Traditional and novel methods to assess and prevent chemotherapy-related cardiac dysfunction noninvasively

Cardiac events among a cohort of 17,389 patients receiving cancer chemotherapy: short and long term implications

BACKGROUND

The association between cardiovascular disease and carcinogenesis is bidirectional and well-established. Furthermore, cancer treatment improves overall patient survival, potentially at the cost of incremental and fatal cardiovascular disease (CVD).

AIM

To evaluate (a) In a real-world cohort, the proportion of patients offered cancer chemotherapy who have antecedent CVD (CVDA); (b) The rates of patient admission with subsequent development of CVD (CVDS) requiring hospital admission post assignment to chemotherapy; (c) The impact of CVDA and CVDS on mortality rates relative to those seen in patients without overt CVD (CVD-) and (d) The time course of mortality in CVD- versus CVDS patients.

METHODS

Retrospective analysis was performed in deidentified linked health data sets. Correlates of mortality were evaluated by Cox proportional hazards evaluation. Relative and absolute time-variability of CVD as a primary cause of death were determined.

RESULTS

Of the total 17,389 patients, there were 2,159 with CVDA. Over a median follow-up time of 4.6 years, CVDS admissions (n = 8,529) occurred more commonly in the presence of CVDA (70.0% vs. 46.1%, p < 0.001), and more than 50% of CVDS cases occurred in the first 12 months of follow-up. The 5-year mortality rates were 71.5% for CVDA, 64.7% for CVDS, and 40.8% for CVD- (p < 0.001). Development of CVDS was associated with a substantially increased risk of mortality in the next 12 months. The development of CVDs was also associated with an increased risk of cardiovascular, as against non-cardiovascular, mortality (7.1% vs. 1.6%, p < 0.001).

CONCLUSIONS

Approximately 50% of patients assigned to cancer chemotherapy developed CVDS, heralding a particularly high risk of mortality over the next 12 months. Both CVDA and CVDS are associated with substantial increases in mortality rates relative to those in CVD- patients. This increased risk merits close individual monitoring.

Pediatric Cardio-Oncology: Screening, Risk Stratification, and Prevention of Cardiotoxicity Associated with Anthracyclines

Anthracyclines have significantly improved the survival of children with malignant tumors, but the associated cardiotoxicity, an effect now under the purview of pediatric cardio-oncology, due to its cumulative and irreversible effects on the heart, limits their clinical application. A systematic screening and risk stratification approach provides the opportunity for early identification and intervention to mitigate, reverse, or prevent myocardial injury, remodeling, and dysfunction associated with anthracyclines. This review summarizes the risk factors, surveillance indexes, and preventive strategies of anthracycline-related cardiotoxicity to improve the safety and efficacy of anthracyclines.

The role of stress echocardiography in identifying cardiotoxicity: an in-depth exploration

Cancer treatment might cause heart failure and deteriorate the patients' quality of life. Despite the wide use of conventional echocardiography, it often fails to detect cardiotoxicity until advanced cardiac dysfunction at potentially irreversible stages. Advanced techniques, such as three-dimensional imaging and strain analysis in stress echocardiography, have shown promise in identifying cardiotoxicity at subclinical stages, even when traditional measures remain within normal ranges. These novel techniques have been shown to identify cardiac impairment in 30%-50% of the patients undergoing potentially cardiotoxic chemotherapy, which allows for early intervention and enhanced patient management. Although professional societies are advocating for the inclusion of these techniques into routine monitoring protocols, more research is needed to optimize and standardize their use across various centers and chemotherapeutic agents. This review explores the role of stress echocardiography in the early detection and monitoring of chemotherapy-induced cardiotoxicity. It delves into current knowledge and emerging research, aiming to provide a comprehensive understanding and to highlight areas worthy of further investigation.

Changes in vascular function and correlation with cardiotoxicity in women with newly diagnosed breast cancer undergoing HER2-directed therapy with and without anthracycline/cyclophosphamide

Aims

The objective of this study was to assess the effect of HER2-directed therapy (HER2-Tx) on peripheral vasoreactivity and its correlation with cardiac function changes and the additive effects of anthracycline/cyclophosphamide (AC) therapy and baseline cardiovascular risk.

