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Guo X, Zhang N, Wang N, Zhang Y, Liu Y, Pei M, Liu G, Jia X. Early detection of chemotherapy-induced cardiotoxicity in breast cancer patients: a comprehensive analysis using speckle tracking echocardiography. Front Cardiovasc Med 2024; 11:1413827. [PMID: 39346098 PMCID: PMC11427351 DOI: 10.3389/fcvm.2024.1413827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 08/23/2024] [Indexed: 10/01/2024] Open
Abstract
Introduction Chemotherapy-induced cardiotoxicity poses a significant challenge in the treatment of breast cancer, potentially compromising both the efficacy of cancer therapy and cardiac health of patients. This study aimed to enhance the early detection of cardiotoxic effects by integrating advanced imaging modalities and biomarker analysis, thereby facilitating timely interventions to mitigate cardiac risk. Methods A prospective cohort design was employed, enrolling breast cancer patients scheduled for potentially cardiotoxic chemotherapy regimens. The study utilized a comprehensive diagnostic toolkit, including echocardiography with strain imaging, cardiac MRI, and serial measurements of cardiac biomarkers such as high-sensitivity troponins and natriuretic peptides. Results The analysis revealed that subtle changes in myocardial strain parameters and early biomarker elevations were predictive of subsequent declines in left ventricular function, preceding conventional echocardiographic evidence of cardiotoxicity. Logistic regression analysis highlighted the additive predictive value of integrating biomarker data with advanced imaging findings to identify patients with the highest risk of significant cardiotoxicity. Discussion The study concluded that an integrated diagnostic approach, combining detailed imaging assessments with sensitive biomarker analysis, offers a superior strategy for the early detection of chemotherapy-induced cardiotoxicity in breast cancer patients. This proactive diagnostic strategy empowers clinicians to tailor cancer therapy more precisely, balancing oncologic efficacy with cardiovascular safety and underscores the importance of a multidisciplinary approach in the management of patients undergoing potentially cardiotoxic chemotherapy.
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Affiliation(s)
- Xuejia Guo
- Department of Ultrasound, The First Hospital of Hebei Medical University, Shijiazhuang, China
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2
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Huang X, Fan XY, Cheng Q, Zhang J, Sun J, Tang QY, Deng YB, Bi XJ. Intrinsic Wave Velocity Propagation: A Novel Parameter for Assessing the Effect of Anthracycline Chemotherapy Agents on Cardiac Diastolic Function in Breast Cancer Patients. Curr Med Sci 2023; 43:1229-1237. [PMID: 38041790 DOI: 10.1007/s11596-023-2807-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/08/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Anthracycline chemotherapeutic agents have significant cardiotoxicity. The present study emphasized the effect of anthracycline chemotherapy drugs on left ventricular (LV) myocardial stiffness in breast cancer patients by measuring the intrinsic wave velocity propagation (IVP), and evaluating the potential clinical value of IVP in detecting early LV diastolic function impairment. METHODS A total of 68 newly diagnosed breast cancer patients, who were treated with anthracycline-based chemotherapy, were analyzed. Transthoracic echocardiography was performed at baseline (T0), and after 1, 2, 3, 4 and 8 chemotherapeutic cycles (T1, T2, T3, T4 and T5, respectively). Then, the IVP, LV strain parameters [global longitudinal strain (GLS), longitudinal peak strain rate at systole (LSRs), longitudinal peak strain rate at early diastole (LSRe), longitudinal peak strain rate at late diastole (LSRa), and the E/LSRe ratio], and conventional echocardiographic parameters were obtained and further analyzed. A relative reduction of >15% in GLS was considered a marker of early LV subclinical dysfunction. RESULTS Compared to the T0 stage, IVP significantly increased at the T1 stage. However, there were no significant changes in GLS, LSRs, or LSRe between the T0 and T1 stages. These parameters significantly decreased from the T2 stage. LSRa started to significantly decrease at the T5 stage, and the E/LSRe ratio started to significantly increase at the T3 stage (all P<0.05). At the T0 stage, IVP (AUC=0.752, P<0.001) had a good predictive value for LV subclinical dysfunction after chemotherapy. CONCLUSIONS IVP is a potentially sensitive parameter for the early clinical assessment of anthracycline-related cardiac diastolic impairment.
