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Galis P, Bartosova L, Farkasova V, Szobi A, Horvath C, Kovacova D, Adameova A, Rajtik T. Intermittent Hypoxic Preconditioning Plays a Cardioprotective Role in Doxorubicin-Induced Cardiomyopathy. Cardiovasc Toxicol 2023:10.1007/s12012-023-09793-7. [PMID: 37119387 DOI: 10.1007/s12012-023-09793-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/14/2023] [Indexed: 05/01/2023]
Abstract
Intermittent hypoxic preconditioning (IHP) is a well-established cardioprotective intervention in models of ischemia/reperfusion injury. Nevertheless, the significance of IHP in different cardiac pathologies remains elusive. In order to investigate the role of IHP and its effects on calcium-dependent signalization in HF, we employed a model of cardiomyopathy induced by doxorubicin (Dox), a widely used drug from the class of cardiotoxic antineoplastics, which was i.p. injected to Wistar rats (4 applications of 4 mg/kg/week). IHP-treated group was exposed to IHP for 2 weeks prior to Dox administration. IHP ameliorated Dox-induced reduction in cardiac output. Western blot analysis revealed increased expression of sarco/endoplasmic reticulum Ca2+-ATPase (SERCA2a) while the expression of hypoxia inducible factor (HIF)-1-α, which is a crucial regulator of hypoxia-inducible genes, was not changed. Animals administered with Dox had further decreased expression of TRPV1 and TRPV4 (transient receptor potential, vanilloid subtype) ion channels along with suppressed Ca2+/calmodulin-dependent protein kinase II (CaMKII) activation. In summary, IHP-mediated improvement in cardiac output in the model of Dox-induced cardiomyopathy is likely a result of increased SERCA2a expression which could implicate IHP as a potential protective intervention in Dox cardiomyopathy, however, further analysis of observed effects is still required.
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Affiliation(s)
- Peter Galis
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Odbojárov 10, 832 32, Bratislava, Slovakia
| | - Linda Bartosova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Odbojárov 10, 832 32, Bratislava, Slovakia
| | - Veronika Farkasova
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská Cesta 9, 841 04, Bratislava, Slovakia
| | - Adrian Szobi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Odbojárov 10, 832 32, Bratislava, Slovakia
| | - Csaba Horvath
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Odbojárov 10, 832 32, Bratislava, Slovakia
| | - Dominika Kovacova
- Faculty of Medicine, Institute of Pathophysiology, Comenius University, Špitálska 24, 813 72, Bratislava, Slovakia
| | - Adriana Adameova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Odbojárov 10, 832 32, Bratislava, Slovakia
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská Cesta 9, 841 04, Bratislava, Slovakia
| | - Tomas Rajtik
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Odbojárov 10, 832 32, Bratislava, Slovakia.
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská Cesta 9, 841 04, Bratislava, Slovakia.
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2
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Wolf CM, Reiner B, Kühn A, Hager A, Müller J, Meierhofer C, Oberhoffer R, Ewert P, Schmid I, Weil J. Subclinical Cardiac Dysfunction in Childhood Cancer Survivors on 10-Years Follow-Up Correlates With Cumulative Anthracycline Dose and Is Best Detected by Cardiopulmonary Exercise Testing, Circulating Serum Biomarker, Speckle Tracking Echocardiography, and Tissue Doppler Imaging. Front Pediatr 2020; 8:123. [PMID: 32296665 PMCID: PMC7136405 DOI: 10.3389/fped.2020.00123] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Survivors of childhood cancer are at risk for anthracycline- and/or radiotherapy-induced cardiotoxicity. Aims: The aim of this study was to assess clinical, laboratory, and imaging parameters of subclinical cardiovascular disease in childhood cancer survivors. Methods: Patients underwent cardiopulmonary exercise test (CPET), laboratory testing, transthoracic echocardiography (TTE) with tissue doppler imaging (TDI) and speckle tracking. A subset of patients also underwent cardiovascular magnetic resonance imaging (CMR). Findings were correlated to cumulative anthracycline and exposure to mediastinal irradiation during cancer treatment. In a subgroup analysis, TTE and CMR findings were compared to data from 40 gender- and age-matched patients with childhood onset hypertrophic cardiomyopathy (HCM). Results: Cardiac evaluation was performed in 79 patients (43 males) at 11.2 ± 4.5 years after cancer treatment. Oncologic diagnosis at a median age of 12.0 years was Hodgkin lymphoma in 20, sarcoma in 17, acute leukemia in 24, relapse leukemia in 10, and others in 8 patients. Cumulative anthracycline dose exceeded 300 mg/m2 in 28 patients. Twenty six patients also received mediastinal irradiation. Decreased peak respiratory oxygen uptake in % predicted on CPET, increased levels of N-terminal pro-brain natriuretic peptide (NTproBNP), increased global longitudinal strain on TTE speckle tracking, and diastolic dysfunction on TDI were the most prominent findings on detailed cardiology follow-up. In contrast to HCM patients, childhood cancer survivors did not show left ventricular hypertrophy (LVPWd z-score median 0.9 vs. 2.8, p < 