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Diba P, Sattler AL, Korzun T, Habecker BA, Marks DL. Unraveling the lost balance: Adrenergic dysfunction in cancer cachexia. Auton Neurosci 2024; 251:103136. [PMID: 38071925 PMCID: PMC10883135 DOI: 10.1016/j.autneu.2023.103136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 01/23/2024]
Abstract
Cancer cachexia, characterized by muscle wasting and widespread inflammation, poses a significant challenge for patients with cancer, profoundly impacting both their quality of life and treatment management. However, existing treatment modalities remain very limited, accentuating the necessity for innovative therapeutic interventions. Many recent studies demonstrated that changes in autonomic balance is a key driver of cancer cachexia. This review consolidates research findings from investigations into autonomic dysfunction across cancer cachexia, spanning animal models and patient cohorts. Moreover, we explore therapeutic strategies involving adrenergic receptor modulation through receptor blockers and agonists. Mechanisms underlying adrenergic hyperactivity in cardiac and adipose tissues, influencing tissue remodeling, are also examined. Looking ahead, we present a perspective for future research that delves into autonomic dysregulation in cancer cachexia. This comprehensive review highlights the urgency of advancing research to unveil innovative avenues for combatting cancer cachexia and improving patient well-being.
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Affiliation(s)
- Parham Diba
- Medical Scientist Training Program, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Papé Family Pediatric Research Institute, Oregon Health & Science University, SW Sam Jackson Park Rd, Mail Code L481 Portland, OR 97239, USA
| | - Ariana L Sattler
- Papé Family Pediatric Research Institute, Oregon Health & Science University, SW Sam Jackson Park Rd, Mail Code L481 Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, 2720 S Moody Avenue, Portland, OR 97201, USA; Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, 2730 S Moody Avenue, Portland, OR 97201, USA
| | - Tetiana Korzun
- Medical Scientist Training Program, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Papé Family Pediatric Research Institute, Oregon Health & Science University, SW Sam Jackson Park Rd, Mail Code L481 Portland, OR 97239, USA
| | - Beth A Habecker
- Department of Chemical Physiology and Biochemistry, Oregon Health and Science University, Portland, OR 97239, USA; Department of Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR 97239, USA
| | - Daniel L Marks
- Papé Family Pediatric Research Institute, Oregon Health & Science University, SW Sam Jackson Park Rd, Mail Code L481 Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, 2720 S Moody Avenue, Portland, OR 97201, USA; Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, 2730 S Moody Avenue, Portland, OR 97201, USA.
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2
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Al Younis SM, Hadjileontiadis LJ, Stefanini C, Khandoker AH. Non-invasive technologies for heart failure, systolic and diastolic dysfunction modeling: a scoping review. Front Bioeng Biotechnol 2023; 11:1261022. [PMID: 37920244 PMCID: PMC10619666 DOI: 10.3389/fbioe.2023.1261022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/09/2023] [Indexed: 11/04/2023] Open
Abstract
The growing global prevalence of heart failure (HF) necessitates innovative methods for early diagnosis and classification of myocardial dysfunction. In recent decades, non-invasive sensor-based technologies have significantly advanced cardiac care. These technologies ease research, aid in early detection, confirm hemodynamic parameters, and support clinical decision-making for assessing myocardial performance. This discussion explores validated enhancements, challenges, and future trends in heart failure and dysfunction modeling, all grounded in the use of non-invasive sensing technologies. This synthesis of methodologies addresses real-world complexities and predicts transformative shifts in cardiac assessment. A comprehensive search was performed across five databases, including PubMed, Web of Science, Scopus, IEEE Xplore, and Google Scholar, to find articles published between 2009 and March 2023. The aim was to identify research projects displaying excellence in quality assessment of their proposed methodologies, achieved through a comparative criteria-based rating approach. The intention was to pinpoint distinctive features that differentiate these projects from others with comparable objectives. The techniques identified for the diagnosis, classification, and characterization of heart failure, systolic and diastolic dysfunction encompass two primary categories. The first involves indirect interaction with the patient, such as ballistocardiogram (BCG), impedance cardiography (ICG), photoplethysmography (PPG), and electrocardiogram (ECG). These methods translate or convey the effects of myocardial activity. The second category comprises non-contact sensing setups like cardiac simulators based on imaging tools, where the manifestations of myocardial performance propagate through a medium. Contemporary non-invasive sensor-based methodologies are primarily tailored for home, remote, and continuous monitoring of myocardial performance. These techniques leverage machine learning approaches, proving encouraging outcomes. Evaluation of algorithms is centered on how clinical endpoints are selected, showing promising progress in assessing these approaches' efficacy.
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Affiliation(s)
- Sona M. Al Younis
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center (HEIC), Khalifa University, Abu Dhabi, United Arab Emirates
| | - Leontios J. Hadjileontiadis
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center (HEIC), Khalifa University, Abu Dhabi, United Arab Emirates
| | - Cesare Stefanini
- Creative Engineering Design Lab at the BioRobotics Institute, Applied Experimental Sciences Scuola Superiore Sant'Anna, Pontedera (Pisa), Italy
| | - Ahsan H. Khandoker
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center (HEIC), Khalifa University, Abu Dhabi, United Arab Emirates
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3
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Evertz R, Diehl C, Gödde K, Valentova M, Garfias-Veitl T, Overbeck TR, Braulke F, Lena A, Hadzibegovic S, Bleckmann A, Keller U, Landmesser U, König AO, Hasenfuss G, Schuster A, Anker MS, von Haehling S. Predictors of lower exercise capacity in patients with cancer. Sci Rep 2023; 13:14861. [PMID: 37684302 PMCID: PMC10491652 DOI: 10.1038/s41598-023-41390-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Maintaining cancer patients' exercise capacity and therefore patients' ability to live a self-determined life is of huge importance, but little is known about major determinants. We sought to identify determinants of exercise capacity in patients with a broad spectrum of cancer types, who were already receiving cancer treatment or about to commence such therapy. Exercise capacity was assessed in 253 consecutive patients mostly suffering from advanced cancer using the 6-min walk test (6-MWT). All patients underwent echocardiography, physical examination, resting electrocardiogram, hand grip strength (HGS) measurement, and laboratory assessments. Patients were divided into two groups according to the median distance in the 6-MWT (459 m). Patients with lower exercise capacity were older, had significantly lower HGS and haemoglobin and higher values of high sensitive (hs) Troponin T and NT-proBNP (all p < 0.05). Whilst the co-morbidity burden was significantly higher in this group, no differences were detected for sex, body mass index, tumor type, or cachexia (all p > 0.2). Using multivariable logistic regression, we found that the presence of anaemia (odds ratio (OR) 6.172, 95% confidence interval (CI) 1.401-27.201, p = 0.016) as well as an increase in hs Troponin T (OR 3.077, 95% CI 1.202-5.301, p = 0.019) remained independent predictors of impaired exercise capacity. Increasing HGS was associated with a reduced risk of a lower exercise capacity (OR 0.896, 95% CI 0.813-0.987, p = 0.026). Screening patients for elevated hs troponin levels as well as reduced HGS may help to identify patients at risk of lower exercise capacity during cancer treatment.