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Affiliation(s)
- Xiao Huang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xin-Ying Fan
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qiao Cheng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jun Zhang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jie Sun
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qiao-Ying Tang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - You-Bin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiao-Jun Bi
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Toma RV, Anca Z, Trifănescu OG, Galeş LN, Folea AR, Stanca L, Bîlteanu L, Anghel RM. Early Echocardiography and ECG Changes Following Radiotherapy in Patients with Stage II-III HER2-Positive Breast Cancer Treated with Anthracycline-Based Chemotherapy with or without Trastuzumab-Based Therapy. Med Sci Monit 2023; 29:e941754. [PMID: 37772333 PMCID: PMC10521333 DOI: 10.12659/msm.941754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/23/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Cardiotoxicity from radiotherapy and anti-cancer therapies have been reported in patients with breast cancer. This study aimed to investigate the early echocardiography and ECG changes following radiotherapy in 68 patients ages 30-78 years with stages II-III HER2-positive breast cancer treated with anthracycline-based chemotherapy with or without trastuzumab-based therapy from 2015 to 2021. MATERIAL AND METHODS We analyzed data of 68 breast cancer patients aged 30-78 years, predominantly in AJCC stages II-III (61) and HER2-positive (58), treated and monitored from 2015 to 2021. Cardiac function was assessed using echo- and electrocardiography. We employed univariate logistic models to gauge associations between pre-existing cardiac conditions, treatment modalities, and changes in cardiac function. RESULTS A decrease in the left ventricle ejection fraction (EF) by >5% was associated with heart doses >49.3 Gy and with maximum and average doses to the left anterior descending artery (LAD) exceeding 46.9 Gy and 32.7 Gy, respectively. An EF drop of ≥10% was correlated with anti-HER2 therapy, pre-existing ECG changes, and the onset of conditions in the left ventricle, major vessels, and valves. Conditions were exacerbated in patients with prior echocardiographic abnormalities, while some emerged concurrent with the EF decline. CONCLUSIONS This research emphasizes the importance of personalized heart monitoring and care for breast cancer patients undergoing multimodal therapies. Significant and potentially irreversible EF declines can result from radiation and anti-HER2 treatments.
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Affiliation(s)
- Radu Valeriu Toma
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Oncological Institute „Alexandru Trestioreanu”, Bucharest, Romania
| | - Zgura Anca
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Oana Gabriela Trifănescu
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Oncological Institute „Alexandru Trestioreanu”, Bucharest, Romania
| | - Laurenţia Nicoleta Galeş
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Oncological Institute „Alexandru Trestioreanu”, Bucharest, Romania
| | | | - Loredana Stanca
- Department of Preclinical Science, Faculty of Veterinary Medicine, University of Agronomic Sciences and Veterinary Medicine, Bucharest, Romania
| | - Liviu Bîlteanu
- Oncological Institute „Alexandru Trestioreanu”, Bucharest, Romania
- Department of Preclinical Science, Faculty of Veterinary Medicine, University of Agronomic Sciences and Veterinary Medicine, Bucharest, Romania
- Laboratory of Molecular Nanotechnologies, National Institute for Research and Development in Microtechnologies, Voluntary, Romania
| | - Rodica M. Anghel
- Department of Oncology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Cancer therapy-related cardiac dysfunction: is endothelial dysfunction at the heart of the matter? Clin Sci (Lond) 2021; 135:1487-1503. [PMID: 34136902 DOI: 10.1042/cs20210059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/10/2021] [Accepted: 06/01/2021] [Indexed: 12/11/2022]
Abstract
Significant improvements in cancer survival have brought to light unintended long-term adverse cardiovascular effects associated with cancer treatment. Although capable of manifesting a broad range of cardiovascular complications, cancer therapy-related cardiac dysfunction (CTRCD) remains particularly common among the mainstay anthracycline-based and human epidermal growth factor receptor-targeted therapies. Unfortunately, the early asymptomatic stages of CTRCD are difficult to detect by cardiac imaging alone, and the initiating mechanisms remain incompletely understood. More recently, circulating inflammatory markers, cardiac biomarkers, microRNAs, and extracellular vesicles (EVs) have been considered as early markers of cardiovascular injury. Concomitantly, the role of the endothelium in regulating cardiac function in the context of CTRCD is starting to be understood. In this review, we highlight the impact of breast cancer therapies on the cardiovascular system with a focus on the endothelium, and examine the status of circulating biomarkers, including inflammatory markers, cardiac biomarkers, microRNAs, and endothelial cell-derived EVs. Investigation of these emerging biomarkers may uncover mechanisms of injury, detect early stages of cardiovascular damage, and elucidate novel therapeutic approaches.
