Use of biomarkers for the assessment of chemotherapy-induced cardiac toxicity

The Essential Strategies to Mitigate Cardiotoxicity Caused by Doxorubicin

The study of mechanisms underlying cardiotoxicity of doxorubicin and the development of strategies to mitigate doxorubicin-induced cardiotoxicity are the most relevant issues of modern cardio-oncology. This is due to the high prevalence of cancer in the population and the need for frequent use of highly effective chemotherapeutic agents, in particular anthracyclines, for optimal management of cancer patients. However, while being a potent agent to counteract cancer, doxorubicin also affects the cardiovascular systems of patients undergoing chemotherapy in a significant and unfavorable fashion. Consecutively reviewed in this article are risk factors and mechanisms of doxorubicin cardiotoxicity, and the essential strategies to mitigate cardiotoxic effects of doxorubicin treatment in cancer patients are discussed.

Assessing the cardioprotective effect of necrosulfonamide in doxorubicin-induced cardiotoxicity in mice

This study aimed to determine the cardioprotective effect of necrosulfonamide (NSA), a pyroptosis and necroptosis inhibitor, against acute doxorubicin cardiotoxicity. Fifteen male mice were divided into three groups (n=5/group). Cardiotoxicity was induced by a single intraperitoneal injection of 20 mg/kg of DOX on the 3rd day of the experiment. The control group received daily intraperitoneal (i.p.) injections of 5% DMSO for five consecutive days. The second group, the DOX group, received a single i.p. injection of 20 mg/kg DOX on the third day of the experiment. The third group, the DOX plus necrosulfonamide (NSA) group, received DOX injections like the second group and 5 mg/kg of NSA i.p. daily for five days, starting two days before the DOX injection. At the end of the study, animals were euthanized, and blood and tissue samples were collected. Various parameters, including cardiac troponin I (cTnI), TNF-α, IL-1β, caspase-1, glutathione peroxidase-4 (GPX-4), and hemeoxygenase 1 (Hmox-1), were measured using ELISA. Cardiac expression of the NF-κB gene was determined by RT-qPCR. A histopathological assessment of myocardial lesions was also performed. DOX administration significantly increased serum cTnI levels and tissue inflammatory biomarkers (TNF-α, IL-1β, caspase-1) while reducing tissue antioxidant enzymes (GPX-4, Hmox-1). In addition, it significantly increased nuclear factor-κB (NF-κB) gene expression compared to the control (about 10.5-fold elevation). Histopathological analysis revealed marked vacuolization and necrosis. However, pretreatment with NSA dramatically altered these findings, with serum cTnI levels significantly lower in this group compared to DOX. Inflammatory indicators decreased, and antioxidant enzymes were restored to varying degrees. NSA pretreatment downregulated NF-κβ gene expression and preserved near-normal myocardial morphology. Our results showed that NSA protected against DOX-induced cardiotoxicity, an effect likely mediated by its anti-pyroptotic, anti-necroptotic, and antioxidant properties.

Chronic Oxidative Stress as a Marker of Long-term Radiation-Induced Cardiovascular Outcomes in Breast Cancer

While biomarkers have been proposed to identify individuals at risk for radiation-induced cardiovascular disease (RICVD), little is known about long-term associations with cardiac events. We examined associations of biomarkers of oxidative stress (myeloperoxidase, growth differentiation factor-15, 8-hydroxy-2'-deoxyguanosine [8-OH-dG], placental growth factor), cardiac injury (troponin I, cystatin-C), inflammation (interleukin-6, C-reactive protein), and myocardial fibrosis (transforming growth factor-ß) with long-term RICVD in breast cancer (BC) survivors. We conducted a nested case-control study within the Women's Health Initiative of postmenopausal women with incident BC stages I-III, who received radiation and had pre- and post-BC diagnosis serum samples. Cases (n = 55) were defined as developing incident, physician-adjudicated myocardial infarction, coronary heart disease death, other CVD death, heart failure, or stroke after BC. Cases were matched to three controls (n = 158). After adjustment, a higher 8-OH-dG ratio was significantly associated with an elevated long-term risk of RICVD, suggesting oxidative DNA damage may be a putative pathway for RICVD.

Global longitudinal strain: an early marker for cardiotoxicity in patients treated for breast cancer

BACKGROUND

Patients treated with anthracyclines and trastuzumab are at increased risk of developing heart failure. Early diagnosis and treatment may prevent irreversible left ventricular (LV) dysfunction. This study investigates whether subclinical deterioration of global longitudinal strain (GLS) is a more reliable early predictor for LV dysfunction than three-dimensional (3D) LV ejection fraction (LVEF).

METHODS

Adult patients receiving anthracyclines and trastuzumab for breast cancer who had serial echocardiographic follow-up were included in this retrospective study. The primary endpoint was the necessity to temporarily pause chemo- or immunotherapy due to declining LVEF (decline in 3D LVEF of > 10 percentage points to < 53%). Linear mixed-effects models were used to assess the longitudinal evolution of 3D LVEF and GLS over time.

RESULTS

Fifty-one women were included, mean age 54 (50.5-57.6) years, with a total of 216 follow-up echocardiograms (mean follow-up 1.1 ± 0.45 years). GLS and 3D LVEF were significantly correlated (Spearman's rho: -0.36, p < 0.001). A decrease in GLS significantly predicted a lower LVEF on the subsequent echocardiogram [ß -0.6, 95% confidence interval (CI) (-1.0 to -0.2), p < 0.006]. Conversely, prior LVEF did not significantly predict GLS on the subsequent echocardiogram [ß -0.04, 95% CI -0.1 to -0.01, p = 0.12]. Nine patients reached the primary endpoint. On average, patients who reached the primary endpoint had a relative decrease of 15% GLS at day 205 and an absolute 10% decrease of LVEF to LVEF < 53% at day 235.