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Affiliation(s)
- Ruben Evertz
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Christine Diehl
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- Department of Paediatrics, University of Göttingen Medical Center (UMG), 37075, Göttingen, Germany
| | - Katharina Gödde
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Miroslava Valentova
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Tania Garfias-Veitl
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Tobias R Overbeck
- Department of Haematology and Medical Oncology, University of Göttingen Medical Center (UMG), 37075, Göttingen, Germany
- Comprehensive Cancer Center G-CCC, Medical Center (UMG), University of Göttingen, 37075, Göttingen, Germany
| | - Friederike Braulke
- Comprehensive Cancer Center G-CCC, Medical Center (UMG), University of Göttingen, 37075, Göttingen, Germany
| | - Alessia Lena
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin, Hindenburgdamm 30, 12203, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), 13353, Berlin, Germany
| | - Sara Hadzibegovic
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin, Hindenburgdamm 30, 12203, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), 13353, Berlin, Germany
| | - Annalen Bleckmann
- Department of Haematology and Medical Oncology, University of Göttingen Medical Center (UMG), 37075, Göttingen, Germany
- West German Cancer Center, University Hospital Münster, 48149, Münster, Germany
- Department of Medicine A for Hematology, Oncology and Pneumology, University Hospital Münster, 48149, Muenster, Germany
| | - Ulrich Keller
- Department of Hematology, Oncology and Cancer Immunology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, 12203, Berlin, Germany
- German Cancer Consortium (DKTK) & German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
- Max-Delbrück-Center for Molecular Medicine, 13125, Berlin, Germany
| | - Ulf Landmesser
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin, Hindenburgdamm 30, 12203, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), 13353, Berlin, Germany
| | - Alexander O König
- Department of Gastroenterology, University of Göttingen Medical Center (UMG), 37075, Göttingen, Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Andreas Schuster
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Markus S Anker
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin, Hindenburgdamm 30, 12203, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), 13353, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center (UMG), Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
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4
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Anker MS, von Haehling S, Landmesser U. Understanding Who Responds to M-TEER in Heart Failure With SMR: Malnutrition Does Not Preclude Benefit. J Am Coll Cardiol 2023; 82:139-141. [PMID: 37407112 DOI: 10.1016/j.jacc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Markus S Anker
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine CBF, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Ulf Landmesser
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine CBF, Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Berlin Institute of Health (BIH) at Charité Berlin, Universitätsmedizin Berlin, Germany
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5
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Mędrek S, Szmit S. Echocardiography-Assessed Changes of Left and Right Ventricular Cardiac Function May Correlate with Progression of Advanced Lung Cancer-A Generating Hypothesis Study. Cancers (Basel) 2022; 14:cancers14194770. [PMID: 36230693 PMCID: PMC9564083 DOI: 10.3390/cancers14194770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022] Open
Abstract
Advanced lung cancer causes damage to lung tissue and the alveolar−capillary barrier, leading to changes in pulmonary circulation and cardiac function. This observational study included 75 patients with inoperable lung cancer. Two echocardiographic assessments were performed: one before the initiation of systemic anticancer therapy and another after the first radiological evaluation of the efficacy of anticancer treatment. In retrospective analysis, diagnosis of early cancer progression was associated significantly (p < 0.05) with some echocardiographic changes: a decrease in EF of at least 5 percentage points (OR = 5.78), an increase in LV GLS of 3 percentage points (OR = 3.81), an increase in E/E′ ratio of at least 3.25 (OR = 3.39), as well as a decrease in RV free wall GLS of at least 4 percentage points (OR = 4.9) and an increase in FAC of at least 4.1 percentage points (OR = 4.9). Cancer therapeutics-related cardiac dysfunction was diagnosed in accordance with the definition of the International Cardio-Oncology Society and was found more frequently in patients with radiologically confirmed lung cancer disease progression (p = 0.003). In further prospective studies, the hypothesis about the possible coexistence of the cardiotoxic effect of cancer therapy and cardiac dysfunction related to the progression of inoperable lung cancer should be clarified.
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Affiliation(s)
- Sabina Mędrek
- Department of Cardiology, Subcarpathian Oncological Center, 36-200 Brzozów, Poland
| | - Sebastian Szmit
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, 05-400 Otwock, Poland
- Correspondence:
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6
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Mędrek S, Szmit S. Are cardiovascular comorbidities always associated with a worse prognosis in patients with lung cancer? Front Cardiovasc Med 2022; 9:984951. [PMID: 36211566 PMCID: PMC9537604 DOI: 10.3389/fcvm.2022.984951] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022] Open
Abstract
Many factors contribute to mortality in lung cancer, including the presence of concomitant cardiovascular disease. In the treatment of early stage of lung cancer, the presence of comorbidities and occurence of cardiotoxicity may be prognostic. The effect of cardiotoxicity of radiotherapy and chemoradiotherapy on overall survival has been documented. Acute arterial and venous thromboembolic events seem to correlate with the degree of the histological malignancy, its clinical advancement, and even with optimal cardiac treatment, they may influence the survival time. In the case of high-grade and advanced lung cancer stage especially in an unresectable stadium, the prognosis depends primarily on the factors related to the histopathological and molecular diagnosis. Electrocardiographic and echocardiographic abnormalities may be prognostic factors, as they seem to correlate with the patient's performance status as well as tumor localization and size.
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Affiliation(s)
- Sabina Mędrek
- Department of Cardiology, Subcarpathian Oncological Center, Brzozów, Poland
- *Correspondence: Sabina Mędrek
| | - Sebastian Szmit
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
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7
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Cuomo A, Mercurio V, Varricchi G, Galdiero MR, Rossi FW, Carannante A, Arpino G, Formisano L, Bianco R, Carlomagno C, De Angelis C, Giuliano M, Matano E, Picardi M, Salvatore D, De Vita F, Martinelli E, Della Corte CM, Morgillo F, Orditura M, Napolitano S, Troiani T, Tocchetti CG. Impact of a cardio-oncology unit on prevention of cardiovascular events in cancer patients. ESC Heart Fail 2022; 9:1666-1676. [PMID: 35362255 PMCID: PMC9065840 DOI: 10.1002/ehf2.13879] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 12/29/2022] Open
Abstract
Aims As the world population grows older, the co‐existence of cancer and cardiovascular comorbidities becomes more common, complicating management of these patients. Here, we describe the impact of a large Cardio‐Oncology unit in Southern Italy, characterizing different types of patients and discussing challenges in therapeutic management of cardiovascular complications. Methods and results We enrolled 231 consecutive patients referred to our Cardio‐Oncology unit from January 2015 to February 2020. Three different types were identified, according to their chemotherapeutic statuses at first visit. Type 1 included patients naïve for oncological treatments, Type 2 patients already being treated with oncological treatments, and Type 3 patients who had already completed cancer treatments. Type 2 patients presented the highest incidence of cardiovascular events (46.2% vs. 12.3% in Type 1 and 17.9% in Type 3) and withdrawals from oncological treatments (5.1% vs. none in Type 1) during the observation period. Type 2 patients presented significantly worse 48 month‐survival (32.1% vs. 16.7% in Type 1 and 17.9% in Type 3), and this was more evident when in the three groups we focused on patients with uncontrolled cardiovascular risk factors or overt cardiovascular disease at the first cardiologic assessment. Nevertheless, these patients showed the greatest benefit from our cardiovascular assessments, as witnessed by a small, but significant improvement in ejection fraction during follow‐up (Type 2b: from 50 [20; 67] to 55 [35; 65]; P = 0.04). Conclusions Patients who start oncological protocols without an accurate baseline cardiovascular evaluation are at major risk of developing cardiac complications due to antineoplastic treatments.