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Liu L, Shen T, Liu H, Zhang G, Shao Y. Toxicity Effects of Anthracycline-Converted Herceptin and Azo-Functionalized Fe₃O₄ Nanoparticles on the Heart of Patients with Breast Cancer Based on Echocardiography. JOURNAL OF NANOSCIENCE AND NANOTECHNOLOGY 2021; 21:878-885. [PMID: 33183419 DOI: 10.1166/jnn.2021.18658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The multifunctional nano-carrier system can simultaneously achieve multiple functions such as diagnostic imaging, targeted delivery of anti-tumor drugs, and combined therapy. Application potential Fe₃O₄ magnetic nanoparticles have the characteristics of low toxicity, superparamagnetism and good photothermal properties. Therefore, a multifunctional magnetic nanocarrier with both magnetic targeting and photothermal properties can be prepared by surface modification of Fe₃O₄ o DOX is an anti-tumor drug widely used in clinical treatment, and its severe toxic and side effects greatly limit its application. In this paper, a temperature-sensitive magnetic nanocarrier was first constructed and proved to have good superparamagnetism, photothermal properties, and biocom-patibility Then, Fe₃O₄-Azo-DOX drug-loaded nanoparticles were constructed by covalently bonding DOX. The prepared Fe₃O₄-Azo-DOX nanoparticles have high stability, sensitive photothermal response and low toxicity. Finally, Fe₃O₄-Azo-DOX was applied to the study of combined photother-motherapy and chemotherapy in vitro and in vivo. Based on Fe₃O₄ nanoparticles, a temperature-sensitive Fe₃O₄-Azo nanocarrier was constructed and its related properties were characterized. Furthermore, anthracycline nanodrugs were used in chemotherapy of breast cancer patients, and their effects were analyzed according to echocardiography parameter change. The results show that Fe₃O₄-Azo nanoparticles have a good photothermal heating effect. MCF-7 breast cancer cells were selected as a model to investigate the cytotoxicity of Fe₃O₄-Azo. The results proved that they have excellent biocompatibility and can be used as drug carriers. A Fe₃O₄-Azo nanocarrier was used to load DOX to construct a NIR-responsive nano-drug delivery system. By studying the NIR controlled release of Fe₃O₄-Azo-DOX under different pH conditions, it can be seen that it has NIR-responsive release function and the best release effect at pH 5.7. It was found that LVEF, LVFS, and E/A were significantly lower after chemotherapy than before (P < 0.05), which had a certain clinical value in cardiotoxicity The in vitro antitumor effect of Fe₃O₄-Azo-DOX was studied, and the results showed that the combined effect of photothermal-chemotherapy was significantly better than the photothermal treatment based on Fe₃O₄-Azo carrier alone and the chemotherapy based on free DOX alone.
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Affiliation(s)
- Li Liu
- Department of Ultrasonography, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang City, 441021, China
| | - Tingting Shen
- Department of Ultrasonography, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang City, 441021, China
| | - Hongfang Liu
- Department of Oncology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science Xiangyang City, 441021, China
| | - Gen Zhang
- Department of Pediatrics, Maternal and Child Health Hospital of Xiangyang, Hubei Province, Xiangyang City, 441021, China
| | - Yongfu Shao
- Department of Ultrasonography, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang City, 441021, China
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Ebrahimi A, Raichlen JS, Pointon A, Gottfridsson C, Munley J, Hockings P, Cartwright J, Buss N, Wikström J, Gan LM, Whittaker A, Khalil A, George RT, Garkaviy P, Brott D. Drug-induced myocardial dysfunction - recommendations for assessment in clinical and pre-clinical studies. Expert Opin Drug Saf 2020; 19:281-294. [PMID: 32064957 DOI: 10.1080/14740338.2020.1731471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Drug-induced myocardial dysfunction is an important safety concern during drug development. Oncology compounds can cause myocardial dysfunction, leading to decreased left ventricular ejection fraction and heart failure via several mechanisms. Cardiovascular imaging has a major role in the early detection and monitoring of cardiotoxicity. Echocardiography is the method of choice because of its widespread availability, low cost, and absence of radiation exposure. Cardiac magnetic resonance imaging can provide better reliability, reproducibility, and accuracy in the detection of drug-induced myocardial dysfunction. In addition, it enables assessment of myocardial edema, fibrosis, and necrosis. Cardiac serologic biomarkers such as troponins and B-type natriuretic peptides are used in combination with imaging during drug development. This article provides a general overview of each imaging modality and practical guidance for early detection and monitoring of cardiotoxicity.Areas covered: Cardiovascular imaging modalities and cardiac biomarkers for monitoring of cardiac function and early detection of drug-induced myocardial dysfunction in drug development.Expert opinion: Some new drugs especially in the oncology field, can cause myocardial dysfunction. Depending on the strength of pre-clinical or clinical data, CV imaging modalities and cardiac biomarkers play an important role in the early detection and mitigation plans for such drugs during their development.