Methods and results

Single-centre, prospective cohort study of women with newly diagnosed stage 1-3 HER2-positive breast cancer undergoing HER2-Tx +/- AC. All participants underwent baseline and 3-monthly evaluations with Endo-Peripheral Arterial Tonometry (Endo-PAT), vascular biomarkers [C-type natriuretic peptide (CNP) and neuregulin-1 beta (NRG-1β)], and echocardiography. Cardiotoxicity was defined as a decrease in the left ventricular ejection fraction (LVEF) of >10% to a value <53%. Of the 47 patients enrolled, 20 (43%) received AC in addition to HER2-Tx. Deterioration of reactive hyperaemia index (RHI) on Endo-PAT by ≥20% was more common in patients receiving HER-Tx plus AC than HER2-Tx alone (65% vs. 22%; P = 0.003). A decrease in CNP and log NRG-1β levels by 1 standard deviation did not differ significantly between the AC and non-AC groups (CNP: 20.0% vs. 7.4%; P = 0.20 and NRG-1β: 15% vs. 11%; P = 0.69) nor did GLS (35% vs. 37%; P = 0.89). Patients treated with AC had a significantly lower 3D LVEF than non-AC recipients as early as 3 months after exposure (mean 59.3% (SD 3) vs. 63.8% (SD 4); P = 0.02). Reactive hyperaemia index and GLS were the only parameters correlating with LVEF change.

Conclusion

Combination therapy with AC, but not HER2-Tx alone, leads to a decline in peripheral vascular and cardiac function. Larger studies will need to define more precisely the causal correlation between vascular and cardiac function changes in cancer patients.

Activation recovery interval as an electrocardiographic repolarization index to detect doxorubicin-induced cardiotoxicity

BACKGROUND

It has been reported that early detection and treatment of cancer therapy- related cardiac dysfunction (CTRCD) improves its prognosis. The detailed relationships between electrocardiographic repolarization indices and decreased left ventricular function in CTRCD have not been elucidated. We closely assessed such relationships in patients with doxorubicin (DOX)-induced CTRCD.

METHODS

This retrospective, single-center, cohort study included 471 consecutive patients with malignant lymphoma who received chemotherapy including DOX. Of them, 17 patients with CTRCD and 68 patients without CTRCD who underwent 12‑lead electrocardiogram and an echocardiogram before and after chemotherapy were eventually analyzed. The fluctuations of the following electrocardiographic repolarization indices were evaluated in lead V5: QT, JT, T peak to T end interval (Tp-e), and activation recovery interval (ARI). These indices were corrected by heart rate with the Fridericia formula.

RESULTS

The median period from the end of chemotherapy to the diagnosis of the CTRCD group was 346 days (IQR 170-1283 days). After chemotherapy, the QT interval was significantly prolonged in both with and without CTRCD groups compared with that before chemotherapy (pre QTc vs. post QTc in CTRCD group, 386 ± 27 ms vs. 411 ± 37 ms, p = 0.03, pre QTc vs. post QTc in non-CTRCD group, 388 ± 24 ms vs. 395 ± 25 ms, p = 0.04, respectively). ARIc after chemotherapy was characteristically observed only in the CTRCD group (pre ARIc vs. post ARIc in CTRCD group, 258 ± 53 ms vs. 211 ± 28 ms, p = 0.03, pre ARIc vs. post ARIc in non-CTRCD group, 221 ± 19 ms vs. 225 ± 23 ms, NS, respectively) and had negative correlations with left ventricular ejection fraction (r = -0.56, p < 0.001). Using the receiver-operating characteristic curve, the relationship between ARIc and CTRCD morbidity was examined. The optimal cut-off point of ARIc prolongation between before and after chemotherapy was 18 ms (sensitivity 75 %, specificity 79 %, area under the curve 0.76).

CONCLUSIONS

ARIc prolongation may be useful in the early detection of developing late-onset chronic DOX-induced CTRCD and lead to early treatment for cardiac protection.

Challenges in Cardiovascular Imaging in Women with Breast Cancer

Cardiovascular imaging in breast cancer patients is paramount for the surveillance of cancer therapy-related cardiac dysfunction (CTRCD); however, it comes with specific limitations. PURPOSE OF REVIEW: This review aims to describe the unique challenges faced in cardiovascular imaging of breast cancer patients, discuss evidence to support the utility of various imaging modalities, and provide solutions for improvement in imaging this unique population. RECENT FINDINGS: Updated clinical society guidelines have introduced more unifying surveillance of CTRCD, although there remains a lack of a universally accepted definition. Traditional and novel multi-modality imaging can be used to detect CTRCD and myocarditis in breast cancer patients. Cardiovascular imaging in breast cancer patients is difficult due to reconstructive surgery. Although echocardiography with myocardial strain is the cornerstone, multi-modality imaging can be used to evaluate for CTRCD and myocarditis. Novel imaging techniques to improve the diagnosis of cardiotoxicities in breast cancer patients are needed.

CARDIOTOXICITY IN BREAST CANCER PATIENTS: RELATIONSHIP OF HS-TROPONIN T CHANGES AND HEART FUNCTION IN CANCER TREATMENT

Breast cancer patients (BC) have a high risk of cardiotoxicity (CT) due to a combination of cancer treatments.Cardiovascular (CV) complications lead to delay or withdrawal of BC therapy and worsen the survival. Therefore, it isimportant to detect CT at the early stages before the occurrence of cardiac dysfunction and heart failure (HF) signs.