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Affiliation(s)
- Alessandra Cuomo
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valentina Mercurio
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Gilda Varricchi
- Internal Medicine and Clinical Immunology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Maria Rosaria Galdiero
- Internal Medicine and Clinical Immunology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Francesca Wanda Rossi
- Internal Medicine and Clinical Immunology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy
| | - Antonio Carannante
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Grazia Arpino
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Luigi Formisano
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Roberto Bianco
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Chiara Carlomagno
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Carmine De Angelis
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Mario Giuliano
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Elide Matano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marco Picardi
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Ferdinando De Vita
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Erika Martinelli
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | | | - Floriana Morgillo
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Michele Orditura
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Stefania Napolitano
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Teresa Troiani
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Carlo G Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy.,Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy.,WAO Center of Excellence, Naples, Italy.,Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
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8
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Vasileiou PVS, Siasos G, Gorgoulis VG. Molecular biomarkers in cardio-oncology: Where we stand and where we are heading. Bioessays 2022; 44:e2100234. [PMID: 35352831 DOI: 10.1002/bies.202100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/01/2022] [Accepted: 03/15/2022] [Indexed: 11/08/2022]
Abstract
Until recently, cardiotoxicity in the setting of a malignant disease was attributed solely to the detrimental effects of chemo- and/or radio-therapy to the heart. On this account, the focus was on the evaluation of well-established cardiac biomarkers for the early detection of myocardial damage. Currently, this view has been revised. Cardiotoxicity is not restricted to a single organ but instead affects the endothelium as a whole. Indeed, it has come into light that not only cancer therapy but also malignant cells per se can impair the cardiovascular system, through a paracrine and endocrine mode of action. Even more intriguingly, a clear interplay between molecular pathways involved in cancer and cardiovascular disease has become prevalent, suggesting a common nominator that governs the pathophysiology of these two entities. Taken together, our strategy in the quest of novel biomarkers in the emerging field of cardio-oncology should be critically reshaped.
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Affiliation(s)
- Panagiotis V S Vasileiou
- Molecular Carcinogenesis Group, Department of Histology and Embryology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vassilis G Gorgoulis
- Molecular Carcinogenesis Group, Department of Histology and Embryology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Faculty Institute for Cancer Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.,Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Center for New Biotechnologies and Precision Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK
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9
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Anker MS, Sanz AP, Zamorano JL, Mehra MR, Butler J, Riess H, Coats AJS, Anker SD. Advanced cancer is also a heart failure syndrome: a hypothesis. Eur J Heart Fail 2021; 23:140-144. [PMID: 33247608 DOI: 10.1002/ejhf.2071] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/11/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022] Open
Abstract
We present the hypothesis that advanced stage cancer is also a heart failure syndrome. It can develop independently of or in addition to cardiotoxic effects of anti-cancer therapies. This includes an increased risk of ventricular arrhythmias. We suggest the pathophysiologic link for these developments includes generalized muscle wasting (i.e. sarcopenia) due to tissue homeostasis changes leading to cardiac wasting associated cardiomyopathy. Cardiac wasting with thinning of the ventricular wall increases ventricular wall stress, even in the absence of ventricular dilatation. In addition, arrhythmias may be facilitated by cellular wasting processes affecting structure and function of electrical cells and conduction pathways. We submit that in some patients with advanced cancer (but not terminal cancer), heart failure therapy or defibrillators may be relevant treatment options. The key points in selecting patients for such therapies may be the predicted life expectancy, quality of life at intervention time, symptomatic burden, and consequences for further anti-cancer therapies. The cause of death in advanced cancer is difficult to ascertain and consensus on event definitions in cancer is not established yet. Clinical investigations on this are called for. Broader ethical considerations must be taken into account when aiming to target cardiovascular problems in cancer patients. We suggest that focused attention to evaluating cardiac wasting and arrhythmias in cancer will herald a further evolution in the rapidly expanding field of cardio-oncology.
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Affiliation(s)
- Markus S Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Charité-Universitätsmedizin Berlin (Campus CVK), Berlin, Germany.,Department of Cardiology, Charité Universitätsmedizin Berlin (Campus CBF), Berlin, Germany
| | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Javed Butler
- Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Hanno Riess
- Department for Hematology, Oncology and Tumor Immunology (Campus CCM), Charite, University Medicine, Berlin, Germany
| | | | - Stefan D Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Charité-Universitätsmedizin Berlin (Campus CVK), Berlin, Germany
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10
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Anker MS, von Haehling S, Coats AJS, Riess H, Eucker J, Porthun J, Butler J, Karakas M, Haverkamp W, Landmesser U, Anker SD. Ventricular tachycardia, premature ventricular contractions, and mortality in unselected patients with lung, colon, or pancreatic cancer: a prospective study. Eur J Heart Fail 2021; 23:145-153. [PMID: 33222388 DOI: 10.1002/ejhf.2059] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/11/2020] [Accepted: 11/15/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS Many cancer patients die due to cardiovascular disease and sudden death, but data on ventricular arrhythmia prevalence and prognostic importance are not known. METHODS AND RESULTS Between 2005 and 2010, we prospectively enrolled 120 unselected patients with lung, colon, or pancreatic cancer due to one of three diagnoses: colorectal (n = 33), pancreatic (n = 54), or non-small cell lung cancer (n = 33). All were free of manifest cardiovascular disease. They were compared to 43 healthy controls similar in age and sex distribution. Each participant underwent 24 h electrocardiogram recording and cancer patients were followed for up to 12.5 years for survival (median 21 months). Ninety-six cancer patients (80%) died during follow-up [5-year survival: 27% (95% confidence interval 19-35%)]. Non-sustained ventricular tachycardia (NSVT) was more frequent in cancer patients vs. controls (8% vs. 0%, P = 0.021). The number of premature ventricular contractions (PVCs) over 24 h was not increased in cancer patients vs. controls (median 4 vs. 9, P = 0.2). In multivariable analysis, NSVT [hazard ratio (HR) 2.44, P = 0.047] and PVCs (per 100, HR 1.021, P = 0.047) were both significant predictors of mortality, independent of other univariable mortality predictors including tumour stage, cancer type, potassium concentration, prior surgery, prior cardiotoxic chemotherapy, and haemoglobin. In patients with colorectal and pancreatic cancer, ≥50 PVCs/24 h predicted mortality (HR 2.30, P = 0.0024), and was identified in 18% and 26% of patients, respectively. CONCLUSIONS Non-sustained ventricular tachycardia is more frequent in unselected patients with colorectal, pancreatic, and non-small cell lung cancer and together with PVCs predict long-term mortality. This raises the prospect of cardiovascular mortality being a target for future treatment interventions in selected cancers.