0.001), hyperdynamic systolic function on TTE (Ejection fraction 62 ± 7 vs. 72 ± 12%, p = 0.001), or fibrotic myocardial changes on CMR (Late gadolinium positive 0/13 vs. 13/36, p = 0.001; extracellular volume fraction 22 ± 2 vs. 28 ± 3, p < 0.001) at time of follow-up. There was no correlation between chest radiation exposure and abnormal cardiac findings. Cumulative anthracycline dose was the only significant independent predictor on multivariate analysis for any cardiovascular abnormality on follow-up (p = 0.036). Conclusion: Increasing cumulative anthracycline dose during cancer treatment correlates with subclinical cardiac dysfunction in childhood cancer survivors best detected by elevated cardiac serum biomarkers, decreased exercise capacity on CPET, and abnormalities on echocardiographic speckle tracking and TDI.
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Affiliation(s)
- Cordula Maria Wolf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Barbara Reiner
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Andreas Kühn
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Jan Müller
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Renate Oberhoffer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Faculty of Sport and Health Sciences, Institute of Preventive Pediatrics, Technical University Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Irene Schmid
- Department of Pediatric Hematology and Oncology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jochen Weil
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
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3
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Abstract
Anthracycline chemotherapy maintains a prominent role in treating many forms of cancer. Cardiotoxic side effects limit their dosing and improved cancer outcomes expose the cancer survivor to increased cardiovascular morbidity and mortality. The basic mechanisms of cardiotoxicity may involve direct pathways for reactive oxygen species generation and topoisomerase 2 as well as other indirect pathways. Cardioprotective treatments are few and those that have been examined include renin angiotensin system blockade, beta blockers, or the iron chelator dexrazoxane. New treatments exploiting the ErbB or other novel pro-survival pathways, such as conditioning, are on the cardioprotection horizon. Even in the forthcoming era of targeted cancer therapies, the substantial proportion of today's anthracycline-treated cancer patients may become tomorrow's cardiac patient.
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Affiliation(s)
- John V McGowan
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - Robin Chung
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - Angshuman Maulik
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - Izabela Piotrowska
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - J Malcolm Walker
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, WC1E 6HX, UK.
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4
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Aminkeng F, Ross CJD, Rassekh SR, Hwang S, Rieder MJ, Bhavsar AP, Smith A, Sanatani S, Gelmon KA, Bernstein D, Hayden MR, Amstutz U, Carleton BC. Recommendations for genetic testing to reduce the incidence of anthracycline-induced cardiotoxicity. Br J Clin Pharmacol 2016; 82:683-95. [PMID: 27197003 PMCID: PMC5338111 DOI: 10.1111/bcp.13008] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 12/15/2022] Open
Abstract
AIMS Anthracycline-induced cardiotoxicity (ACT) occurs in 57% of treated patients and remains an important limitation of anthracycline-based chemotherapy. In various genetic association studies, potential genetic risk markers for ACT have been identified. Therefore, we developed evidence-based clinical practice recommendations for pharmacogenomic testing to further individualize therapy based on ACT risk. METHODS We followed a standard guideline development process, including a systematic literature search, evidence synthesis and critical appraisal, and the development of clinical practice recommendations with an international expert group. RESULTS RARG rs2229774, SLC28A3 rs7853758 and UGT1A6 rs17863783 variants currently have the strongest and the most consistent evidence for association with ACT. Genetic variants in ABCC1, ABCC2, ABCC5, ABCB1, ABCB4, CBR3, RAC2, NCF4, CYBA, GSTP1, CAT, SULT2B1, POR, HAS3, SLC22A7, SCL22A17, HFE and NOS3 have also been associated with ACT, but require additional validation. We recommend pharmacogenomic testing for the RARG rs2229774 (S427L), SLC28A3 rs7853758 (L461L) and UGT1A6*4 rs17863783 (V209V) variants in childhood cancer patients with an indication for doxorubicin or daunorubicin therapy (Level B - moderate). Based on an overall risk stratification, taking into account genetic and clinical risk factors, we recommend a number of management options including increased frequency of echocardiogram monitoring, follow-up, as well as therapeutic options within the current standard of clinical practice. CONCLUSIONS Existing evidence demonstrates that genetic factors have the potential to improve the discrimination between individuals at higher and lower risk of ACT. Genetic testing may therefore support both patient care decisions and evidence development for an improved prevention of ACT.