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Li H, Liu C, Zhang G, Wang C, Sun P, Du G, Tian J. The early alteration of left ventricular strain and dys‐synchrony index in breast cancer patients undergoing anthracycline therapy using layer‐specific strain analysis. Echocardiography 2019; 36:1675-1681. [PMID: 31454106 DOI: 10.1111/echo.14460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hairu Li
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
- Key Laboratories of Myocardial Ischemia Mechanism and Treatment Ministry of Education Harbin Medical University Harbin China
| | - Cong Liu
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
| | - Ge Zhang
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
| | - Chao Wang
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
- Key Laboratories of Myocardial Ischemia Mechanism and Treatment Ministry of Education Harbin Medical University Harbin China
| | - Ping Sun
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
- Key Laboratories of Myocardial Ischemia Mechanism and Treatment Ministry of Education Harbin Medical University Harbin China
| | - Guoqing Du
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
- Key Laboratories of Myocardial Ischemia Mechanism and Treatment Ministry of Education Harbin Medical University Harbin China
| | - Jiawei Tian
- Department of Ultrasound The Second Affiliated Hospital of Harbin Medical University Harbin China
- Key Laboratories of Myocardial Ischemia Mechanism and Treatment Ministry of Education Harbin Medical University Harbin China
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HER2+ breast cancer treatment and cardiotoxicity: monitoring and management. Breast Cancer Res Treat 2019; 177:237-250. [PMID: 31165940 PMCID: PMC6661020 DOI: 10.1007/s10549-019-05303-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/27/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Breast cancer is a leading cause of death for women worldwide, with incidence increasing in lower-income countries. For patients with human epidermal growth factor receptor-2-positive (HER2+) breast cancer, widespread availability of several agents targeting the HER2 receptor has resulted in survival gains over the past decades. However, improved survival has resulted in an increased need for management and mitigation of adverse events associated with anticancer therapy. Cardiac adverse events such as decreased ejection fraction and heart failure have been of particular concern in patients with HER2+ breast cancer. Anti-HER2 agents and chemotherapies (specifically anthracyclines, which are frequently used to treat HER2+ disease) have been associated with cardiotoxicity. As increasing numbers of patients are living longer due to more effective therapy, a better understanding of both monitoring and management of cardiotoxicity is urgently needed. METHODS A comprehensive review of the literature was conducted via PubMed in January 2018 for phase II and phase III trials of "trastuzumab", "lapatinib", "pertuzumab", "T-DM1", "neratinib", in "breast cancer". Literature was evaluated for content related to cardiac adverse events. FINDINGS We describe the incidence of and proposed mechanisms for the cardiotoxicity of available HER2-targeted therapies. We summarize current and emerging practices in the management of cardiotoxicity and provide guidance for routine patient care in real-world practice using illustrative patient scenarios. CONCLUSIONS The future of cardiotoxicity management in patients with HER2+ breast cancer is discussed, with a focus on novel techniques to improve cardiac outcomes, including new imaging modalities, biomarkers, interventional therapies, and ongoing trials.
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Souza CAD, Simões R, Borges KBG, Oliveira AND, Zogeib JB, Alves B, Malachias MVB, Drummond-Lage AP, Rezende BA. Arterial Stiffness Use for Early Monitoring of Cardiovascular Adverse Events due to Anthracycline Chemotherapy in Breast Cancer Patients. A Pilot Study. Arq Bras Cardiol 2018; 111:721-728. [PMID: 30281690 PMCID: PMC6248238 DOI: 10.5935/abc.20180168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/23/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Chemotherapy with doxorubicin and cyclophosphamide, although efficient for treating breast cancer, is associated with cardiovascular complications. Recent studies seek to identify methods that can early detect cardiological and vascular changes as a strategy to decrease the incidence of cardiovascular comorbidities. OBJECTIVE To evaluate the role of arterial stiffness measurement in the monitoring of doxorubicin and cyclophosphamide-induced cardiotoxicity in breast cancer patients. METHODS Prospective longitudinal study in 24 breast cancer patients undergoing treatment with doxorubicin and cyclophosphamide. Patients underwent an indirect evaluation of arterial stiffness through non-invasive measurement of hemodynamic parameters such as pulse wave velocity with the Mobil-O-Graph® 24H PWA device at three different times of the chemotherapy treatment (pre-chemotherapy, after the first and the fourth cycle). The left ventricular ejection fraction was also evaluated by Doppler echocardiography (pre-chemotherapy and after the fourth chemotherapy cycle). Data were considered significant when p ≤ 0.05. RESULTS Patients had a mean age of 52.33 ± 8.85 years and body mass index of 31 ± 5.87 kg/m2. There was no significant difference between the hemodynamic parameters evaluated by the oscillometric method or in the left ventricular ejection fraction in the different evaluated periods. CONCLUSION Evaluations of arterial stiffness by oscillometry and measurement of left ventricular ejection fraction by Doppler echocardiography showed equivalence in the values found, suggesting that the evaluation method of arterial stiffness studied could be used as a marker for cardiovascular adverse events associated with doxorrubicin-based chemotherapy drugs.