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Affiliation(s)
- Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité University Medicine Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin, Germany.,Department of Cardiology (CBF), Charité University Medicine Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Göttingen, Germany
| | | | - Hanno Riess
- Department of Hematology and Oncology, Charité - Campus Virchow-Klinikum (CVK), Berlin, Germany
| | - Jan Eucker
- Department of Hematology and Oncology, Benjamin Franklin Campus, Charité University of Medicine Berlin, Berlin, Germany
| | - Jan Porthun
- Norwegian University of Science and Technology, Campus Gjøvik (NTNU-Gjøvik), Norway
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackons, MS, USA
| | - Mahir Karakas
- Clinic for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,Partner Site Hamburg/Kiel/Lübeck, German Center for Cardiovascular Research, Hamburg, Germany
| | - Wilhelm Haverkamp
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité University Medicine Berlin, Berlin, Germany
| | - Ulf Landmesser
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin, Germany.,Department of Cardiology (CBF), Charité University Medicine Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité University Medicine Berlin, Berlin, Germany
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11
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Skipina TM, Upadhya B, Soliman EZ. Secondhand Smoke Exposure is Associated with Prevalent Heart Failure: Longitudinal Examination of the National Health and Nutrition Examination Survey. Nicotine Tob Res 2021; 23:1512-1517. [PMID: 34213549 DOI: 10.1093/ntr/ntab047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 03/16/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Serum cotinine is a sensitive and specific biomarker for tobacco exposure including second-hand smoke exposure (SHS). We sought to examine whether SHS is associated with heart failure (HF) among non-hospitalized adults. METHODS This analysis included 11 219 non-smokers (age 48.4 ± 20.5 years, 55.9% women, 70.5% whites) from the United States Third National Health and Nutrition Examination (NHANES) years 1988-1994. SHS was defined as serum cotinine ≥1 ng/mL. To assess dose-response, cut-points of serum cotinine ≥3 ng/mL and ≥6 ng/mL were used. Multivariable logistic regression was used to examine the association between SHS and HF. The consistency of this association was tested among subgroups stratified by race, gender, and comorbidities. NHANES years 2003-2006 were examined for longitudinal comparison. RESULTS 18.9% (n = 2125) of participants had SHS exposure while 3.7% (n = 416) had HF. After adjusting for covariates, SHS was associated with a 35% increased odds of HF with a dose-response relationship between levels of serum cotinine and HF. This association was stronger in males than females (interaction p-value = 0.03) and those with a history of CVD versus those without (interaction p-value < 0.001). This association persisted in the NHANES 2003-2006 analysis. CONCLUSION There is a dose-response relationship between SHS and HF with possible effect modification by gender and prior CVD. This is a novel finding that underscores the harmful effects of passive smoking on the cardiovascular system and highlights the needs for further prohibition of smoking in public areas and a personalized risk assessment among high-risk groups, especially in regions with less-stringent public health policies. IMPLICATIONS This study showed a novel association between secondhand smoke exposure and prevalent heart failure among non-smokers, adding to the list of harmful cardiovascular manifestations of secondhand smoke exposure. This was more apparent in men and those with a prior history of cardiovascular disease. Heart failure is a debilitating disease process, so this finding has important policy implications in low-income countries and poor communities with less-stringent health policies because they are known to have the highest levels of exposure. Smoke-free policies targeting these regions would thus yield substantial public health benefits.
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Affiliation(s)
- T M Skipina
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - B Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - E Z Soliman
- Institute of Global Health and Human Ecology, School of Sciences and Engineering, American University in Cairo, New Cairo, Egypt
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12
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Anker MS, Sanz AP, Zamorano JL, Mehra MR, Butler J, Riess H, Coats AJS, Anker SD. Advanced cancer is also a heart failure syndrome: a hypothesis. J Cachexia Sarcopenia Muscle 2021; 12:533-537. [PMID: 33734609 PMCID: PMC8200419 DOI: 10.1002/jcsm.12694] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We present the hypothesis that advanced stage cancer is also a heart failure syndrome. It can develop independently of or in addition to cardiotoxic effects of anti-cancer therapies. This includes an increased risk of ventricular arrhythmias. We suggest the pathophysiologic link for these developments includes generalized muscle wasting (i.e. sarcopenia) due to tissue homeostasis changes leading to cardiac wasting associated cardiomyopathy. Cardiac wasting with thinning of the ventricular wall increases ventricular wall stress, even in the absence of ventricular dilatation. In addition, arrhythmias may be facilitated by cellular wasting processes affecting structure and function of electrical cells and conduction pathways. We submit that in some patients with advanced cancer (but not terminal cancer), heart failure therapy or defibrillators may be relevant treatment options. The key points in selecting patients for such therapies may be the predicted life expectancy, quality of life at intervention time, symptomatic burden, and consequences for further anti-cancer therapies. The cause of death in advanced cancer is difficult to ascertain and consensus on event definitions in cancer is not established yet. Clinical investigations on this are called for. Broader ethical considerations must be taken into account when aiming to target cardiovascular problems in cancer patients. We suggest that focused attention to evaluating cardiac wasting and arrhythmias in cancer will herald a further evolution in the rapidly expanding field of cardio-oncology.
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Affiliation(s)
- Markus S Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Charité-Universitätsmedizin Berlin (Campus CVK), Berlin, Germany.,Department of Cardiology, Charité Universitätsmedizin Berlin (Campus CBF), Berlin, Germany
| | | | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Javed Butler
- Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Hanno Riess
- Department for Hematology, Oncology and Tumor Immunology (Campus CCM), Charite, University Medicine, Berlin, Germany
| | | | - Stefan D Anker
- Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Charité-Universitätsmedizin Berlin (Campus CVK), Berlin, Germany
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13
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Cancer Therapy-Related Cardiovascular Complications in Clinical Practice: Current Perspectives. J Clin Med 2021; 10:jcm10081647. [PMID: 33924543 PMCID: PMC8069381 DOI: 10.3390/jcm10081647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular (CV) diseases and cancer are the leading causes of death in Europe and the United States. Both diseases have extensive overlap and share common risk factors, symptoms, and outcomes. As the number of patients with both cancer and CV diseases continues to rise, the field of cardio-oncology is gaining increased attention. A frequent problem during anti-cancer treatment is cardiotoxicity caused by the side-effects of chemo-, immuno-, targeted, and radiation therapies. This problem may manifest as acute coronary syndrome, myocarditis, arrhythmias, or heart failure. Modern cardio-oncology spans many different research areas. While some researchers focus on treating patients that have already developed cardiotoxicity, others aim to identify new methods for preventing cardiotoxicity before, during, and after anti-cancer therapy. Both groups share the common understanding that regular monitoring of cancer patients is the basis for optimal medical treatment. Optimal treatment can only be achieved through close cooperation between cardiologists and oncologists. This review summarizes the current views on cardio-oncology and discusses the cardiotoxicities associated with commonly used chemotherapeutics.
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14
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Rhoden A, Friedrich FW, Brandt T, Raabe J, Schweizer M, Meisterknecht J, Wittig I, Ulmer BM, Klampe B, Uebeler J, Piasecki A, Lorenz K, Eschenhagen T, Hansen A, Cuello F. Sulforaphane exposure impairs contractility and mitochondrial function in three-dimensional engineered heart tissue. Redox Biol 2021; 41:101951. [PMID: 33831709 PMCID: PMC8056268 DOI: 10.1016/j.redox.2021.101951] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 12/18/2022] Open
Abstract
Sulforaphane (SFN) is a phytochemical compound extracted from cruciferous plants, like broccoli or cauliflower. Its isothiocyanate group renders SFN reactive, thus allowing post-translational modification of cellular proteins to regulate their function with the potential for biological and therapeutic actions. SFN and stabilized variants recently received regulatory approval for clinical studies in humans for the treatment of neurological disorders and cancer. Potential unwanted side effects of SFN on heart function have not been investigated yet. The present study characterizes the impact of SFN on cardiomyocyte contractile function in cardiac preparations from neonatal rat, adult mouse and human induced-pluripotent stem cell-derived cardiomyocytes. This revealed a SFN-mediated negative inotropic effect, when administered either acutely or chronically, with an impairment of the Frank-Starling response to stretch activation. A direct effect of SFN on myofilament function was excluded in chemically permeabilized mouse trabeculae. However, SFN pretreatment increased lactate formation and enhanced the mitochondrial production of reactive oxygen species accompanied by a significant reduction in the mitochondrial membrane potential. Transmission electron microscopy revealed disturbed sarcomeric organization and inflated mitochondria with whorled membrane shape in response to SFN exposure. Interestingly, administration of the alternative energy source l-glutamine to the medium that bypasses the uptake route of pyruvate into the mitochondrial tricarboxylic acid cycle improved force development in SFN-treated EHTs, suggesting indeed mitochondrial dysfunction as a contributor of SFN-mediated contractile dysfunction. Taken together, the data from the present study suggest that SFN might impact negatively on cardiac contractility in patients with cardiovascular co-morbidities undergoing SFN supplementation therapy. Therefore, cardiac function should be monitored regularly to avoid the onset of cardiotoxic side effects. Sulforaphane has negative inotropic effects and increases diastolic tension. Sulforaphane exposure increases lactate levels and mitochondrial ROS production and reduces mitochondrial membrane potential. l-glutamine supplementation rescues the sulforaphane-mediated reduction in force development. Sulforaphane plasma levels and cardiac function should be monitored to avoid unwanted cardiac side effects in patients.