OBJECTIVE

to study the dynamic changes of high-sensitivity (hs) troponin (Tn) T (hs-TnT) level in BC patients during cancer treatment with the use of chemotherapy and radiation therapy (RT) to predict and prevent CV complications during individualized management.

MATERIAL AND METHODS

40 BC patients were included in the pilot study. The analysis of the dynamic changes of hs-TnT and ejection fraction (EF) of the left ventricle (LV) was performed before and within 6 months of cancer treatment. Based on the data analysis, a definition of a significant increase in hs-TnT was developed and proposed. Therise of hs-TnT was calculated by the difference (%) between its baseline level and in the 6 months of cancer treatment. BC patients are grouped into tertiles according to the hs-TnT increase: group 1 - low level (0-50 %), group 2 -moderate level (> 50-100 %), and group 3 - high level (> 100 %).

RESULTS

Before the start of cancer treatment, LVEF did not differ significantly between groups (mean EF (62.6 ± 1.0) %)and the hs-TnT level was also within normal values (0.008±0.001 ng/ml). In 6 months of cancer treatment, LVEF waswithin the normal ranges and did not differ significantly in patients of group 1. However, in patients of groups 2and 3 - LVEF drop (δLV EF) was 5.7 % (р < 0.01) and 10.8 % (р < 0.01), consequently. According to the correlationanalysis, the percentage of increase in hs-TnT (δhs-TnT) was associated with δEF LV (r = 0.39, р < 0.05) and the useof anthracyclines (AC) (r = 0.37, р < 0.05). Using logistic regression and ROC analysis, the diagnostic threshold valueof the hs-TnT increase > 165 % was defined, which can be considered as a reliable marker of early biochemical CT,with a sensitivity of 99 % and a specificity of 56 %.

CONCLUSIONS

In BC patients, based on the level of hs-TnT increase, proposed a new early biochemical CT detectionmethod. Under the new approach, BC patients with hsTnT increase of > 165 % from baseline can be considered as areliable marker of early biochemical CT, with a sensitivity of 99 % and a specificity of 56 %.

Cardiovascular toxicity of PI3Kα inhibitors

The phosphoinositide 3-kinases (PI3Ks) are a family of intracellular lipid kinases that phosphorylate the 3'-hydroxyl group of inositol membrane lipids, resulting in the production of phosphatidylinositol 3,4,5-trisphosphate from phosphatidylinositol 4,5-bisphosphate. This results in downstream effects, including cell growth, proliferation, and migration. The heart expresses three PI3K class I enzyme isoforms (α, β, and γ), and these enzymes play a role in cardiac cellular survival, myocardial hypertrophy, myocardial contractility, excitation, and mechanotransduction. The PI3K pathway is associated with various disease processes but is particularly important to human cancers since many gain-of-function mutations in this pathway occur in various cancers. Despite the development, testing, and regulatory approval of PI3K inhibitors in recent years, there are still significant challenges when creating and utilizing these drugs, including concerns of adverse effects on the heart. There is a growing body of evidence from preclinical studies revealing that PI3Ks play a crucial cardioprotective role, and thus inhibition of this pathway could lead to cardiac dysfunction, electrical remodeling, vascular damage, and ultimately, cardiovascular disease. This review will focus on PI3Kα, including the mechanisms underlying the adverse cardiovascular effects resulting from PI3Kα inhibition and the potential clinical implications of treating patients with these drugs, such as increased arrhythmia burden, biventricular cardiac dysfunction, and impaired recovery from cardiotoxicity. Recommendations for future directions for preclinical and clinical work are made, highlighting the possible role of PI3Kα inhibition in the progression of cancer-related cachexia and female sex and pre-existing comorbidities as independent risk factors for cardiac abnormalities after cancer treatment.

The mRNA expression of Il6 and Pdcd1 are predictive and protective factors for doxorubicin‑induced cardiotoxicity

Anthracyclines, such as doxorubicin (DOX), have been widely used in the treatment of a number of different solid and hematological malignancies. However, these drugs can inflict cumulative dose-dependent and irreversible damage to the heart, and can occasionally lead to heart failure. The cardiotoxic susceptibility varies among patients treated with anthracycline, and delays in the recognition of cardiotoxicity can result in poor prognoses. Accordingly, if the risk of cardiotoxicity could be predicted prior to drug administration, it would aid in safer and more effective chemotherapy treatment. The present study was carried out to identify genes that can predict DOX-induced cardiotoxicity (DICT). In an in vivo study, mice cumulatively treated with DOX demonstrated increases in serum levels of cardiac enzymes (aspartate aminotransferase, lactate dehydrogenase, creatine kinase MB isoenzyme and troponin T), in addition to decreases in body and heart weights. These changes were indicative of DICT, but the severity of these effects varied among individual mice. In the current study, the correlation in these mice between the extent of DICT and circulating blood concentrations of relevant transcripts before DOX administration was analyzed. Among various candidate genes, the plasma mRNA levels of the genes encoding interleukin 6 (Il6) and programmed cell death 1 (Pdcd1) in blood exhibited significant and positive correlations with the severity of DICT. In an in vitro study using cardiomyocyte H9c2 cells, knockdown of Il6 or Pdcd1 by small interfering RNA was revealed to enhance DOX-induced apoptosis, as determined by luminescent assays. These results suggested that the levels of transcription of Il6 and Pdcd1 in cardiomyocytes serve a protective role against DICT, and that the accumulation of these gene transcripts in blood is a predictive marker for DICT. To the best of our knowledge, this is the first report to demonstrate a role for Il6 and Pdcd1 mRNA expression in DICT.