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Affiliation(s)
- Cláudio Antônio de Souza
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brazil.,Hospital Alberto Cavalcanti, Belo Horizonte, MG - Brazil
| | - Ricardo Simões
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brazil.,Hospital Alberto Cavalcanti, Belo Horizonte, MG - Brazil.,Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brazil
| | | | | | | | - Bruno Alves
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brazil
| | | | | | - Bruno Almeida Rezende
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brazil.,Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG - Brazil
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10
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Kim H, Chung WB, Cho KI, Kim BJ, Seo JS, Park SM, Kim HJ, Lee JH, Kim EK, Youn HJ. Diagnosis, Treatment, and Prevention of Cardiovascular Toxicity Related to Anti-Cancer Treatment in Clinical Practice: An Opinion Paper from the Working Group on Cardio-Oncology of the Korean Society of Echocardiography. J Cardiovasc Ultrasound 2018; 26:1-25. [PMID: 29629020 PMCID: PMC5881080 DOI: 10.4250/jcu.2018.26.1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular (CV) toxicity associated with anti-cancer treatment is commonly encountered and raises critical problems that often result in serious morbidity or mortality. Most cardiac toxicities are related to the cumulative dose of chemotherapy; however, the type of chemotherapy, concomitant agents, and/or conventional CV risk factors have been frequently implicated in CV toxicity. Approximately half of the patients exhibiting CV toxicity receive an anthracycline-based regimen. Therefore, serologic biomarkers or cardiac imagings are important during anti-cancer treatment for early detection and the decision of appropriate management of cardiotoxicity. However, given the difficulty in determining a causal relationship, a multidisciplinary collaborative approach between cardiologists and oncologists is required. In this review, we summarize the CV toxicity and focus on the role of cardiac imaging in management strategies for cardiotoxicity associated with anti-cancer treatment.
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Affiliation(s)
- Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Woo-Baek Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyoung Im Cho
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Bong-Joon Kim
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Department of Internal Medicine, Busan Paik Hospital, Inje University, Busan, Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hak Jin Kim
- Department of Cardiology, Center for Clinical Specialty, National Cancer Center, Goyang, Korea
| | - Ju-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Cardiovascular and Stroke Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Joong Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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11
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Nguyen KL, Hu P, Ennis DB, Shao J, Pham KA, Chen JJ. Cardiac MRI: a Translational Imaging Tool for Characterizing Anthracycline-Induced Myocardial Remodeling. Curr Oncol Rep 2017; 18:48. [PMID: 27292153 DOI: 10.1007/s11912-016-0533-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cardiovascular side effects of cancer therapeutics are the leading causes of morbidity and mortality in cancer survivors. Anthracyclines (AC) serve as the backbone of many anti-cancer treatment strategies, but dose-dependent myocardial injury limits their use. Cumulative AC exposure can disrupt the dynamic equilibrium of the myocardial microarchitecture while repeated injury and repair leads to myocyte loss, interstitial myocardial fibrosis, and impaired contractility. Although children are assumed to have greater myocardial plasticity, AC exposure at a younger age portends worse prognosis. In older patients, there is lower overall survival once they develop cardiovascular disease. Because aberrations in the myocardial architecture predispose the heart to a decline in function, early detection with sensitive imaging tools is crucial and the implications for resource utilization are substantial. As a comprehensive imaging modality, cardiac magnetic resonance (CMR) imaging is able to go beyond quantification of ejection fraction and myocardial deformation to characterize adaptive microstructural and microvascular changes that are important to myocardial tissue health. Herein, we describe CMR as an established translational imaging tool that can be used clinically to characterize AC-associated myocardial remodeling.