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Affiliation(s)
- Alexandra Rhoden
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Felix W Friedrich
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Theresa Brandt
- Institute of Experimental Pharmacology and Toxicology, University of Würzburg, Versbacher Str., 9 97078, Würzburg, Germany
| | - Janice Raabe
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Michaela Schweizer
- Department of Morphology and Electron Microscopy, Center for Molecular Neurobiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jana Meisterknecht
- Functional Proteomics, Faculty of Medicine, Goethe University Frankfurt, 60590, Frankfurt, Germany
| | - Ilka Wittig
- Functional Proteomics, Faculty of Medicine, Goethe University Frankfurt, 60590, Frankfurt, Germany
| | - Bärbel M Ulmer
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Birgit Klampe
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - June Uebeler
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Angelika Piasecki
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Kristina Lorenz
- Institute of Experimental Pharmacology and Toxicology, University of Würzburg, Versbacher Str., 9 97078, Würzburg, Germany; Leibniz-Institut für Analytische Wissenschaften - ISAS e.V., Bunsen-Kirchhoff-Str. 11, 44139, Dortmund, Germany
| | - Thomas Eschenhagen
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Arne Hansen
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Friederike Cuello
- Institute of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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15
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Tomasoni D, Adamo M, Metra M. December 2020 at a glance: focus on COVID-19, comorbidities and palliative care. Eur J Heart Fail 2021; 22:2173-2174. [PMID: 33556231 PMCID: PMC8013496 DOI: 10.1002/ejhf.1527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/25/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiac Catheterization Laboratory and Cardiology, Cardio-thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiac Catheterization Laboratory and Cardiology, Cardio-thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiac Catheterization Laboratory and Cardiology, Cardio-thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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16
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Ausoni S, Calamelli S, Saccà S, Azzarello G. How progressive cancer endangers the heart: an intriguing and underestimated problem. Cancer Metastasis Rev 2021; 39:535-552. [PMID: 32152913 DOI: 10.1007/s10555-020-09869-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Since it came into being as a discipline, cardio-oncology has focused on the prevention and treatment of cardiotoxicity induced by antitumor chemotherapy and radiotherapy. Over time, it has been proved that even more detrimental is the direct effect generated by cancer cells that release pro-cachectic factors in the bloodstream. Secreted molecules target different organs at a distance, including the heart. Inflammatory and neuronal modulators released by the tumor bulk, either as free molecules or through exosomes, contribute to the pathogenesis of cardiac disease. Progressive cancer causes cachexia and severe cardiac muscle wasting accompanied by cardiomyocyte atrophy, tissue fibrosis, and several functional impairments up to heart failure. The molecular mechanisms responsible for such a cardiac muscle wasting have been partially elucidated in animal models, but minimally investigated in humans, although severe cardiac dysfunction exacerbates global cachexia and hampers efficient anti-cancer treatments. This review provides an overview of cancer-induced structural cardiac and functional damage, drawing on both clinical and scientific research. We start by looking at the pathophysiological mechanisms and evolving epidemiology and go on to discuss prevention, diagnosis, and a multimodal policy of intervention aimed at providing overall prognosis and global care for patients. Despite much interest in the cardiotoxicity of cancer therapies, the direct tumor effect on the heart remains poorly explored. There is still a lack of diagnostic criteria for the identification of the early stages of cardiac disease in cancer patients, while the possibilities that there are for effective prevention are largely underestimated. Research on innovative therapies has claimed considerable advances in preclinical studies, but none of the molecular targets suitable for clinical application has been approved for therapy. These issues are critically discussed here.
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Affiliation(s)
- Simonetta Ausoni
- Department of Biomedical Sciences, University of Padua, Padova, Italy.
| | - Sara Calamelli
- Department of Cardiology, Local Health Unit 3 Serenissima, Mirano Hospital, Mirano, Venice, Italy
| | - Salvatore Saccà
- Department of Cardiology, Local Health Unit 3 Serenissima, Mirano Hospital, Mirano, Venice, Italy
| | - Giuseppe Azzarello
- Department of Medical Oncology, Local Health Unit 3 Serenissima, Mirano Hospital, Mirano, Venice, Italy.
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17
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Cuomo A, Pirozzi F, Attanasio U, Franco R, Elia F, De Rosa E, Russo M, Ghigo A, Ameri P, Tocchetti CG, Mercurio V. Cancer Risk in the Heart Failure Population: Epidemiology, Mechanisms, and Clinical Implications. Curr Oncol Rep 2020; 23:7. [PMID: 33263821 PMCID: PMC7716920 DOI: 10.1007/s11912-020-00990-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Along with population aging, the incidence of both heart failure (HF) and cancer is increasing. However, little is known about new-onset cancer in HF patients. This review aims at showing recent discoveries concerning this subset of patients. RECENT FINDINGS Not only cancer and HF share similar risk factors but also HF itself can stimulate cancer development. Some cytokines produced by the failing heart induce mild inflammation promoting carcinogenesis, as it has been recently suggested by an experimental model of HF in mice. The incidence of new-onset cancer is higher in HF patients compared to the general population, and it significantly worsens their prognosis. Moreover, the management of HF patients developing new-onset cancer is challenging, especially due to the limited therapeutic options for patients affected by both cancer and HF and the higher risk of cardiotoxicity from anticancer drugs.
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Affiliation(s)
- Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Umberto Attanasio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Riccardo Franco
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Francesco Elia
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Eliana De Rosa
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Michele Russo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Italian Cardiovascular Network, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
- Interdepartmental Center of Clinical and Translational Research, Federico II University, Naples, Italy.
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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18
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Tomasoni D, Adamo M, Anker MS, von Haehling S, Coats AJS, Metra M. Heart failure in the last year: progress and perspective. ESC Heart Fail 2020; 7:3505-3530. [PMID: 33277825 PMCID: PMC7754751 DOI: 10.1002/ehf2.13124] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM-HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA-HF and EMPEROR-Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65-0.85; P < 0.001 and HR 0.75; 95% CI 0.65-0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82-0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.
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Affiliation(s)
- Daniela Tomasoni
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
- Cardiology and Cardiac Catheterization Laboratory, Cardio‐thoracic DepartmentCivil HospitalsBresciaItaly
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
- Cardiology and Cardiac Catheterization Laboratory, Cardio‐thoracic DepartmentCivil HospitalsBresciaItaly
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK)Charité–University Medicine BerlinBerlinGermany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT)BerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- Department of Cardiology (CBF)Charité–University Medicine BerlinBerlinGermany
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Göttingen Medical CenterGöttingenGermany
- German Centre for Cardiovascular Research (DZHK), partner site GöttingenGöttingenGermany
| | - Andrew J. S. Coats
- Centre for Clinical and Basic Research, Department of Medical SciencesIRCCS San Raffaele PisanaRomeItaly
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
- Cardiology and Cardiac Catheterization Laboratory, Cardio‐thoracic DepartmentCivil HospitalsBresciaItaly
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19
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Yu YD, Xiu YP, Li YF, Xue YT. To Explore the Mechanism and Equivalent Molecular Group of Fuxin Mixture in Treating Heart Failure Based on Network Pharmacology. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2020; 2020:8852877. [PMID: 33273955 PMCID: PMC7700035 DOI: 10.1155/2020/8852877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/25/2020] [Accepted: 11/11/2020] [Indexed: 12/27/2022]
Abstract
Fuxin mixture (FXHJ) is a prescription for the treatment of heart failure. It has been shown to be effective in clinical trials, but its active ingredients and mechanism of action are not completely clear, which limits its clinical application and international promotion. In this study, we used network pharmacology to find, conclude, and summarize the mechanism of FXHJ in the treatment of heart failure. From FXHJ, we found 39 active ingredients and 47 action targets. Next, we constructed the action network and was conducted enrichment analysis. The results showed that FXHJ mainly treated heart failure by regulating the MAPK signaling pathway, PI3KAkt signaling pathway, cAMP signaling pathway, TNF signaling pathway, toll-like receptor signaling pathway, VEGF signaling pathway, NF-kappa B signaling pathway, and the apoptotic signaling molecule BCL2. Through the research method of network pharmacology, this study summarized the preliminary experiments of the research group and revealed the probable mechanism of FXHJ in the treatment of heart failure to a certain extent, which provided some ideas for the development of new drugs.