Usefulness of Stress Echocardiography in the Management of Patients Treated with Anticancer Drugs

In recent years, the survival of patients with cancer has improved thanks to advances in antineoplastic therapeutic protocols. This has led to an increasing burden of cardiovascular complications related to cancer treatment. Therefore, a new branch of cardiology has been created, "cardio-oncology," with the aims of preventing cardiovascular complications related to antineoplastic treatment, achieving early diagnosis and treatment of any complications, and allowing completion of the expected antineoplastic treatment. Stress echocardiography has a pivotal role in achieving a timely diagnosis of coronary artery disease and thus is the best management approach in this clinical setting. Atherosclerotic processes can be exacerbated by both chemotherapy and chest irradiation in patients with cancer, even several years after anticancer treatment completion. Moreover, stress echocardiography has many other potential applications, such as in the evaluation of subclinical left ventricular dysfunction and contractile reserve in patients treated with anticancer drugs that have the potential to induce myocardial damage, as well as evaluating valve disease. The objective of this review is to delineate the role of stress echocardiography in cardio-oncology.

The Preventive role of Regular Physical Training in Ventricular Remodeling, Serum Cardiac Markers, and Exercise Performance Changes in Breast Cancer in Women Undergoing Trastuzumab Therapy-An REH-HER Study

Cardiotoxicity is known as a severe clinical problem in oncological practice that reduces the options for cancer therapy. Physical exercise is recognized as a well-established protective measure for many heart and cancer diseases. In our study, we hypothesized that supervised and moderate-intensity exercise training would prevent heart failure and its consequences induced by trastuzumab therapy. The aim of this study was to examine the effect of physical training on ventricular remodeling, serum cardiac markers, and exercise performance in women with human epidermal growth receptor 2 (HER2+) breast cancer (BC) undergoing trastuzumab therapy. This was a prospective, randomized, clinical controlled trial. Forty-six BC women were randomized into either an intervention group (IG) or a control group (CG). An exercise program (IG) was performed after 3–6 months of trastuzumab therapy at 5 d/week (to 80% maximum heart rate (HRmax)) for 9 weeks. We then evaluated their cardiac function using echocardiography, a 6-Minute Walk Test (6MWT), and plasma parameters (C-reactive protein (CRP), myoglobin (MYO), interleukin-6 (IL-6), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and creatine kinase (CK)). After the physical training program, we did not observe any significant changes in the left ventricular (LV) ejection fraction (LVEF) and 6MWT (p > 0.05) in the IG compared to the CG (decrease p < 0.05). The differences in the blood parameters were not significant (p < 0.05). To conclude, moderate-intensity exercise training prevented a decrease in the LVEF and physical capacity during trastuzumab therapy in HER2+ BC. Further research is needed to validate our results.

Drug-induced myocardial dysfunction - recommendations for assessment in clinical and pre-clinical studies

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.

Cardiotoxicity of Cancer Therapies

Cardiotoxicity is a known complication of many cancer therapies. While the cardiotoxicity of established agents such as anthracyclines, antimetabolites, and alkylating agents is well known, it is important to realize that newer anticancer therapies such as tyrosine kinase inhibitors, angiogenesis inhibitors, and checkpoint inhibitors are also associated with significant adverse cardiovascular effects. Echocardiography, magnetic resonance imaging, and radionuclide imaging have been used to identify these complications early and prevent further consequences. We will discuss the different classes of cancer therapeutic agents that cause cardiotoxicity, the mechanisms that lead to these effects, and strategies that can be used to prevent the cardiac morbidity and mortality associated with their use.

Effects of physical exercise on outcomes of cardiac (dys)function in women with breast cancer undergoing anthracycline or trastuzumab treatment: study protocol for a systematic review

BACKGROUND

Cardiotoxicity is a known complication and one of the most adverse effects from the use of conventional treatments such as anthracyclines and trastuzumab in breast cancer (BC) care. This phenomenon has been associated with the restriction of therapeutic options and the increase of cardiovascular complications, which may compromise the survival of patients. Implementation of preventive strategies is an important approach for the management of this issue. Physical exercise has been proposed as a non-pharmacological strategy to counteracting cardiotoxicity. The aim of this protocol is to describe the rationale and methods for a systematic review of published randomized controlled trials (RCTs) that have analysed the effects of physical exercise on outcomes of cardiac (dys)function in women with BC undergoing neoadjuvant or adjuvant treatment containing anthracyclines and/or trastuzumab.