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Affiliation(s)
- Kim-Lien Nguyen
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA, 90024, USA.
| | - Peng Hu
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Daniel B Ennis
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jiaxin Shao
- Diagnostic Cardiovascular Imaging Laboratory, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kimberly A Pham
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA, 90024, USA
| | - Joseph J Chen
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, MC 111E, Los Angeles, CA, 90024, USA
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12
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Lorenzini C, Lamberti C, Aquilina M, Rocca A, Cortesi P, Corsi C. Reliability of Left Ventricular Ejection Fraction from Three-Dimensional Echocardiography for Cardiotoxicity Onset Detection in Patients with Breast Cancer. J Am Soc Echocardiogr 2017; 30:1103-1110. [PMID: 28822666 DOI: 10.1016/j.echo.2017.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiotoxicity is a well-known adverse effect of various chemotherapeutic agents that can be monitored by echocardiography. A decrease in left ventricular ejection fraction (LVEF) triggers consideration for therapy modification or interruption. The aim of this study was to evaluate how variability in LVEF estimates computed using three-dimensional echocardiography could influence cardiotoxicity onset detection. METHODS One hundred eighty one patients with breast cancer treated with anthracycline and trastuzumab were analyzed. LVEF was computed using two commercial software packages. In a subgroup of 40 patients, three-dimensional echocardiographic data were reanalyzed to assess intra- and interobserver variability by two expert investigators using both packages. Global longitudinal strain (GLS) imaging was evaluated in 64 patients. RESULTS End-diastolic volume, end-systolic volume, and LVEF measurements obtained applying the two software packages were in good agreement, with small bias and acceptable limits of agreement. Intra- and interobserver variability was smaller using one of the two software packages. However, for both packages, variability indexes were in the range of affecting LVEF estimates at a level that could lead to an inaccurate assessment of cardiac adverse effects of cancer therapeutic drugs. On the basis of LVEF, 11 of 181 patients (6.1%) had cardiotoxicity at 3-month follow-up. The absolute value of GLS was smaller in 16 of 64 patients (25%) thought to have cardiotoxicity on the basis of GLS results, including six of seven patients who had cardiotoxicity considering LVEF in this subgroup. CONCLUSIONS Following clinical definition of cardiotoxicity onset, variability in LVEF computation by three-dimensional echocardiography could be a confounding factor for cardiotoxicity diagnosis, and different software packages should not be used interchangeably for LVEF monitoring. GLS confirms its predictive value for subsequent cardiotoxicity.
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Affiliation(s)
| | | | - Michele Aquilina
- Romagnolo Scientific Institute for Cancer Research and Treatment, Meldola, Italy
| | - Andrea Rocca
- Romagnolo Scientific Institute for Cancer Research and Treatment, Meldola, Italy
| | - Pietro Cortesi
- Romagnolo Scientific Institute for Cancer Research and Treatment, Meldola, Italy
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13
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Reddy P, Shenoy C, Blaes AH. Cardio-oncology in the older adult. J Geriatr Oncol 2017; 8:308-314. [PMID: 28499724 PMCID: PMC5776715 DOI: 10.1016/j.jgo.2017.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/21/2017] [Accepted: 04/20/2017] [Indexed: 12/28/2022]
Abstract
Heart disease and cancer are the leading causes of death in older adults. Many first-line cancer treatments have the potential for cardiotoxicity. Age-related risk factors, pre-existing cardiac disease, and a high prevalence of comorbidities are reasons for increased cardiotoxicity in older adults. Concerns regarding cardiotoxicity may lead to frailty bias and undertreatment, resulting in suboptimal outcomes. There is an urgent need for geriatric-specific evidence and guidelines to help tailor care for this vulnerable group. A multi-disciplinary approach based on close collaboration between oncologists, cardiologists, and geriatricians, among other specialist clinicians is essential.
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Affiliation(s)
- Prajwal Reddy
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA.
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Anne H Blaes
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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14
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The Role of Echocardiography in Detection of Chemotherapy-Induced Cardiotoxicity in Breast Cancer Patients. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2017. [DOI: 10.5812/ijcm.8109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Arab C, Dias DPM, Barbosa RTDA, Carvalho TDD, Valenti VE, Crocetta TB, Ferreira M, Abreu LCD, Ferreira C. Heart rate variability measure in breast cancer patients and survivors: A systematic review. Psychoneuroendocrinology 2016; 68:57-68. [PMID: 26943345 DOI: 10.1016/j.psyneuen.2016.02.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE In the current study, we aimed to review literature findings showing the clinical importance of cardiac autonomic modulation assessed by heart rate variability analysis in breast cancer (BC) patients and survivors. METHODS We conducted a systematic review according to The PRISMA Statement in Medline, Scopus and Web of Science (_-2015) databases. The search was limited to articles in English language, published in peer-reviewed journals, and with adult age samples only (e.g., women, patients, or survivors, diagnosed with BC in any stage). We included observational studies and randomized trials. Detailed heart rate variability analysis (instruments, data collection protocol, and analysis methods) was required. Search terms included autonomic nervous system, heart rate variability, sympathetic and parasympathetic nervous system, autonomic dysfunction, vagal nervous and breast neoplasms, breast cancer and breast tumor. RESULTS Twelve studies were included in this review. The clinical importance of cardiac autonomic modulation assessed by heart rate variability analysis in BC patients and survivors is demonstrated by association with effects of BC surgery, and treatments, and the adverse effects of surgery and treatments on survivors (e.g., cardiotoxicity, fatigue, and stress). LIMITATIONS The strength of evidence of included studies is low: small samples size and heterogeneity, presence of confounders, and observational studies design. CONCLUSIONS The heart rate variability analysis could be used as a complementary non-invasive tool for the early diagnosis and better prognosis of autonomic dysfunction, and survival in BC patients. There are many potential clinical applications of heart rate variability analysis in BC patients, and the employment of such approaches could lead to lower impairment of autonomic function in this individuals.
