Cardio-Oncology: Vascular and Metabolic Perspectives: A Scientific Statement From the American Heart Association

Peroxiredoxin-1 Overexpression Attenuates Doxorubicin-Induced Cardiotoxicity by Inhibiting Oxidative Stress and Cardiomyocyte Apoptosis

Background. Previous research has shown that peroxiredoxin 1 (Prdx1) is an important modulator of physiological and pathophysiological cardiovascular events. This study is aimed at investigating the role and underlying mechanism of Prdx1 in doxorubicin- (DOX-) induced cardiotoxicity. Cardiac-specific expression of Prdx1 was induced in mice, and the mice received a single dose of DOX (15 mg/kg) to generate cardiotoxicity. First, our study demonstrated that Prdx1 expression was upregulated in the heart and in cardiomyocytes after DOX treatment. Second, we provided direct evidence that Prdx1 overexpression ameliorated DOX-induced cardiotoxicity by attenuating oxidative stress and cardiomyocyte apoptosis. Mechanistically, we found that DOX treatment increased the phosphorylation level of apoptosis signal-regulating kinase-1 (ASK1) and the downstream protein p38 in the heart and in cardiomyocytes, and these effects were decreased by Prdx1 overexpression. In contrast, inhibiting Prdx1 promoted DOX-induced cardiac injury via the ASK1/p38 pathway. These results suggest that Prdx1 may be an effective therapeutic option to prevent DOX-induced cardiotoxicity.

Anticancer Therapy-Related Increases in Arterial Stiffness: A Systematic Review and Meta-Analysis

Background

Cardio‐oncology is a clinical discipline focused primarily on the early detection of anticancer therapy–related cardiomyopathy. However, there is growing evidence that the direct adverse consequences extend beyond the myocardium to affect the vasculature, but this evidence remains limited. In addition, there remains a paucity of clinically based strategies for monitoring vascular toxicity in these patients. Importantly, arterial stiffness is increasingly recognized as a surrogate end point for cardiovascular disease and may be an important vascular outcome to consider. Therefore, the aim of this systematic review and meta‐analysis was to summarize evidence of increased arterial stiffening with anticancer therapy and evaluate the effect of treatment modifiers.

Methods and Results

A total of 19 longitudinal and cross‐sectional studies that evaluated arterial stiffness both during and following anticancer therapy were identified using multiple databases. Two separate analyses were performed: baseline to follow‐up (12 studies) and control versus patient groups (10 studies). Subgroup analysis evaluated whether stiffness differed as a function of treatment type and follow‐up time. Standard mean differences and mean differences were calculated using random effect models. Significant increases in arterial stiffness were identified from baseline to follow‐up (standard mean difference, 0.890; 95% CI, 0.448–1.332; P<0.0001; mean difference, 1.505; 95% CI, 0.789–2.221; P≤0.0001) and in patient versus control groups (standard mean difference, 0.860; 95% CI, 0.402–1.318; P=0.0002; mean difference, 1.437; 95% CI, 0.426–2.448; P=0.0052). Subgroup analysis indicated differences in arterial stiffness between anthracycline‐based and non‐anthracycline‐based therapies (standard mean difference, 0.20; 95% CI, 0.001–0.41; P=0.048), but not follow‐up time.

Conclusions

Significant arterial stiffening occurs following anticancer therapy. Our findings support the use of arterial stiffness as part of a targeted vascular imaging strategy for the identification of early cardiovascular injury during treatment and for the detection of long‐term cardiovascular injury into survivorship.

Cardiovascular mortality and morbidity burden in successive and age pre-stratified case-control cohorts of breast cancer women. A population-based study

AIMS

To assess the existence, components and clinical relevance of cardiac causes of death and cardiovascular (CV) hospitalizations in a population-wide database of patients with breast cancer (BC).

METHODS AND RESULTS

A population-wide database of the Puglia Region, Italy was analyzed, with a prospective comparative design. Three successive closely matched case/control cohorts representing current care in the period 2007-2014 were also stratified according to age to focus specifically on the potential interaction of treatment-related cardiac toxicity and the expected different baseline CV risk profiles.

RESULTS

At 3-year follow-up, in the successive cohorts the incidence of BC-related (7.7, 7.0, 6.5%) and cardiac causes of death, specifically attributed to heart failure (HF, 1.3, 0.5, 0.5%), decreased. Significant mortality hazard ratio (HR) for HF was found in the total population (1.47, 95% CI 1.14-1.90), in particular in the 2007-2009 cohort (1.71, 95% CI 1.19-2.46) and in the 50-69 age group (7.96, 95% CI 2.81-22.55). Results at 5 years confirm the mortality findings, and a significant HR for hospitalizations for HF, non-atrial arrhythmias and ischemic heart disease in the younger than 50 subpopulation pointed to a late expression of toxicity in the youngest BC population.