METHODS AND ANALYSIS

This is a protocol for a systematic review reported according to the PRISMA-P 2015 checklist. Randomized controlled trials (RCTs) will be included. The literature will be screened on MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, ISI Web of Science and Scopus. The risk of bias of the included RCTs will be assessed using the Cochrane Collaboration's tool. The primary outcomes will be systolic function (left ventricular ejection fraction), diastolic function (E/A' ratio, deceleration time of early left ventricular filling, isovolumetric relaxation time, E/E' septal and lateral ratio) and myocardial deformation imaging outcomes (strain and strain rate [measured in longitudinal, radial, or circumferential directions]). Secondary outcomes will be cardiac biomarkers (troponin I or T, high-sensitivity troponin I or T, brain natriuretic peptide, amino terminal of B-type natriuretic peptide). Data will be descriptively reported, and quantitative synthesis will also be considered if the included studies are sufficiently homogenous.

DISCUSSION

This systematic review will help to understand the effectiveness of physical exercise on counteracting cardiotoxicity related to anticancer therapies in women with BC.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018096060.

MRI in cardio-oncology: A review of cardiac complications in oncologic care

From detailed characterization of cardiac abnormalities to the assessment of cancer treatment-related cardiac dysfunction, cardiac MRI is playing a growing role in the evaluation of cardiac pathology in oncology patients. Current guidelines are now incorporating the use of MRI for the comprehensive multidisciplinary approach to cancer management, and innovative applications of MRI in research are expanding its potential to provide a powerful noninvasive tool in the arsenal against cancer. This review focuses on the application of cardiac MRI to diagnose and manage cardiovascular complications related to cancer and its treatment. Following an introduction to current cardiac MRI methods and principles, this review is divided into two sections: functional cardiovascular analysis and anatomical or tissue characterization related to cancer and cancer therapeutics. Level of Evidence: 5 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2019;50:1349-1366.

Imaging doxorubicin and polymer-drug conjugates of doxorubicin-induced cardiotoxicity with bispecific anti-myosin-anti-DTPA antibody and Tc-99m-labeled polymers

BACKGROUND

Radiolabeled anti-myosin imaging is well-established for imaging doxorubicin-induced cardiotoxicity. However, to enable imaging of drug-induced cardiotoxicity in small experimental animals, pretargeting with bispecific anti-myosin-anti-DTPA-Fab-Fab' and targeting with high-specific radioactivity Tc-99m-DTPA-succinylated-polylysine (DSPL) was developed.

METHODS

Mice were injected biweekly with 10 mg/kg Dox or its equivalent as D-Dox-PGA. Tc-99m-DSPL myocardial activity after pretargeting with bsAb-Fab-Fab' was determined after gamma imaging performed at day 7 for Dox-treated mice and day 39 for all others.

RESULTS

Mice treated with 10 mg/kg Dox lost 10% total body weight in 1 week and 20% after a second dose. Pretargeted mice treated with 30 mg/kg cumulative D-Dox-PGA dose showed no loss of body weight for the duration of the study. Cardiotoxicity was confirmed by gamma imaging and scintillation counting (1.9 ± 0.25 [mean% ID/g ± SD]) after 1 dose of Dox. Mice injected with 3 × 10 mg/kg Dox equivalent as D-Dox-PGA (0.4 ± 0.04, P < .01) and untreated 2 control groups (0.20 ± 0.05 and 0.19 ± 0.04, P < .01) showed significantly lower myocardial anti-myosin radioactivity relative to the 10 mg/kg Dox group.

CONCLUSION

Pretargeting with bsAb-Fab-Fab' and targeting with Tc-99m labeled high-specific activity polymers enabled early visualization of doxorubicin induce cardiotoxicity in mice. Tolerated dose of D-Dox-PGA was greater than to 30 mg/kg Dox-equivalent dose with minimal cardiotoxicity.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document (J Am Coll Cardiol 2017;70:1647-1672) addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities.Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines.A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario.The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document¹ addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Early diagnosis of cardiotoxic complications of chemotherapy: the possibility of radiation research methods

Oncological diseases are the main causes of death in the world. Modern treatment of cancer patients contributes to an increase in survival rate due to strong chemotherapeutic drugs, the use of which is accompanied by toxic effects on cardiomyocytes. The main manifestations of cardiotoxicity are left ventricular dysfunction, myocardial ischemia, thromboembolic complications, chronic heart failure. As a result, the risk of cardiovascular mortality may be higher than the risk of death from the tumor process. An important task of oncologists and cardiologists is the early diagnosis of cardiotoxic complications in order to start treatment in time and reduce mortality from cardiovascular pathology in cancer patients.