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Affiliation(s)
- Claudia Arab
- Departamento de Medicina (Cardiologia), Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), 715 Napoleão De Barros St., São Paulo, SP 04024-002, Brazil.
| | - Daniel Penteado Martins Dias
- Departamento de Fisiologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), 3900 Bandeirantes Av, Ribeirão Preto, SP 14049-900, Brazil.
| | - Renata Thaís de Almeida Barbosa
- Departamento de Saúde da Coletividade, Faculdade de Medicina do ABC (FMABC), 821 P Rincipe De Gales Av, Santo Andre, SP 09060-650, Brazil.
| | - Tatiana Dias de Carvalho
- Departamento de Saúde da Coletividade, Faculdade de Medicina do ABC (FMABC), 821 P Rincipe De Gales Av, Santo Andre, SP 09060-650, Brazil.
| | - Vitor Engrácia Valenti
- Centro de Estudos do Sistema Nervoso Autônomo, Departamento de Fonoaudiologia, Faculdade de Filosofia e Ciências, Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP), 737 Hygino Muzzi Filho Av, Marília, SP 17525-901, Brazil.
| | - Tânia Brusque Crocetta
- Departamento de Saúde da Coletividade, Faculdade de Medicina do ABC (FMABC), 821 P Rincipe De Gales Av, Santo Andre, SP 09060-650, Brazil.
| | - Marcelo Ferreira
- Departamento de Saúde da Coletividade, Faculdade de Medicina do ABC (FMABC), 821 P Rincipe De Gales Av, Santo Andre, SP 09060-650, Brazil.
| | - Luiz Carlos de Abreu
- Departamento de Saúde da Coletividade, Faculdade de Medicina do ABC (FMABC), 821 P Rincipe De Gales Av, Santo Andre, SP 09060-650, Brazil; Faculdade de Saúde Pública, Universidade de São Paulo (USP), 715 Doutor Arnaldo Av, Sao Paulo, SP 01246-904, Brazil.
| | - Celso Ferreira
- Departamento de Medicina (Cardiologia), Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), 715 Napoleão De Barros St., São Paulo, SP 04024-002, Brazil.
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16
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Shaikh AY, Suryadevara S, Tripathi A, Ahmed M, Kane JL, Escobar J, Cerny J, Nath R, McManus DD, Shih J, McGuiness ME, Tighe DA, Meyer TE, Ramanathan M, Aurigemma GP. Mitoxantrone-Induced Cardiotoxicity in Acute Myeloid Leukemia-A Velocity Vector Imaging Analysis. Echocardiography 2016; 33:1166-77. [PMID: 27109429 DOI: 10.1111/echo.13245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The purpose of this investigation was to: (1) determine incidence and predictors of mitoxantrone-induced early cardiotoxicity and (2) study left ventricular mechanics before and after receiving mitoxantrone. METHOD AND RESULTS We retrospectively analyzed 80 subjects diagnosed with acute myeloid leukemia (AML) who underwent chemotherapy with bolus high-dose mitoxantrone. Echocardiographic measurements were taken at baseline and at a median interval of 55 days after receiving mitoxantrone. Thirty-five (44%) of the patients developed clinically defined early cardiotoxicity, 29 (36%) of which developed heart failure. There was a significant decrease in the ejection fraction (EF) not only in the cardiotoxicity group (17.6 ± 14.8%, P < 0.001) but also in the noncardiotoxicity group (5.3 ± 8.4%, P < 0.001). Decrease in global longitudinal strain (GLS) (-3.7 ± 4.5, P < 0.001 vs. -2.4 ± 4.3, P = 0.01) and global circumferential strain (GCS) (-5.6 ± 9, P = 0.003 vs. -5.3 ± 8.7, P < 0.001) was significant in both the cardiotoxicity and noncardiotoxicity group, respectively. A multivariate model including baseline left ventricular end-systolic diameter, baseline pre-E/A ratio, and baseline pre-E/e' ratio was found to be the best-fitted model for prediction of mitoxantrone-induced early clinical cardiotoxicity. CONCLUSION High-dose mitoxantrone therapy is associated with an excellent remission rate but with a significantly increased risk of clinical and subclinical early cardiotoxicity and heart failure. Mitoxantrone-induced systolic dysfunction is evident from reduction in EF, increase in Tei index, and significant reduction in GLS and GCS. Baseline impaired ventricular relaxation evident from higher E/e' ratio and lower E/A ratio independently predicts increased risk of mitoxantrone-induced early cardiotoxicity.