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Affiliation(s)
- Yi-ding Yu
- Shandong University of Traditional Chinese Medicine, Jinan 250014, China
| | - Yi-ping Xiu
- Shandong University of Traditional Chinese Medicine, Jinan 250014, China
| | - Yang-fan Li
- Shandong University of Traditional Chinese Medicine, Jinan 250014, China
| | - Yi-tao Xue
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250014, China
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20
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Ausoni S, Azzarello G. Development of Cancer in Patients With Heart Failure: How Systemic Inflammation Can Lay the Groundwork. Front Cardiovasc Med 2020; 7:598384. [PMID: 33195486 PMCID: PMC7649135 DOI: 10.3389/fcvm.2020.598384] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022] Open
Abstract
In the last decade, cardiologists and oncologists have provided clinical and experimental evidence that cancer, and not only chemotherapeutic agents, can cause detrimental effects on heart structure and function, a consequence that has serious clinical implications for patient management. In parallel, the intriguing idea that heart failure (HF) may be an oncogenic condition has also received growing attention. A number of epidemiological and clinical studies have reported that patients with HF have a higher risk of developing cancer. Chronic low-grade systemic inflammation has been proposed as a major pathophysiological process linking the failing heart to the multi-step process of carcinogenesis. According to this view, pro-inflammatory mediators secreted by the damaged heart generate a favorable milieu that promotes tumor development and accelerates malignant transformation. HF-associated inflammation synergizes with tumor-associated inflammation, so that over time it is no longer possible to distinguish the effects of one or the other. Experimental studies have just begun to search for the molecular effectors of this process, with the ultimate goal that of identifying mechanisms suitable for anti-cancer target therapy to reduce the risk of incident cancer in patients already affected by HF. In this review we critically discuss strengths and limitations of clinical and experimental studies that support a causal relationship between HF and cancer, and focus on HF-associated inflammation, cardiokines and their endocrine functions linking one and the other disease.
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Affiliation(s)
- Simonetta Ausoni
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Giuseppe Azzarello
- Local Health Unit 3 Serenissima, Department of Medical Oncology, Mirano Hospital, Venice, Italy
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21
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[Tumor effects on the heart and circulation]. Internist (Berl) 2020; 61:1120-1124. [PMID: 33052455 DOI: 10.1007/s00108-020-00887-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
As a result of the continuous development of modern cancer treatment, more cancer patients can be cured every year. However, since many patients experience cardiovascular problems before, during and after their cancer treatment, cardio-oncology is becoming increasingly important. Numerous therapies can cause cardiotoxicity, such as chemotherapy, immunotherapy, antibody therapy and radiotherapy. If these remain undetected, the patient may develop, e.g. heart failure or severe heart valve damage. The broad spectrum of cardiovascular comorbidities has become an immense challenge for cardiologists and oncologists. Cardio-oncology also deals with the effects that cancer has on the cardiovascular system. New research indicates that the tumor itself also has direct negative effects on the heart, mediated by messenger substances. Therefore, it is important to understand which cancer patients are at increased cardiovascular risk, thereby enabling the development of new therapeutic approaches in the long term to maintain mobility and improve patient prognosis.
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22
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Mercurio V, Cuomo A, Cadeddu Dessalvi C, Deidda M, Di Lisi D, Novo G, Manganaro R, Zito C, Santoro C, Ameri P, Spallarossa P, Arboscello E, Tocchetti CG, Penna C. Redox Imbalances in Ageing and Metabolic Alterations: Implications in Cancer and Cardiac Diseases. An Overview from the Working Group of Cardiotoxicity and Cardioprotection of the Italian Society of Cardiology (SIC). Antioxidants (Basel) 2020; 9:E641. [PMID: 32708201 PMCID: PMC7402085 DOI: 10.3390/antiox9070641] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022] Open
Abstract
Metabolic syndrome (MetS) is a well established risk factor for cardiovascular (CV) diseases. In addition, several studies indicate that MetS correlates with the increased risk of cancer in adults. The mechanisms linking MetS and cancer are not fully understood. Several risk factors involved in MetS are also cancer risk factors, such as the consumption of high calorie-food or high fat intake, low fibre intake, and sedentary lifestyle. Other common aspects of both cancer and MetS are oxidative stress and inflammation. In addition, some anticancer treatments can induce cardiotoxicity, including, for instance, left ventricular (LV) dysfunction and heart failure (HF), endothelial dysfunction and hypertension. In this review, we analyse several aspects of MetS, cancer and cardiotoxicity from anticancer drugs. In particular, we focus on oxidative stress in ageing, cancer and CV diseases, and we analyse the connections among CV risk factors, cancer and cardiotoxicity from anticancer drugs.
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Affiliation(s)
- Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy; (V.M.); (A.C.)
| | - Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy; (V.M.); (A.C.)
| | - Christian Cadeddu Dessalvi
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Cagliari, Italy; (C.C.D.); (M.D.)
| | - Martino Deidda
- Department of Medical Sciences and Public Health, University of Cagliari, 09042 Cagliari, Italy; (C.C.D.); (M.D.)
| | - Daniela Di Lisi
- Cardiology Unit AUOP Policlinico, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (D.D.L.); (G.N.)
| | - Giuseppina Novo
- Cardiology Unit AUOP Policlinico, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (D.D.L.); (G.N.)
| | - Roberta Manganaro
- Cardiology with Coronary Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital Policlinico “G. Martino”, University of Messina, 98124 Messina, Italy; (R.M.); (C.Z.)
| | - Concetta Zito
- Cardiology with Coronary Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital Policlinico “G. Martino”, University of Messina, 98124 Messina, Italy; (R.M.); (C.Z.)
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy;
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy—IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, 16121 Genova, Italy; (P.A.); (P.S.); (E.A.)
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy—IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, 16121 Genova, Italy; (P.A.); (P.S.); (E.A.)
| | - Eleonora Arboscello
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy—IRCCS Italian Cardiovascular Network & Department of Internal Medicine, University of Genova, 16121 Genova, Italy; (P.A.); (P.S.); (E.A.)
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy; (V.M.); (A.C.)