Cardio-oncology: Understanding cardiotoxicity to guide patient focused imaging

Current cancer therapy has led to tremendous improvements in outcomes. These therapies rely both on established therapies, such as anthracyclines and radiation, and molecularly-targeted therapies, such as tyrosine kinase inhibitors and immune modulators. Integrative care for patients with cancer must consider the potential effects of these therapies on a variety of organ systems, including the cardiovascular system. As a result, specialties such as cardio-oncology have developed to identify these effects, determine how to best monitor for these effects, and how to treat and ultimately prevent these effects while allowing the patient to receive the therapy they require for their cancer. This review provides a basis for understanding the cardiovascular effects of cancer therapies so that the most appropriate imaging modality may be selected to prevent and treat these effects.

Cancer and the Broken Heart: Complications and Implications of Therapy-Related Cardiotoxicity

The growing number of adult long-term cancer survivors has expanded our knowledge of negative physiologic sequelae associated with curative therapies. Of note are the cardiovascular corollaries of chest radiotherapy and some commonly used chemotherapy agents. A contemporary understanding of risk factors has facilitated the development of guidelines for prevention and surveillance of cardiac compromise. The future holds promise with enhanced opportunities to use cardioprotectant drugs and biomarkers to prevent and detect early myocardial changes. Infusion therapy nurses must keep abreast of these developments to facilitate their roles as patient educators and advocates in the face of this toxicity's prevalence.

Anticancer Therapy-Induced Atrial Fibrillation: Electrophysiology and Related Mechanisms

Some well-established immunotherapy, radiotherapy, postoperation, anticancer drugs such as anthracyclines, antimetabolites, human epidermal growth factor receptor 2 blockers, tyrosine kinase inhibitors, alkylating agents, checkpoint inhibitors, and angiogenesis inhibitors, are significantly linked to cardiotoxicity. Cardiotoxicity is a common complication of several cancer treatments. Some studies observed complications of cardiac arrhythmia associated with the treatment of cancer, including atrial fibrillation (AF), supraventricular arrhythmias, and cardiac repolarization abnormalities. AF increases the risk of cardiovascular morbidity and mortality; it is associated with an almost doubled risk of mortality and a nearly 5-fold increase in the risk of stroke. The occurrence of AF is also usually researched in patients with advanced cancer and those undergoing active cancer treatments. During cancer treatments, the incidence rate of AF affects the prognosis of tumor treatment and challenges the treatment strategy. The present article is mainly focused on the cardiotoxicity of cancer treatments. In our review, we discuss these anticancer therapies and how they induce AF and consequently provide information on the precaution of AF during cancer treatment.

Cardiotoxicity of cancer chemotherapy in clinical practice

Several anticancer agents are associated with significant cardiotoxicity. The list of cardiotoxic cancer therapeutic agents includes anthracyclines, trastuzumab, alkylating agents, antimetabolites, which have been in use for decades; and recently introduced anticancer therapies such as tyrosine kinase inhibitors, angiogenesis inhibitors, checkpoint inhibitors and proteasome inhibitors. Cardiac imaging using echocardiography, nuclear imaging techniques, and magnetic resonance (MR) imaging can help in the early detection of chemotherapy-related cardiotoxicity. This can prevent the morbidity and mortality resulting from the cardiotoxicity of these agents. Further research is needed to improve our understanding of the underlying mechanism of their cardiotoxicity and to develop newer preventive and therapeutic strategies for chemotherapy related cardiotoxicity.

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

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.

Current views on anthracycline cardiotoxicity

Anthracyclines are well established and effective anticancer agents used to treat a variety of adult and pediatric cancers. Unfortunately, these drugs are also among the commonest chemotherapeutic agents that have been recognized to cause cardiotoxicity. In the last years, several experimental and clinical investigations provided new information and perspectives on anthracycline-related cardiotoxicity. In particular, molecular mechanisms of cardiotoxicity have been better elucidated, early diagnosis has improved through the use of advanced noninvasive cardiac imaging techniques, and emerging data indicate a genetic predisposition to develop anthracycline-related cardiotoxicity. In this article, we review established and new knowledge about anthracycline cardiotoxicity, with special focus on recent advances in cardiotoxicity diagnosis and genetic profiling.

Cardiac Magnetic Resonance Imaging in Oncology

BACKGROUND

Cardiac magnetic resonance imaging (MRI) is emerging as an important diagnostic modality in the management of cardiovascular-related dysfunction in oncological diseases. Advances in imaging techniques have enhanced the detection and evaluation of cardiac masses; meanwhile, innovative applications have created a growing role for cardiac MRI for the management of cardiotoxicity caused by cancer therapies.

METHODS

An overview is provided of the clinical indications and technical considerations of cardiac MRI. Its role in the evaluation of cardiac masses and cardiac function is reviewed, and novel sequences are discussed that are giving rise to future directions in cardio-oncology research. A review of the literature was also performed, focusing on cardiac MRI findings associated with cardiac dysfunction related to cancer treatment.

