardiac events. In patients developing cancer treatment induced-cardiomyopathy, complete left ventricular ejection fraction recovery and a reduction of cardiac events may be achieved only when left ventricular dysfunction is detected early after the end of cancer treatment and treatment with angiotensin-converting enzyme inhibitors, possibly in combination with beta-blockers, is promptly initiated.
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94
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Mong MC, Hsia TC, Yin MC. Dietary trans fats enhance doxorubicin-induced cardiotoxicity in mice. J Food Sci 2013; 78:H1621-H1628. [PMID: 24024564 DOI: 10.1111/1750-3841.12257] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 08/02/2013] [Indexed: 12/24/2022]
Abstract
This study investigated the combined effects of trans fat diet (TFD) and doxorubicin upon cardiac oxidative, inflammatory, and coagulatory stress. TFD increased trans fatty acid deposit in heart (P < 0.05), and decreased protein C and antithrombin-III activities in circulation (P < 0.05). TFD plus doxorubicin treatment elevated activities of plasminogen activator inhibitor-1, lactate dehydrogenase, and creatine phosphokinase (P < 0.05). This combination also raised xanthine oxidase activity, and enhanced cardiac levels of reactive oxygen species, interleukin (IL)-6, IL-10, tumor necrosis factor-alpha, and monocyte chemoattractant protein-1 than TFD or doxorubicin treatment alone (P < 0.05). TFD alone increased cardiac nuclear factor kappa B (NF-κB) activity (P < 0.05), but failed to affect expression of NF-κB and mitogen-activated protein kinase (MAPK) (P > 0.05). Doxorubicin treatment alone augmented cardiac activity, mRNA expression, and protein production of NF-κB and MAPK (P < 0.05). TFD plus doxorubicin treatment further upregulated cardiac expression of NF-κB p65, p-p38, and p-ERK1/2 (P < 0.05). These findings suggest that TFD exacerbates doxorubicin-induced cardiotoxicity.
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Affiliation(s)
- Mei-Chin Mong
- Dept. of Health and Nutrition Biotechnology, Asia Univ., Taichung City, Taiwan
| | - Te-Chun Hsia
- Dept. of Respiratory Therapy, China Medical Univ., Taichung City, Taiwan
| | - Mei-Chin Yin
- Dept. of Health and Nutrition Biotechnology, Asia Univ., Taichung City, Taiwan.,Dept. of Nutrition, China Medical Univ., Taichung City, Taiwan
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Conti E, Romiti A, Musumeci MB, Passerini J, Zezza L, Mastromarino V, D'Antonio C, Marchetti P, Paneni F, Autore C, Volpe M. Arterial thrombotic events and acute coronary syndromes with cancer drugs: Are growth factors the missed link? Int J Cardiol 2013; 167:2421-9. [DOI: 10.1016/j.ijcard.2013.01.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/18/2013] [Indexed: 12/21/2022]
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96
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Morris PG, Iyengar NM, Patil S, Chen C, Abbruzzi A, Lehman R, Steingart R, Oeffinger KC, Lin N, Moy B, Come SE, Winer EP, Norton L, Hudis CA, Dang CT. Long-term cardiac safety and outcomes of dose-dense doxorubicin and cyclophosphamide followed by paclitaxel and trastuzumab with and without lapatinib in patients with early breast cancer. Cancer 2013; 119:3943-51. [PMID: 24037735 DOI: 10.1002/cncr.28284] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/04/2013] [Accepted: 06/11/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND The authors have previously reported 2 consecutive phase 2 trials in patients with early breast cancer that overexpresses human epidermal growth factor receptor 2 (HER2) to assess the feasibility of incorporating anti-HER2 therapies into dose-dense (dd) chemotherapy regimens. The incidence of congestive heart failure (CHF) at a median follow-up of 2 years was 1.4% and 3.2%, respectively. METHODS In trial A, patients received dd doxorubicin and cyclophosphamide (AC)→paclitaxel (T) (each given every 2 weeks) × 4 with trastuzumab (H) given × 1 year. In trial B, weekly T (weekly × 12) was substituted for ddT and lapatinib × 1 year was added. Herein, the authors report the longer-term incidence of CHF and distant disease-free survival (DDFS). RESULTS From January 2005 to May 2008, 165 patients enrolled (median age, 46 years, with a median left ventricular ejection fraction of 68% [range, 52%-81%]), 17%of whom had previous hypertension. With a median follow-up of 84 months (trial A) and 57 months (trial B), 1 additional patient developed CHF. Therefore, the cumulative incidence of CHF was 1.4% (95% confidence interval [95% CI], 1.36%-7.7%) for trial A and 4.2% (95% CI, 4.2%-10.4%) for trial B. The 5-year DDFS for trials A and B was 92% (95% CI, 83%-97%) and 89% (95% CI, 81%-94%), respectively. CONCLUSIONS Longer follow-up of these 2 studies has demonstrated that ddAC→TH only or with lapatinib is associated with a low risk of CHF and promising DDFS in patients with early breast cancer.