- Interdepartmental Center of Clinical and Translational Sciences, Federico II University, 80131 Naples, Italy
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Turin, 10043 Torino, Italy
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23
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Tocchetti CG, Ameri P, de Boer RA, D’Alessandra Y, Russo M, Sorriento D, Ciccarelli M, Kiss B, Bertrand L, Dawson D, Falcao-Pires I, Giacca M, Hamdani N, Linke WA, Mayr M, van der Velden J, Zacchigna S, Ghigo A, Hirsch E, Lyon AR, Görbe A, Ferdinandy P, Madonna R, Heymans S, Thum T. Cardiac dysfunction in cancer patients: beyond direct cardiomyocyte damage of anticancer drugs: novel cardio-oncology insights from the joint 2019 meeting of the ESC Working Groups of Myocardial Function and Cellular Biology of the Heart. Cardiovasc Res 2020; 116:1820-1834. [DOI: 10.1093/cvr/cvaa222] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/17/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022] Open
Abstract
Abstract
In western countries, cardiovascular (CV) disease and cancer are the leading causes of death in the ageing population. Recent epidemiological data suggest that cancer is more frequent in patients with prevalent or incident CV disease, in particular, heart failure (HF). Indeed, there is a tight link in terms of shared risk factors and mechanisms between HF and cancer. HF induced by anticancer therapies has been extensively studied, primarily focusing on the toxic effects that anti-tumour treatments exert on cardiomyocytes. In this Cardio-Oncology update, members of the ESC Working Groups of Myocardial Function and Cellular Biology of the Heart discuss novel evidence interconnecting cardiac dysfunction and cancer via pathways in which cardiomyocytes may be involved but are not central. In particular, the multiple roles of cardiac stromal cells (endothelial cells and fibroblasts) and inflammatory cells are highlighted. Also, the gut microbiota is depicted as a new player at the crossroads between HF and cancer. Finally, the role of non-coding RNAs in Cardio-Oncology is also addressed. All these insights are expected to fuel additional research efforts in the field of Cardio-Oncology.
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Affiliation(s)
- Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, via Pansini 5, 80131 Naples, Italy
- Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, AB31, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Yuri D’Alessandra
- Immunology and Functional Genomics Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Michele Russo
- Department of Translational Medical Sciences, Federico II University, via Pansini 5, 80131 Naples, Italy
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Daniela Sorriento
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Michele Ciccarelli
- Department of Medicine Surgery and Odontology, University of Salerno, Salerno, Italy
| | - Bernadett Kiss
- Department of Pharmacology and Pharmacotherapy, Cardiometabolic Research Group and MTA-SE System Pharmacology Research Group, Semmelweis University, Budapest, Hungary
| | - Luc Bertrand
- IREC Institute, Pole of Cardiovascular Research, Université Catholique de Louvain, Brussels, Belgium
| | - Dana Dawson
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Ines Falcao-Pires
- Unidade de Investigação e Desenvolvimento Cardiovascular, Departamento de Cirurgia e Fisiologia, Faculdade de Medicina, Universidade do Porto, Portugal
| | - Mauro Giacca
- Department of Medicine, Surgery and Health Sciences and Cardiovascular Department, Centre for Translational Cardiology, Azienda Sanitaria Universitaria Integrata Trieste, Trieste, Italy
- International Center for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- King’s British Heart Foundation Centre, King’s College London, London, UK
| | - Nazha Hamdani
- Department of Molecular and Experimental Cardiology, Ruhr Universität Bochum, Bochum, Germany
- Department of Cardiology, St. Joseph Hospital, Ruhr University Bochum, Witten, Germany
| | | | - Manuel Mayr
- King’s British Heart Foundation Centre, King’s College London, London, UK
| | - Jolanda van der Velden
- Department of Physiology, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Serena Zacchigna
- Department of Medicine, Surgery and Health Sciences and Cardiovascular Department, Centre for Translational Cardiology, Azienda Sanitaria Universitaria Integrata Trieste, Trieste, Italy
- International Center for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Emilio Hirsch
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, Imperial College London, London, UK
| | - Anikó Görbe
- Department of Pharmacology and Pharmacotherapy, Cardiometabolic Research Group and MTA-SE System Pharmacology Research Group, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Cardiometabolic Research Group and MTA-SE System Pharmacology Research Group, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Rosalinda Madonna
- Institute of Cardiology, University of Pisa, Pisa, Italy
- Center for Cardiovascular Biology and Atherosclerosis Research, McGovern School of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephane Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Thum
- Institute for Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
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24
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Duraes AR, Filho CRH, de Souza Lima Bitar Y, Neto MG. Heart Failure and Comorbidities—Part 1. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00210-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Rosano GMC, Seferović PM. Physiological monitoring in the complex multi-morbid heart failure patient - Introduction. Eur Heart J Suppl 2020; 21:M1-M4. [PMID: 31908606 PMCID: PMC6937512 DOI: 10.1093/eurheartj/suz229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Repeated physiological monitoring of comorbidities in heart failure (HF) is pivotal. This document introduces the main challenges related to physiological monitoring in the complex multimorbid HF patient, arising during an ESC consensus meeting on this topic.
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Affiliation(s)
- Giuseppe M C Rosano
- Department of Medical Sciences, IRCCS San Raffaele IRCCS San Raffaele Pisana, via della Pisana, 235, 00163 Roma, Italy
| | - Petar M Seferović
- Faculty of Medicine, Belgrade University, Studentski trg 1, 11000 Belgrade, Serbia
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26
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Anker MS, Hadzibegovic S, Lena A, Belenkov Y, Bergler‐Klein J, de Boer RA, Farmakis D, von Haehling S, Iakobishvili Z, Maack C, Pudil R, Skouri H, Cohen‐Solal A, Tocchetti CG, Coats AJ, Seferović PM, Lyon AR. Recent advances in cardio-oncology: a report from the 'Heart Failure Association 2019 and World Congress on Acute Heart Failure 2019'. ESC Heart Fail 2019; 6:1140-1148. [PMID: 31884717 PMCID: PMC6989292 DOI: 10.1002/ehf2.12551] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
While anti-cancer therapies, including chemotherapy, immunotherapy, radiotherapy, and targeted therapy, are constantly advancing, cardiovascular toxicity has become a major challenge for cardiologists and oncologists. This has led to an increasing demand of cardio-oncology units in Europe and a growing interest of clinicians and researchers. The Heart Failure 2019 meeting of the Heart Failure Association of the European Society of Cardiology in Athens has therefore created a scientific programme that included four dedicated sessions on the topic along with several additional lectures. The major points that were discussed at the congress included the implementation and delivery of a cardio-oncology service, the collaboration among cardio-oncology experts, and the risk stratification, prevention, and early recognition of cardiotoxicity. Furthermore, sessions addressed the numerous different anti-cancer therapies associated with cardiotoxic effects and provided guidance on how to treat cancer patients who develop cardiovascular disease before, during, and after treatment.