CONCLUSIONS

The incidence of CV causes of death 3 and 5 years after BC diagnosis was very low, even if an excess in risk of death for HF as compared with the control cohort was observed. While younger patients seems to tolerate BC and BC therapy better in the short term, HF mortality and morbidity resulted significantly increased at 5-year follow-up. As the risk for hospitalization for CV reasons increased at 5-year follow-up in particular in women aged less than 50 years, CV monitoring in this subgroup of patients seems mandatory.

Cardiac Imaging in Oncology Patients in Europe: a Model for Advancement of CV Safety and Development of Comprehensive CV Care

Cancer therapy-related cardiovascular events are widely recognized as a global problem, and cardio-oncology has been proposed as a new approach to coordinate preventive strategies in oncologic patients. Cardiac imaging plays a critical role in this process. This article summarizes current practices and future needs in cardiac imaging to improve the cardiovascular surveillance of cancer patients.

Optimizing screening and management of cardiovascular health in prostate cancer: A review

In clinical practice, cancer management does not consistently encompass screening and identification of cardiovascular (CV) risk. The use of androgen deprivation therapy (ADT) in prostate cancer has been associated with increased CV risk and development of metabolic syndrome, necessitating identification of patients at risk in this population (e.g., those with pre-existing CV disease). A multidisciplinary team of Canadian physicians was assembled to develop a series of recommendations intended to identify patients who may benefit from optimal management of their CV disease and/or modification of cardiac risk factors. A key goal was the development of a simple screening tool for identification of patients with pre-existing CV disease. This simple and inclusive set of recommendations are intended for use within urology clinics to facilitate holistic approaches and simplify the management of patients.

Clinical Practice and Research in Cardio-Oncology: Finding the "Rosetta Stone" for Establishing Program Excellence in Cardio-oncology

The burgeoning field of cardio-oncology (C-O) is now necessary for the delivery of excellent care for patients with cancer. Many factors have contributed to this increasing population of cancer survivors or those being treated with novel and targeted cancer therapies. There is a tremendous need to provide outstanding cardiovascular (CV) care for these patients; however, current medical literature actually provides a paucity of guidance. C-O therefore provides a novel opportunity for clinical, translational, and basic research to advance patient care. This review aims to be a primer for cardio-oncologists on how to develop a vibrant and comprehensive C-O program, use practical tools to assist in the construction of C-O services, and to proactively incorporate translational and clinical research into the training of future leaders as well as enhance clinical care.

Acute myocardial infarction in a high-risk cancer population: Outcomes following conservative versus invasive management

BACKGROUND

The benefits of invasive versus noninvasive management in oncology patients with acute myocardial infarction (AMI) are unclear. We aimed to retrospectively determine outcome differences between conservative and invasive management of AMI in cancer patients.

METHODS

Patients from our institution between March 2016 and December 2018 with type 1 and type 2 AMI (excluding STEMI) were classified into 2 groups: medical therapy only and invasive strategies. Analyzed outcomes were overall survival (OS), procedural complications, subsequent events, and hospice referral. Kaplan-Meier method and log-rank test were used to compare OS between subgroups. Cox proportional hazards regression analyses were conducted to find factors associated with OS.

RESULTS

We included 201 patients. Type 1 MI was seen in 152 patients (76%) and type 2 MI in 49 (24%). Median OS was 13 months. Most presented with symptoms other than dyspnea or chest pain (49%) and with ECG revealing changes other than ST-segment depression and T-wave inversion (62%). Patients with type 2 MI had worse OS than patients with type 1 MI (HR = 2.3, p = 0.0002). Early coronary angiography (≤72 h; HR = 0.327, p < 0.0001), late coronary angiography (>72 h; HR = 0.496, p = 0.0426), and percutaneous coronary intervention (HR = 0.481, p = 0.0116) were associated with better OS than noninvasive approaches. Single and dual agent antiplatelet therapy, beta blockers, and statins were each associated with better OS.

CONCLUSIONS

Cancer patients without STEMI who underwent invasive treatment for AMI had better OS compared with those treated only medically, with the highest benefit when coronary angiography was performed within 72 h of admission for AMI.