RESULTS

Cardiac MRI can be used to differentiate benign and malignant primary cardiac tumors, metastatic disease, and pseudotumors with high spatial and temporal resolution. Cardiac MRI can also be used to detect the early and long-term effects of cardiotoxicity related to cancer therapy. This is accomplished through a multiparametric approach that uses conventional bright blood, dark blood, and postcontrast sequences while also considering the applicability of newer T1 and T2 mapping sequences and other emerging techniques.

CONCLUSIONS

Cardio-oncology programs have an expanding presence in the multidisciplinary approach of cancer care. Consequently, knowledge of cardiac MRI and its potential applications is critical to the success of contemporary cancer diagnostics and cancer management.

Cardiac Complications of Cancer Therapy: Pathophysiology, Identification, Prevention, Treatment, and Future Directions

PURPOSE OF REVIEW

Cardiotoxicity is an important complication of cancer therapy. With a significant improvement in the overall survival and prognosis of patients undergoing cancer therapy, cardiovascular toxicity of cancer therapy has become an important public health issue. Several well-established as well as newer anticancer therapies such as anthracyclines, trastuzumab, and other HER2 receptor blockers, antimetabolites, alkylating agents, tyrosine kinase inhibitors, angiogenesis inhibitors, checkpoint inhibitors, and thoracic irradiation are associated with significant cardiotoxicity.

RECENT FINDINGS

Cardiovascular imaging employing radionuclide imaging, echocardiography, and magnetic resonance imaging is helpful in early detection of the cardiotoxicity and prevention of overt heart failure. These techniques also provide important tools for understanding the mechanism of cardiotoxicity of these modalities, which would help develop strategies for the prevention of cardiac morbidity and mortality related to the use of these agents. An understanding of the mechanism of the cardiotoxicity of cancer therapies can help prevent and treat their adverse cardiovascular consequences. Clinical implementation of algorithms based upon cardiac imaging and several non-imaging biomarkers can prevent cardiac morbidity and mortality associated with the use of cardiotoxic cancer therapies.

Cardiotoxicity of cancer chemotherapy: identification, prevention and treatment

Cardiotoxicity is an important complication of several cancer therapeutic agents. Several well established and newer anticancer therapies such as anthracyclines, trastuzumab and other HER2 receptor blockers, antimetabolites, alkylating agents, tyrosine kinase inhibitors (TKIs), angiogenesis inhibitors, and checkpoint inhibitors are associated with significant cardiotoxicity. Cardiovascular imaging employing radionuclide imaging, echocardiography and magnetic resonance imaging are helpful in early detection and prevention of overt heart failure secondary to cardiotoxicity of cancer therapy. An understanding of the mechanism of the cardiotoxicity of cancer therapies can help prevent and treat their adverse cardiovascular consequences. Clinical implementation of algorithms based upon cardiac imaging and several non-imaging biomarkers can prevent cardiac morbidity and mortality associated with the use of cardiotoxic cancer therapies.

Frequency of Left Ventricular End-Diastolic Volume-Mediated Declines in Ejection Fraction in Patients Receiving Potentially Cardiotoxic Cancer Treatment

We sought to determine the frequency by which decreases in left ventricular (LV) end-diastolic volume (LVEDV) with and without increases in end-systolic volume (LVESV) influenced early cancer treatment-associated declines in LV ejection fraction (LVEF) or LV mass. One hundred twelve consecutively recruited subjects (aged 52 ± 14 years) with cancer underwent blinded cardiovascular magnetic resonance measurements of LV volumes, mass, and LVEF before and 3 months after initiating potentially cardiotoxic chemotherapy (72% of participants received anthracyclines). Twenty-six participants developed important declines in LVEF of >10% or to values <50% at 3 months, in whom 19% versus 60%, respectively, experienced their decline in LVEF due to isolated declines in LVEDV versus an increase in LVESV; participants who dropped their LVEF due to decreases in LVEDV lost more LV mass than those who dropped their LVEF due to an increase in LVESV (p = 0.03). Nearly one fifth of subjects experience marked LVEF declines due to an isolated decline in LVEDV after initiating potentially cardiotoxic chemotherapy. Because reductions in intravascular volume (which could be treated by volume repletion) may account for LVEDV-related declines in LVEF, these data indicate that LV volumes should be reviewed along with LVEF when acquiring imaging studies for cardiotoxicity during the treatment for cancer.

Cardiomyopathic Toxicity From Chemotherapy: Is There an Opportunity for Preemptive Intervention?