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Affiliation(s)
- Folefac Aminkeng
- Centre for Molecular Medicine and Therapeutics, Department of Medical GeneticsUniversity of British ColumbiaVancouverBCCanada
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
| | - Colin J. D. Ross
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Division of Translational Therapeutics, Department of PediatricsUniversity of British ColumbiaVancouverBCCanada
| | - Shahrad R. Rassekh
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Division of Pediatric Hematology/Oncology/BMT, Department of PediatricsUniversity of British ColumbiaVancouverBCCanada
| | - Soomi Hwang
- Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBCCanada
| | | | - Amit P. Bhavsar
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Division of Translational Therapeutics, Department of PediatricsUniversity of British ColumbiaVancouverBCCanada
| | - Anne Smith
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Pharmaceutical Outcomes & Policy Innovations ProgrammeBC Children's HospitalVancouverBCCanada
| | - Shubhayan Sanatani
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
| | | | - Daniel Bernstein
- Department of Pediatrics, Division of CardiologyStanford UniversityStanfordCAUSA
| | - Michael R. Hayden
- Centre for Molecular Medicine and Therapeutics, Department of Medical GeneticsUniversity of British ColumbiaVancouverBCCanada
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Translational Laboratory in Genetic Medicine, National University of Singapore and Association for ScienceTechnology and Research (A*STAR)Singapore
| | - Ursula Amstutz
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Division of Translational Therapeutics, Department of PediatricsUniversity of British ColumbiaVancouverBCCanada
- University Institute of Clinical Chemistry, Inselspital Bern University Hospital and University of BernSwitzerland
| | - Bruce C. Carleton
- Child & Family Research InstituteUniversity of British ColumbiaVancouverBCCanada
- Pharmaceutical Outcomes & Policy Innovations ProgrammeBC Children's HospitalVancouverBCCanada
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Lipshultz SE, Diamond MB, Franco VI, Aggarwal S, Leger K, Santos MV, Sallan SE, Chow EJ. Managing chemotherapy-related cardiotoxicity in survivors of childhood cancers. Paediatr Drugs 2014; 16:373-89. [PMID: 25134924 PMCID: PMC4417358 DOI: 10.1007/s40272-014-0085-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the US, children diagnosed with cancer are living longer, but not without consequences from the same drugs that cured their cancer. In these patients, cardiovascular disease is the leading cause of non-cancer-related morbidity and mortality. Although this review focuses on anthracycline-related cardiomyopathy in childhood cancer survivors, the global lifetime risk of other cardiovascular diseases such as atherosclerosis, arrhythmias and intracardiac conduction abnormalities, hypertension, and stroke also are increased. Besides anthracyclines, newer molecularly targeted agents, such as vascular endothelial growth factor receptor and tyrosine kinase inhibitors, also have been associated with acute hypertension, cardiomyopathy, and increased risk of ischemic cardiac events and arrhythmias, and are summarized here. This review also covers other risk factors for chemotherapy-related cardiotoxicity (including both modifiable and non-modifiable factors), monitoring strategies (including both blood and imaging-based biomarkers) during and following cancer treatment, and discusses the management of cardiotoxicity (including prevention strategies such as cardioprotection by use of dexrazoxane).
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine and the Children's Research Center of Michigan at the Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA,
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6
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The role of antioxidants in the era of cardio‑oncology. Cancer Chemother Pharmacol 2014; 72:1157-68. [PMID: 23959462 DOI: 10.1007/s00280-013-2260-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/04/2013] [Indexed: 10/26/2022]
Abstract
Although most chemotherapeutic drugs have the potential to exert cardiotoxicity, these drugs have been chosen for use in cancer treatment because survival and curability benefits outweigh the risk of these complications. Anthracyclines, for example, are a powerful class of chemotherapeutic agents; however, their use is restricted by dose-related cardiotoxicity. Experimental evidence strongly supports the role of reactive oxygen species in this process, suggesting that antioxidants may be effective in protecting the heart from toxicity. Clinical use of antioxidants to protect the heart during anthracycline chemotherapy has been controversial due to the potential for reduced cytotoxic efficacy toward cancer cells. Results from randomized clinical trials addressing whether antioxidants either reduce the incidence of clinical heart failure among patients undergoing anthracycline-based chemotherapy or reduce the response rates to anthracycline-based chemotherapy have been unclear. While anthracyclines are by far the most well-studied antitumor agents with cardiotoxic properties, evidence now shows that reactive oxygen species may play roles in cardiotoxicity induced by other chemotherapeutic agents such as cyclophosphamide, cisplatin, 5-fluorouracil, and trastuzumab. Thus, in the new era of combination therapy and long-term survival of cancer patients, the use of antioxidants to support cancer therapy should be revisited.