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Affiliation(s)
- Patrick G Morris
- Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New York, New York
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97
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Colombo A, Cardinale D. Using cardiac biomarkers and treating cardiotoxicity in cancer. Future Cardiol 2013; 9:105-18. [PMID: 23259478 DOI: 10.2217/fca.12.73] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cardiotoxicity is a frequent and serious adverse effect of both conventional and novel anticancer treatments, affecting patient survival and quality of life. The current standard for cardiac monitoring during cancer therapy, mainly based on left ventricular ejection fraction assessment, detects myocardial damage only when a functional impairment has already occurred, not allowing for early preventive strategies. Measurement of cardiospecific biomarkers has proven to have higher prognostic value than imaging modalities. In particular, cardiac troponin elevation during chemotherapy allows the identification of patients who are more prone to develop myocardial dysfunction and cardiac events during follow-up. In these patients, the use of an angiotensin-converting enzyme inhibitor such as enalapril has shown to be effective in improving clinical outcome, giving the chance for a cardioprotective strategy in a selected population. Once left ventricular dysfunction occurs, heart failure therapies currently used for other forms of left ventricular dysfunction, particularly angiotensin-converting enzyme inhibitors and β-blockers, seem to be effective. However, their use in cancer patients is still undervalued.
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Affiliation(s)
- Alessandro Colombo
- Cardiology Division, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.
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98
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Cardinale D, Bacchiani G, Beggiato M, Colombo A, Cipolla CM. Strategies to prevent and treat cardiovascular risk in cancer patients. Semin Oncol 2013; 40:186-98. [PMID: 23540744 DOI: 10.1053/j.seminoncol.2013.01.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Cardiotoxicity due to cancer treatment is of rising concern, for both cardiologists and oncologists, because it may have a significant impact on cancer patient management and outcome. The most typical manifestation of cardiotoxicity is a hypokinetic cardiomyopathy leading to heart failure. However, the spectrum of the toxic effects that can impair the cardiovascular system may also include acute coronary syndromes, hypertension, arrhythmias, and thromboembolic events. Patients undergoing cancer treatment are more vulnerable to cardiovascular injuries, and their risk of premature cardiovascular disease and death is higher than that of the general population. Prevention of cardiotoxicity remains the most important strategy, and several measures, including cardiac function monitoring, limitation of chemotherapy dose, use of anthracycline analogues and cardioprotectants, and early detection of myocardial cell injury by biomarkers, have been proposed. The response to modern heart failure therapy of cancer treatment-induced cardiomyopathy has never been evaluated in clinical trials, and currently there are no definitive guidelines. Although it is likely that medications used for other forms of cardiomyopathy, particularly angiotensin-converting enzyme inhibitors and β-blockers, may be highly effective, there is still some unjustified concern regarding their use in cancer patients. Specific guidelines that take cardiologic conditions of cancer patients into account are currently lacking and need to be developed.
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Lin MC, Yin MC. Preventive Effects of Ellagic Acid Against Doxorubicin-Induced Cardio-Toxicity in Mice. Cardiovasc Toxicol 2013; 13:185-93. [DOI: 10.1007/s12012-013-9197-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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100
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Khouri MG, Douglas PS, Mackey JR, Martin M, Scott JM, Scherrer-Crosbie M, Jones LW. Cancer therapy-induced cardiac toxicity in early breast cancer: addressing the unresolved issues. Circulation 2012; 126:2749-63. [PMID: 23212997 PMCID: PMC3667651 DOI: 10.1161/circulationaha.112.100560] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | | | | | - Miguel Martin
- Hospital General Universitario Gregorio Maranon, Universidad Complutense, Madrid, Spain
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