OPINION STATEMENT

The fight against cancer has never appeared more optimistic with multiple ongoing advances in cancer therapeutics; however, the prevention of cardiotoxicity from these treatments, both old and new, is a major focus of recent research. We recommend conceptualizing the prevention of cardiotoxicity as binary whereby primary prevention involves a uniform application of preventative efforts to anyone receiving a potentially cardiotoxic drug and secondary prevention directed towards those with left ventricular dysfunction, whether symptomatic or not. Recent studies suggest that cardioprotective medications such as renin-angiotensin inhibitors and beta blockers, among others, may be beneficial in the primary prevention of cardiotoxicity. Importantly, the magnitude of this protective effect appears to be driven by baseline risk of cardiac disease. In terms of secondary prevention, we recommend that patients with symptomatic heart failure related to cancer treatment should be treated as aggressively as patients with heart failure from other causes, as indicated by the most recent guidelines. We identify a relative paucity of data to guide those with asymptomatic left ventricular dysfunction. We summarize the literature to date with an emphasis on recent investigation and outline the importance of a continued partnership between cardiologists, oncologists, and primary care providers.

Alternative Biomarkers for Combined Biology

Chemotherapy-related cardiac dysfunction (CRCD) has challenged clinicians to hesitate in using cardiotoxic agents such as anthracycline and several protein kinase inhibitors. As early detection of CRCD and timely cessation of cardiotoxic agents became a strategy to avoid CRCD, cardiac troponin and natriuretic peptide are measured to monitor cardiotoxicity; however, there are inconsistencies in their predictability of CRCD. Alternative biomarkers have been researched extensively for potential use as more sensitive and accurate biomarkers. The mechanisms of CRCD and previous studies on traditional and novel biomarkers for CRCD are examined to enlighten future direction of investigation in this combined biology.

Assessment of late anthracycline-induced cardiotoxicity by 123I-mIBG cardiac scintigraphy in patients treated during childhood and adolescence

PURPOSE

The goal of this study was to evaluate late cardiotoxic effects of anthracyclines (ATC) by evaluating cardiac sympathetic activity in a cohort of asymptomatic patients previously treated with ATC for childhood cancers.

METHODS

We studied 89 asymptomatic patients previously treated with ATC with a normal echocardiogram (49 men and 40 women) and a control group of 40 healthy individuals (26 men and 14 women). Both groups underwent planar myocardial 123I-meta-iodobenzylguanidine scintigraphy (123I-mIBG). From these images, the early and late heart-to-mediastinum (H/M) ratio and washout rate (WR) were assessed.

RESULTS

The mean survival at the time of the 123I-mIBG scintigraphy was 5.3 ± 3.4 years. Patients treated with ATC had a lower but clinical normal left ventricular ejection fraction (LVEF) compared to controls (60.44 ± 6.5 vs 64.1 ± 6.0%, P < 0.01). Both the late H/M ratio and WR were not able to discriminate ATC treated patients from controls. The cumulative ATC dose was the only independent predictor of the LVEF, explaining approximately 12% of the variation in LVEF (P = 0.01).

CONCLUSIONS

Although the pathophysiology behind ATC cardiotoxicity is most likely multifactorial, myocardial sympathetic activity is not associated with a reduction in LVEF 5-years after completion of chemotherapy.

Noninvasive early detection of anthracycline-induced cardiotoxicity in patients with hematologic malignancies using the phased tracking method

Anthracyclines are among the most effective and widely used anticancer drugs; however, their use is limited by serious cardiotoxicity. Early detection is necessary to prevent the high mortality rate associated with heart failure (HF). We evaluated cardiac function in 142 patients using conventional echocardiography and the phased tracking method (PTM), which was measured using the minute vibration and the rapid motion components, neither of which is recognized in standard M-mode nor in tissue Doppler imaging. For systolic function comparison, we compared left ventricular ejection fraction (LVEF) in conventional echocardiography with the average velocity of ventricular septum myocytes (Vave ) in the PTM. The Vave of 12 healthy volunteers was 1.5 (m/s)/m or more. At baseline of 99 patients, there was a positive correlation between LVEF and Vave in all patients. There were no significant differences in baseline cardiac function between patients with and without HF. There was a negative correlation between the cumulative anthracycline dose and LVEF or Vave among all patients. We determined that Vave 1.5 (m/s)/m was equivalent to LVEF 60%, 1.25 (m/s)/m to 55%, and 1.0 (m/s)/m to 50%. During the follow-up period, there was a pathological decrease in LVEF (<55%) and Vave (<1.25 m/s/m) in patients with HF; decreases in Vave were detected significantly earlier than those in LVEF (P < 0.001). When Vave declined to 1.5 (m/s)/m or less, careful continuous observation and cardiac examination was required. When Vave further declined to 1.0 (m/s)/m or lower, chemotherapy was postponed or discontinued; thus, serious drug-induced cardiomyopathy was avoided in patients who did not relapse. The PTM was superior to echocardiography for early, noninvasive detection and intermediate-term monitoring of left ventricle systolic function associated with anthracycline chemotherapy, among patients with hematologic malignancies. The PTM was an effective laboratory procedure to avoid the progression to serious cardiomyopathy.