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7
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van Dalen EC, Caron HN, Dickinson HO, Kremer LCM. Cardioprotective interventions for cancer patients receiving anthracyclines. Cochrane Database Syst Rev 2011; 2011:CD003917. [PMID: 21678342 PMCID: PMC6457676 DOI: 10.1002/14651858.cd003917.pub4] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anthracyclines are among the most effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent this cardiotoxicity, different cardioprotective agents have been studied. OBJECTIVES The objective of this review was to assess the efficacy of different cardioprotective agents in preventing heart damage in cancer patients treated with anthracyclines. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10), MEDLINE (1966 to November 2010) and EMBASE (1980 to November 2010) databases. In addition, we handsearched reference lists, conference proceedings of the International Society of Paediatric Oncology (SIOP) and American Society of Clinical Oncology (ASCO) meetings (1998 to 2010) and ongoing trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) in which any cardioprotective agent was compared to no additional therapy or placebo in cancer patients (children and adults) receiving anthracyclines. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, risk of bias assessment and data extraction including adverse effects. MAIN RESULTS We identified RCTs for the eight cardioprotective agents N-acetylcysteine, phenethylamines, coenzyme Q10, a combination of vitamins E and C and N-acetylcysteine, L-carnitine, carvedilol, amifostine and dexrazoxane (mostly for adults with advanced breast cancer). All studies had methodological limitations and for the first seven agents there were too few studies to allow pooling of results. None of the individual studies showed a cardioprotective effect. The 10 included studies on dexrazoxane enrolled 1619 patients. The meta-analysis for dexrazoxane showed a statistically significant benefit in favour of dexrazoxane for the occurrence of heart failure (risk ratio (RR) 0.29, 95% CI 0.20 to 0.41). No evidence was found for a difference in response rate or survival between the dexrazoxane and control groups. The results for adverse effects were ambiguous. No significant difference in the occurrence of secondary malignancies was identified. AUTHORS' CONCLUSIONS No definitive conclusions can be made about the efficacy of cardioprotective agents for which pooling of results was impossible. Dexrazoxane prevents heart damage and no evidence for a difference in response rate or survival between the dexrazoxane and control groups was identified. The evidence available did not allow us to reach any definite conclusions about adverse effects. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in patients with cancer treated with anthracyclines. However, clinicians should weigh the cardioprotective effect of dexrazoxane against the possible risk of adverse effects for each individual patient.
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Affiliation(s)
- Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660 (room H4‐139)AmsterdamNetherlands1100 DD
| | - Huib N Caron
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660 (room H4‐139)AmsterdamNetherlands1100 DD
| | - Heather O Dickinson
- Newcastle UniversityInstitute of Health & Society21 Claremont PlaceNewcastle upon TyneUKNE2 4AA
| | - Leontien CM Kremer
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660 (room H4‐139)AmsterdamNetherlands1100 DD
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van Dalen EC, Caron HN, Dickinson HO, Kremer LCM. Cardioprotective interventions for cancer patients receiving anthracyclines. Cochrane Database Syst Rev 2008:CD003917. [PMID: 18425895 DOI: 10.1002/14651858.cd003917.pub3] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Anthracyclines are among the most effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent this cardiotoxicity, different cardioprotective agents have been studied. OBJECTIVES The objective of this review was to assess the efficacy of different cardioprotective agents in preventing heart damage in cancer patients treated with anthracyclines. SEARCH STRATEGY We searched the databases of the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2007), MEDLINE (1966 to April 2007) and EMBASE (1980 to April 2007). In addition, we handsearched reference lists and conference proceedings of the SIOP and ASCO meetings (1998 to 2006). SELECTION CRITERIA Randomised controlled trials (RCTs) in which any cardioprotective agent was compared to no additional or placebo therapy in cancer patients (children and adults) receiving anthracyclines. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection, quality assessment and data-extraction including adverse effects. MAIN RESULTS We identified RCTs for seven cardioprotective agents: N-acetylcysteine, phenetylamines, coenzyme Q10, combination of vitamins E and C and N-acetylcysteine, L-carnitine, carvedilol and dexrazoxane (mostly adults with advanced breast cancer). All studies had methodological limitations. For the first six agents, there were too few studies to allow pooling of results. None of the individual studies showed a cardioprotective effect. The nine included studies of dexrazoxane enrolled 1403 patients. The meta-analysis of dexrazoxane showed a statistically significant benefit in favour of dexrazoxane for the occurrence of heart failure (Relative Risk (RR) 0.29, 95% CI 0.20 to 0.41). No evidence was found for a difference in response rate or survival between the dexrazoxane and control group. Only for one adverse effect (abnormal white blood cell count at nadir) a difference in favour of the control group was identified. AUTHORS' CONCLUSIONS For cardioprotective agents for which pooling was impossible, no definitive conclusions can be made about their efficacy. Dexrazoxane prevents heart damage and no evidence for a difference in response rate or survival between the dexrazoxane and control group was identified. Only for an abnormal white blood cell count at nadir a clearly significant difference in favour of the control group was identified. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in patients with cancer treated with anthracyclines. However, for each individual patient clinicians should weigh the cardioprotective effect of dexrazoxane against the possible risk of adverse effects.