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Affiliation(s)
- Amir Y Shaikh
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sourabh Suryadevara
- Department of Medicine, Providence Holy Cross Medical Center, Mission Hills, California
| | - Abhishek Tripathi
- Division of Hematology-Oncology, Baystate Medical Center, Springfield, Massachusetts
| | - Mohamed Ahmed
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jennifer L Kane
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jorge Escobar
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jan Cerny
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Hematology-Oncology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Rajneesh Nath
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Hematology-Oncology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jeffrey Shih
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Matthew E McGuiness
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Dennis A Tighe
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Theo E Meyer
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Muthalagu Ramanathan
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Hematology-Oncology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Gerard P Aurigemma
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Division of Cardiology, University of Massachusetts Medical School, Worcester, Massachusetts
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17
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Ahmed SH, Moussa Sherif DE, Fouad Y, Kelany M, Abdel-Rahman O. Principles of a risk evaluation and mitigation strategy (REMS) for breast cancer patients receiving potentially cardiotoxic adjuvant treatments. Expert Opin Drug Saf 2016; 15:911-23. [DOI: 10.1517/14740338.2016.1170115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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18
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Tan TC, Neilan TG, Francis S, Plana JC, Scherrer-Crosbie M. Anthracycline-Induced Cardiomyopathy in Adults. Compr Physiol 2016; 5:1517-40. [PMID: 26140726 DOI: 10.1002/cphy.c140059] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Anthracyclines are one of the most commonly used antineoplastic agent classes, and a core part of the treatment in breast cancers, hematological malignancies, and sarcomas. Their benefit is decreased by their well-recognized cardiotoxicity. The purpose of this review is to outline the presentation, mechanisms, diagnosis, and treatment of anthracyclines-induced cardiotoxicity. Symptomatic heart failure occurs in 2% to 5% of patients treated with anthrayclines and may be higher in older patients or patients with cardiovascular risk factors. The mechanisms involved in anthracycline-induced cardiotoxicity involve myocyte loss by apoptosis in the presence of a limited regenerative capacity. Once symptomatic, anthracycline-induced cardiotoxicity is associated with markedly decreased survival. Left ventricular ejection fraction (LVEF), mostly determined using echocardiography, is used to monitor patients treated with anthracyclines. As more than 1/3 of patients treated with anthracyclines do not recover their baseline LVEF once it is decreased, more sensitive echocardiographic indices of LV function such as myocardial deformation or biomarkers have been studied in patients monitoring. Cardioprotective treatments such as angiotensin-converting enzyme inhibitors, beta-blockers, iron chelators, statins, and metformin are also the topic of research efforts.
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Affiliation(s)
- Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Cardiology, Blacktown Hospital, University of Western Sydney, Australia
| | - Tomas G Neilan
- Cardio-oncology program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sanjeev Francis
- Cardio-oncology program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juan Carlos Plana
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardio-oncology program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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19
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Abstract
OPINION STATEMENT As advancements are made in cancer treatment, there is an increasing recognition of the cardiotoxic potential of chemotherapies and the need to monitor for the development of cardiac dysfunction in survivors. Echocardiography is the cornerstone of cardiac imaging and provides a feasible and non-invasive method to assess cardiac dysfunction in patients with cancer. In recent years, there has been increasing research in echocardiographic techniques to improve diagnosis of cardiotoxicity, including a more accurate assessment of the left ventricular function and the detection of subclinical disease. These specialized techniques include stress and contrast echocardiography, three-dimensional echocardiography, diastolic dysfunction, tissue Doppler imaging, and strain parameters.
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20
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Affiliation(s)
- Salvatore Patanè
- Cardiologia Ospedale San Vincenzo - Taormina (Me) Azienda Sanitaria Provinciale di Messina, Contrada Sirina, 98039 Taormina (Messina), Italy. patane-@libero.it
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