Risk Profiling of Cancer Treatment-Related Cardiovascular Disorders in Breast Cancer Patients Who Received Adjuvant Chemotherapy With Trastuzumab

Background: The prognosis of cancer survivors has dramatically improved, but effective strategies for cancer treatment-related cardiovascular disorders (CTRCD) remain to be elucidated in the emerging field of cardio-oncology. In this study, we investigated risk factors for CTRCD in breast cancer patients treated with trastuzumab. Methods and Results: We performed a retrospective analysis of 141 consecutive women who received adjuvant trastuzumab, and underwent baseline (BL) and follow-up (FU) echocardiography at Juntendo University between April 2010 and December 2016. The major concomitant treatment was anthracyclines in 94% and radiotherapy in 53%. During the median treatment period of 11 months, there were 22 (15.6%) cardiology consultations, 3 (2.1%) treatment interruptions with irreversible CTRCD, and no deaths. Left ventricular ejection fraction (LVEF) was decreased from a median 67.5% (BL) to 63.4% (FU; P<0.0001), with reduced LVEF noted in 26.2% at FU<90%BL, in 13.5% at FU Collapse

Key Words

• Breast cancer
• Cancer treatment-related cardiovascular disorder
• Cardio-oncology
• Cardiovascular risk factor
• Trastuzumab

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Affiliation(s)

Hiromi Shinano Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University Tokyo Japan
Sakiko Miyazaki Department of Cardiovascular Medicine, Graduate School of Medicine, Juntendo University Tokyo Japan
Kayo Miura Department of Breast and Endocrine Surgery, Graduate School of Medicine, Juntendo University Tokyo Japan
Hiroshi Ohtsu Leading Center for the Development and Research of Cancer Medicine, Juntendo University Tokyo Japan Center for Clinical Sciences, Department of Data Science, National Center for Global Health and Medicine Tokyo Japan Institute for Medical Regulatory Science, Organization for University Research Initiatives, Waseda University Tokyo Japan
Naohiro Yonemoto Innovative Medical Technology Research & Development Center, Juntendo University Tokyo Japan Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry Tokyo Japan
Kiyoshi Matsuoka Innovative Medical Technology Research & Development Center, Juntendo University Tokyo Japan Center for Clinical Sciences, Department of Data Science, National Center for Global Health and Medicine Tokyo Japan
Hakuou Konishi Department of Cardiovascular Medicine, Graduate School of Medicine, Juntendo University Tokyo Japan
Hiroyuki Daida Department of Cardiovascular Medicine, Graduate School of Medicine, Juntendo University Tokyo Japan Innovative Medical Technology Research & Development Center, Juntendo University Tokyo Japan
Mitsue Saito Department of Breast and Endocrine Surgery, Graduate School of Medicine, Juntendo University Tokyo Japan
Kazuhiro Sase Clinical Pharmacology and Regulatory Science, Graduate School of Medicine, Juntendo University Tokyo Japan Institute for Medical Regulatory Science, Organization for University Research Initiatives, Waseda University Tokyo Japan

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Cardiovascular Safety of Degarelix Versus Leuprolide for Advanced Prostate Cancer: The PRONOUNCE Trial Study Design

OBJECTIVES

This study will compare the incidence of major adverse cardiovascular events (MACEs) with androgen deprivation therapy (ADT) among men with advanced prostate cancer who are being treated with a gonadotropin-releasing hormone (GnRH) antagonist versus a GnRH agonist.

BACKGROUND

Treatment of advanced prostate cancer with ADT might increase the risk of subsequent cardiovascular events among men with known atherosclerotic cardiovascular disease (ASCVD), but a recent meta-analysis suggested that this risk might be lower with ADT using a GnRH antagonist versus a GnRH agonist.

METHODS

PRONOUNCE is a multicenter, prospective, randomized, open, blinded endpoint trial that will enroll approximately 900 patients with advanced prostate cancer and pre-existing ASCVD who will be treated with ADT. Participants will be randomized to receive the GnRH antagonist degarelix or the GnRH agonist leuprolide as ADT for 12 months. The primary endpoint is time from randomization to first confirmed, adjudicated occurrence of a MACE, which is defined as a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke through 12 months of ADT treatment. Baseline cardiovascular biomarkers (high-sensitivity C-reactive protein, high-sensitivity troponin T, and N-terminal pro-brain natriuretic peptide), as well as serial inflammatory and immune biomarkers, will be evaluated in exploratory analyses.

RESULTS

As of October 1, 2019, a total of 364 patients have been enrolled. The mean age is 74 years, 90% are white, 80% have hypertension or dyslipidemia, 30% diabetes mellitus, 40% have had a previous myocardial infarction, and 65% have had previous revascularization. Regarding prostate cancer features at randomization, 48% of the patients had localized disease, 23% had locally advanced disease, and 18% had metastatic disease.