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Affiliation(s)
- E C van Dalen
- Emma Children's Hospital / Academic Medical Center (room F8-257), Pediatric Oncology, Meibergdreef 9, PO Box 22660, Amsterdam, Netherlands, 1100 DD.
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9
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van Dalen EC, Caron HN, Dickinson HO, Kremer LCM. Cardioprotective interventions for cancer patients receiving anthracyclines. Cochrane Database Syst Rev 2005:CD003917. [PMID: 15674919 DOI: 10.1002/14651858.cd003917.pub2] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Anthracyclines are among the most effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent this cardiotoxicity, different cardioprotective agents have been studied. OBJECTIVES The objective of this review was to assess the efficacy of different cardioprotective agents in preventing heart damage in cancer patients treated with anthracyclines. SEARCH STRATEGY We searched the databases of CENTRAL (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 to August 2002) and EMBASE (1980 to August 2002). In addition, we handsearched reference lists and conference proceedings of the International Society for Paediatric Oncology (SIOP) and the American Society of Clinical Oncology (ASCO) (1998 to 2002). SELECTION CRITERIA Randomised controlled trials (RCTs) in which any cardioprotective agent was compared to no additional or placebo therapy in cancer patients (children and adults) receiving anthracyclines. DATA COLLECTION AND ANALYSIS Two reviewers independently performed the study selection, quality assessment and data-extraction including adverse effects. MAIN RESULTS We identified RCTs for 5 cardioprotective agents: N-acetylcysteine (1 study; 54 patients), phenetylamines (2 studies; 100 patients), coenzyme Q10 (1 study; 20 patients), combination of vitamin E, vitamin C and N-acetylcysteine (1 study; 14 patients) and dexrazoxane (6 studies; 1013 patients). All studies had methodological limitations. Due to the insufficient number of studies, for the first four mentioned cardioprotective agents pooling of the results was impossible. None of the individual studies showed a cardioprotective effect. The meta-analysis of the dexrazoxane-studies showed a statistically significant benefit in favour of dexrazoxane for the occurrence of heart failure (Relative Risk (RR) = 0.28, 95% Confidence Interval (CI) 0.18 to 0.42, P < 0.00001). No statistically significant difference in response rate between the dexrazoxane and control group was found (RR = 0.88, 95% CI 0.77 to 1.01, P = 0.06), but there was some suggestion that patients treated with dexrazoxane might have a lower anti-tumour response rate. Our meta-analysis of survival showed no significant difference between the dexrazoxane and control group. For adverse effects pooling was impossible. However, no important differences in the occurrence of side effects were found. The majority of the patients included in this meta-analysis were adults with advanced breast cancer. AUTHORS' CONCLUSIONS For cardioprotective agents for which pooling was impossible no high quality evidence was available and therefore, no definitive conclusions can be made about their efficacy. Dexrazoxane prevents heart damage, however there was some suggestion that patients treated with dexrazoxane might have a lower anti-tumour response rate. There was no significant difference in survival between the dexrazoxane and control group. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in patients with cancer treated with anthracyclines. However, for each individual patient clinicians should weigh the cardioprotective effect of dexrazoxane against the possible risk of a lower response rate.
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Affiliation(s)
- E C van Dalen
- Pediatric Oncology, Emma Children's Hospital / Academic Medical Center (room F8-257), PO Box 22660, Amsterdam, Netherlands, 1100 DD.
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