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Affiliation(s)
- Markus S. Anker
- Division of Cardiology and Metabolism, Department of CardiologyCharité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research)partner site Berlin and Department of Cardiology, Charité Campus Benjamin FranklinBerlinGermany
| | - Sara Hadzibegovic
- Division of Cardiology and Metabolism, Department of CardiologyCharité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research)partner site Berlin and Department of Cardiology, Charité Campus Benjamin FranklinBerlinGermany
| | - Alessia Lena
- Division of Cardiology and Metabolism, Department of CardiologyCharité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research)partner site Berlin and Department of Cardiology, Charité Campus Benjamin FranklinBerlinGermany
| | | | | | - Rudolf A. de Boer
- Department of CardiologyUniversity of GroningenUniversity Medical Center Groningen, GroningenThe Netherlands
| | - Dimitrios Farmakis
- University of Cyprus Medical SchoolNicosiaCyprus
- Department of Cardiology, Cardio‐Oncology Clinic, Heart Failure UnitAthens University Hospital ‘Attikon’, National and Kapodistrian University of AthensAthensGreece
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Heart Center Göttingen, German Center for Cardiovascular Medicine (DZHK)University of Göttingen Medical Center, Georg‐August‐UniversityGöttingenGermany
| | - Zaza Iakobishvili
- Department of Community Cardiology, Clalit Health Fund, and Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Christoph Maack
- Comprehensive Heart Failure Center (CHFC)University Clinic WürzburgWürzburgGermany
| | - Radek Pudil
- 1st Department of Medicine–Cardioangiology, Faculty of MedicineUniversity HospitalHradec KrálovéCzech Republic
| | - Hadi Skouri
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirutLebanon
| | - Alain Cohen‐Solal
- Department of Cardiology, Lariboisière Hospital and U942 INSERM, BIOCANVAS (Biomarqueurs Cardiovasculaires)Paris UniversityParisFrance
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Sciences (CIRCET)Federico II UniversityNaplesItaly
| | | | - Petar M. Seferović
- Faculty of Medicine and Heart Failure CenterBelgrade University Medical Center, University of BelgradeBelgradeSerbia
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27
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Tomasoni D, Adamo M, Lombardi CM, Metra M. Highlights in heart failure. ESC Heart Fail 2019; 6:1105-1127. [PMID: 31997538 PMCID: PMC6989277 DOI: 10.1002/ehf2.12555] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. It is an area of active research. This article is aimed to give an update on recent advances in all aspects of this syndrome. Major changes occurred in drug treatment of HF with reduced ejection fraction (HFrEF). Sacubitril/valsartan is indicated as a substitute to ACEi/ARBs after PARADIGM-HF (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73 to 0.87 for sacubitril/valsartan vs. enalapril for the primary endpoint and Wei, Lin and Weissfeld HR 0.79, 95% CI 0.71-0.89 for recurrent events). Its initiation was then shown as safe and potentially useful in recent studies in patients hospitalized for acute HF. More recently, dapagliflozin and prevention of adverse-outcomes in DAPA-HF trial showed the beneficial effects of the sodium-glucose transporter type 2 inhibitor dapaglifozin vs. placebo, added to optimal standard therapy [HR, 0.74; 95% CI, 0.65 to 0.85;0.74; 95% CI, 0.65 to 0.85 for the primary endpoint]. Trials with other SGLT 2 inhibitors and in other patients, such as those with HF with preserved ejection fraction (HFpEF) or with recent decompensation, are ongoing. Multiple studies showed the unfavourable prognostic significance of abnormalities in serum potassium levels. Potassium lowering agents may allow initiation and titration of mineralocorticoid antagonists in a larger proportion of patients. Meta-analyses suggest better outcomes with ferric carboxymaltose in patients with iron deficiency. Drugs effective in HFrEF may be useful also in HF with mid-range ejection fraction. Better diagnosis and phenotype characterization seem warranted in HF with preserved ejection fraction. These and other burning aspects of HF research are summarized and reviewed in this article.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Marianna Adamo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Carlo Mario Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
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28
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Abstract
Heart failure (HF) professionals are managing an older population with multiple, often interconnected comorbidities. The average age of the HF patient has increased substantially and many have a number of comorbidities. For the older HF patient, diligent planning of care has the potential to reduce hospitalization, improve quality of life and mortality; nevertheless, this vital component is often overlooked. Frailty, cachexia, sarcopenia, and cognitive impairment are all common in the older HF patient and require special care considerations. Many older HF patients live for many years with troublesome symptoms that could be better addressed through the incorporation of a palliative approach to care. Effective care plans can help patients maximize their health potential through both lifestyle and pharmacological interventions. However, current evidence remains scarce on what constitutes an optimal plan, therefore further studies are urgently needed. We review the care that could be implemented for the complex older HF patient with comorbidities.
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Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen’s University, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Matthew A Carson
- School of Nursing and Midwifery, Queen’s University, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Via della Pisana, 235 00163 Rome, Italy
- St George’s Hospital, Cranmer Terrace, SW17 ORE, London, UK
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29
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Cuomo A, Rodolico A, Galdieri A, Russo M, Campi G, Franco R, Bruno D, Aran L, Carannante A, Attanasio U, Tocchetti CG, Varricchi G, Mercurio V. Heart Failure and Cancer: Mechanisms of Old and New Cardiotoxic Drugs in Cancer Patients. Card Fail Rev 2019; 5:112-118. [PMID: 31179022 PMCID: PMC6545979 DOI: 10.15420/cfr.2018.32.2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/30/2019] [Indexed: 02/07/2023] Open
Abstract
Although there have been many improvements in prognosis for patients with cancer, anticancer therapies are burdened by the risk of cardiovascular toxicity. Heart failure is one of the most dramatic clinical expressions of cardiotoxicity, and it may occur acutely or appear years after treatment. This article reviews the main mechanisms and clinical presentations of left ventricular dysfunction induced by some old and new cardiotoxic drugs in cancer patients, referring to the most recent advances in the field. The authors describe the mechanisms of cardiotoxicity induced by anthracyclines, which can lead to cardiovascular problems in up to 48% of patients who take them. The authors also describe mechanisms of cardiotoxicity induced by biological drugs that produce left ventricular dysfunction through secondary mechanisms. They outline the recent advances in immunotherapies, which have revolutionised anticancer therapies.
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Affiliation(s)
- Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Alessio Rodolico
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Amalia Galdieri
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Michele Russo
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Giacomo Campi
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Riccardo Franco
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Dalila Bruno
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Luisa Aran
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Antonio Carannante
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Umberto Attanasio
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Federico II University Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University Naples, Italy
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30
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Higuchi S, Kohsaka S, Shiraishi Y, Katsuki T, Nagatomo Y, Mizuno A, Sujino Y, Kohno T, Goda A, Yoshikawa T. Association of renin-angiotensin system inhibitors with long-term outcomes in patients with systolic heart failure and moderate-to-severe kidney function impairment. Eur J Intern Med 2019; 62:58-66. [PMID: 30737061 DOI: 10.1016/j.ejim.2019.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/18/2019] [Accepted: 01/29/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Although guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) should be treated with renin-angiotensin system (RAS) inhibitors, the long-term efficacy of RAS inhibitors in HFrEF patients with moderate-to-severe chronic kidney disease (CKD) remains unclear. METHODS The present study included consecutive patients hospitalized for acute heart failure across five Japanese teaching hospitals. The impact of RAS inhibitors on 2-year all-cause mortality was evaluated in patients with an ejection fraction ≤40% and CKD, defined as an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2, at discharge. Its severity was subclassified from 3B to 5 according to eGFR. RESULTS Overall, 553 patients (age, 76 ± 11 years; 68% male) were included. RAS inhibitors were prescribed more frequently in 227 patients with stage 3B (71.2%) than in 107 patients with stage 4 or 5 CKD (45.7%). All-cause mortality was recorded in 119 patients (23.4%) (55 [18.5%] patients with stage 3B; 64 [30.3%] patients with stage 4 or 5 CKD), within the median follow-up period of 609 (220-983) days. After many-to-one propensity score matching (87 pairs in stage 3; 60 pairs in stage 4 or 5 CKD), those with RAS inhibitors had reduced mortality rate in stage 3B (hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.19-0.83) but not in stage 4 or 5 CKD (HR, 1.08; 95% CI, 0.57-2.03). CONCLUSIONS In HFrEF patients with CKD, RAS inhibitors are associated with reduction in mortality in stage 3B CKD, but the association is less clear in stage 4 or 5 CKD.
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Affiliation(s)
- Satoshi Higuchi
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan.
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshiomi Katsuki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yasumori Sujino
- Department of Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ayumi Goda
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
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31
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Metra M. Figures of the Heart Failure Association: Andrew J. Stewart Coats, President‐Elect, 2018–2020. Eur J Heart Fail 2019; 21:269-271. [DOI: 10.1002/ejhf.1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of Brescia Italy
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32
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Dinatolo E, Sciatti E, Anker MS, Lombardi C, Dasseni N, Metra M. Updates in heart failure: what last year brought to us. ESC Heart Fail 2018; 5:989-1007. [PMID: 30570225 PMCID: PMC6300825 DOI: 10.1002/ehf2.12385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Elisabetta Dinatolo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Edoardo Sciatti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin‐Brandenburg Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Carlo Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Nicolò Dasseni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
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