CONCLUSIONS

PRONOUNCE is the first prospective cardiovascular outcomes trial in advanced prostate cancer that will delineate whether the risk of subsequent cardiovascular events associated with ADT is lower with a GnRH antagonist versus a GnRH agonist for men with pre-existing ASCVD. (A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease [PRONOUNCE]; NCT02663908).

Outcomes of percutaneous coronary interventions in cancer patients

Introduction: There are numerous shared risk factors in the etiopathogenesis of coronary artery disease (CAD) and cancer both at epidemiologic and molecular level. Additionally, different modalities of treatment of cancer such as radiation, chemotherapy, immunotherapy, and hormonal therapies further increase the risk of CAD and acute coronary syndrome. Most large database analysis and single-center experiences have shown that cancer patients undergoing PCI are at an increased risk of in-hospital mortality, bleeding, repeat revascularization.Areas covered: In this review article the authors discuss the associations between CAD and cancer, challenges for PCI in cancer patients and outcome data.Expert opinion: Interventionists performing PCI on cancer patients should be cognizant of the heightened risk of bleeding, thrombosis, possible need for interruption of dual-antiplatelet therapy, and the increased risk of target lesion revascularization in this cohort. These risks may be partially mitigated by utilization of best practices such as the use of radial artery access, intravascular imaging for lesion assessment and stent optimization and avoidance of complex stenting strategies. Finally, it is of paramount importance to have a multidisciplinary approach consisting of the treating cardiologist, medical and/or surgical oncologist, and palliative medicine, and involve the patient and their family in making informed decisions.

Cardiovascular Disease Risk in Survivors of Breast Cancer

PURPOSE OF REVIEW

Early detection and improved treatment in breast cancer have resulted in an increased number of survivors. Cardiovascular disease now remains an important cause for morbidity and mortality in this population. There is a growing gap in the knowledge about the optimal long-term cardiovascular management of this population.

FINDINGS

Breast cancer and cardiovascular disease share a number of common risk factors. Different breast cancer treatment modalities, including anthracyclines, radiation, and hormonal therapy, can act in synergy with preexisting and/or new cardiovascular risk factors to result in significant cardiovascular disease. We summarize the recent evidence about cardiovascular effects of breast cancer therapy and recommendations for their diagnosis and management during the cancer treatment continuum into survivorship. We also present current research initiatives and how they inform clinical care.

Percutaneous Coronary Intervention and Outcomes in Patients With Lymphoma in the United States (Nationwide Inpatient Sample [NIS] Analysis)

Characteristics and outcomes of patients with lymphoma undergoing percutaneous coronary intervention (PCI) are unknown. Therefore, we analyzed clinical characteristics and outcomes in patients that underwent PCI and had a concomitant diagnosis of Hodgkin's (HL) or non-Hodgkin's (NHL) lymphoma. We analyzed patients with and without lymphoma diagnosis from the Nationwide Inpatient Sample in the United States who underwent PCI procedure during 2004 to 2014. Multivariable regression analysis was performed to examine the association between lymphoma diagnosis and clinical outcomes post-PCI including short-term complications and in-hospital mortality. A total of 7,119,539 PCI procedures were included in the analysis and 18,052 patients had a diagnosis of lymphoma (0.25%). These patients were likely to experience in-hospital mortality (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.25 to 1.54), stroke or transient ischemic attack (OR 1.75, 95% CI 1.61 to 1.90), and any in-hospital complication (OR 1.31, 95% CI 1.25 to 1.37), following PCI. In the lymphoma subtype-analysis, diagnosis of HL was associated with an increased odds of in-hospital death (OR 1.40, 95% CI 1.24 to 1.56), any in-hospital complication (OR 1.31, 95% CI 1.25 to 1.38), bleeding complications (OR 1.12 95% CI 1.05 to 1.20), and vascular complications (OR 1.13 95% CI 1.06 to 1.20) whereas these odds were not significantly associated with non-Hodgkin's diagnosis. Finally, both types of lymphoma were associated with increased odds of stroke/transient ischemic attack following PCI (OR 1.82, 95% CI 1.67 to 1.99 and OR 1.31, 95% CI 1.05 to 1.63, respectively). In conclusion, while the prevalence of lymphoma in the observed PCI cohort was low, a diagnosis of lymphoma was associated with an adverse prognosis following PCI, primarily in patients with the HL diagnosis.

Heart Failure in Relation to Tumor-Targeted Therapies and Immunotherapies

Tumor-targeted therapies such as trastuzumab have led to significant improvements in survival of human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, these therapies have also been associated with significant left ventricular dysfunction. The incidence of trastuzumab-induced heart failure has decreased significantly since the initial reports, in large part due to improved screening, closer monitoring for early changes in left ventricular function, and a significant decrease in the concurrent administration of anthracyclines. The mechanism of trastuzumab cardiotoxicity is still not well understood, but current knowledge suggests that ErbB2 inhibition in cardiac myocytes plays a key role. In addition to trastuzumab and other HER2-targeted agents, vascular endothelial growth factor inhibitors, proteasome inhibitors, and immune checkpoint inhibitors are all additional classes of drugs used with great success in the treatment of solid tumors and hematologic malignancies. Yet these, too, have been associated with cardiac toxicity that ranges from a mild asymptomatic decrease in ejection fraction to fulminant myocarditis. In this review, we summarize the cardiotoxic effects of tumor-targeted and immunotherapies with a focus on HER2 antagonists.

Hypertension in the Cardio-Oncology Clinic

As cancer therapies improve, the population of survivors of cancer has increased, and the long-term effects of cancer treatments have become more apparent. Cardiotoxicity is a well-established adverse effect of many antineoplastic agents. Hypertension is common in survivors of cancer, can be caused or worsened by certain agents, and has been shown to increase the risk of other cardiovascular diseases including heart failure. Pretreatment risk assessment and careful monitoring of blood pressure during therapy is essential. Aggressive management of preexisting or incident hypertension in survivors of cancer is paramount to decrease the risk of heart failure and other cardiovascular diseases in these patients.

Cardiotoxicity after cancer treatment: a process map of the patient treatment journey

BACKGROUND/AIM

Cardiotoxicity is a potential complication of anticancer therapy. While guidelines have been developed to assist practitioners, an effective, evidence based clinical pathway for the treatment of cardiotoxicity has not yet been developed. The aim of this study was to describe the journey of patients who developed cardiotoxicity through the healthcare system in order to establish baseline data to inform the development and implementation of a patient-centred, evidence-based clinical pathway.

METHODS

Mixed-methods design with quantitative and qualitative components using process mapping at 3 large medical centres in 2 states between 2010 and 2015.

RESULTS

Fifty (50) confirmed cases of cardiotoxicity were reviewed (39 medical record reviews, 7 medical record review and interviews and 4 internview only). The mean age at cancer diagnosis of this group was 53.3 years (range 6-89 years); 50% female; 30% breast cancer, 23% non-Hodgkin's lymphoma; mean chemotherapy cycles 5.2 (median 6; range 1-18); 49 (89%) presented to chemotherapy with pre-existing cardiovascular risk factors; 39 (85%) had at least one modifiable risk factor and 11 (24%) had more than 4; 44 (96%) were diagnosed by echocardiogram and 27 (57%) were referred to a cardiologist (only 7 (15%) before chemotherapy). Post chemotherapy, 22 (48%) patients were referred to a multidisciplinary heart failure clinic; 8 (17%) to cardiac rehabilitation; 1 (2%) to cancer survivorship clinic and 10 (22%) to a palliative care service. There were 16 (34%) deaths during the timeframe of the study; 4 (25%) cardiac-related, 6 (38%) cancer-related, 4 (25%) due to sepsis and 2 (12%) other causes not recorded. The main concerns participants raised during the interviews were cancer professionals not discussing the potential for cardiotoxicity with them prior to treatment, nor risk modification strategies; a need for health education, particularly regarding risks for developing heart failure related to cancer treatment; and a lack of collaboration between oncologists and cardiologists.

CONCLUSIONS

Our results demonstrate that the clinical management of cancer patients with cardiotoxicity was variable and fragmented and not patient centered. This audit establishes practice gaps that can be addressed through the design of an evidence-based clinical pathway for cancer patients with, or at risk, of cardiotoxicity.

Clonal Hematopoiesis: Crossroads of Aging, Cardiovascular Disease, and Cancer: JACC Review Topic of the Week

A novel, common, and potent cardiovascular risk factor has recently emerged: clonal hematopoiesis of indeterminate potential (CHIP). CHIP arises from somatic mutations in hematopoietic stem cells that yield clonal progeny of mutant leukocytes in blood. Individuals with CHIP have a doubled risk of coronary heart disease and ischemic stroke, and worsened heart failure outcomes independent of traditional cardiovascular risk factors. The recognition of CHIP as a nontraditional risk factor challenges specialists in hematology/oncology and cardiovascular medicine alike. Should we screen for CHIP? If so, in whom? How should we assess cardiovascular risk in people with CHIP? How should we manage the excess cardiovascular risk in the absence of an evidence base? This review explains CHIP, explores the clinical quandaries, strives to provide reasonable recommendations for the multidisciplinary management of cardiovascular risk in individuals with CHIP, and highlights current knowledge gaps.