DISCUSSION

GLS is able to identify subclinical LV dysfunction earlier than 3D LVEF measurement in women undergoing treatment for breast cancer with anthracyclines followed by trastuzumab.

Efficacy and safety of cardioprotective drugs in chemotherapy-induced cardiotoxicity: an updated systematic review & network meta-analysis

BACKGROUND

Cancer patients receiving chemotherapy have an increased risk of cardiovascular complications. This limits the widespread use of lifesaving therapies, often necessitating alternate lower efficacy regimens, or precluding chemotherapy entirely. Prior studies have suggested that using common cardioprotective agents may attenuate chemotherapy-induced cardiotoxicity. However, small sample sizes and conflicting outcomes have limited the clinical significance of these results.

HYPOTHESIS

A comprehensive network meta-analysis using updated and high-quality data can provide more conclusive information to assess which drug or drug class has the most significant effect in the management of chemotherapy-induced cardiotoxicity.

METHODS

We performed a literature search for randomized controlled trials (RCTs) investigating the effects of cardioprotective agents in patients with chemotherapy-induced cardiotoxicity. We used established analytical tools (netmeta package in RStudio) and data extraction formats to analyze the outcome data. To obviate systematic bias in the selection and interpretation of RCTs, we employed the validated Cochrane risk-of-bias tools. Agents included were statins, aldosterone receptor antagonists (MRAs), ACEIs, ARBs, and beta-blockers. Outcomes examined were improvement in clinical and laboratory parameters of cardiac function including a decreased reduction in left ventricular ejection fraction (LVEF), clinical HF, troponin-I, and B-natriuretic peptide levels.

RESULTS

Our study included 33 RCTs including a total of 3,285 patients. Compared to control groups, spironolactone therapy was associated with the greatest LVEF improvement (Mean difference (MD) = 12.80, [7.90; 17.70]), followed by enalapril (MD = 7.62, [5.31; 9.94]), nebivolol (MD = 7.30, [2.39; 12.21]), and statins (MD = 6.72, [3.58; 9.85]). Spironolactone was also associated with a significant reduction in troponin elevation (MD =  - 0.01, [- 0.02; - 0.01]). Enalapril demonstrated the greatest BNP reduction (MD =  - 49.00, [- 68.89; - 29.11]), which was followed by spironolactone (MD =  - 16.00, [- 23.9; - 8.10]). Additionally, patients on enalapril had the lowest risk of developing clinical HF compared to the control population (RR = 0.05, [0.00; 0.75]).

CONCLUSION

Our analysis reaffirmed that statins, MRAs, ACEIs, and beta-blockers can significantly attenuate chemotherapy-induced cardiotoxicity, while ARBs showed no significant effects. Spironolactone showed the most robust improvement of LVEF, which best supports its use among this population. Our analysis warrants future clinical studies examining the cardioprotective effects of cardiac remodeling therapy in cancer patients treated with chemotherapeutic agents.

Quantification of Extracellular Volume in CT in Neoadjuvant Chemotherapy in Breast Cancer: New Frontiers in Assessing the Cardiotoxicity of Anthracyclines and Trastuzumab

Breast cancer patients undergoing neoadjuvant chemotherapy with anthracyclines or trastuzumab can suffer cardiotoxic issues. Nowadays, the markers of cardiac damage are still not reliable, and extracellular volume (ECV) calculated from CT could be a promising cardiotoxic marker. Eighty-two patients, treated with two different chemotherapy regimens based on doxorubicin (DOX) or epirubicin-trastuzumab (EPI-TRAS), were retrospectively selected and the variations in extracellular volume (ECV) values were measured and analyzed. Whole Body CT (WB-CT) scans were acquired after 1 min, in the portal phase (PP), and after 5 min, in the delayed phases (DP), at the baseline (T₀), after one year (T₁) and after five years (T₅) from the end of chemotherapies. The values measured by two radiologists with different levels of experience were evaluated in order to assess the inter-reader reproducibility assessment (ICC = 0.52 for PP and DP). Further, we performed a population-based analysis and a drug-oriented subgroup analysis in 54 DOX-treated and 28 EPI-TRAS-treated patients. In the general cohort of women treated with any of the two drugs, we observed in the lapse T₀-T₁ a relative increase (RI) of 25% vs. 20% (PP vs. DP, p < 0.001) as well as in the lapse T₀-T₅ an RI of 17% vs. 15% (PP vs. DP, p < 0.01). The DOX-treated patients reported in the lapse T₀-T₁ an RI of 22% (p < 0.0001) in PP and an RI of 16% (p = 0.018) in the DP, with ECV values remaining stably high at T₅ both in PP (RI 14.0%, p < 0.0001) and in DP (RI 17%, p = 0.005) highlighting a possible hallmark of a persisting CTX sub-damage. On the other hand, ECV measured in EPI-TRAS-treated women showed an RI in T₀-T₁ of 18% (p = 0.001) and 29% (p = 0.006) in PP and DP, respectively, but the values returned to basal levels in T₅ both in the PP (p = 0.12) and in DP setting (p = 0.13), suggesting damage in the first-year post-treatment and a possible recovery over time. For the 82 patients, an echocardiography was performed at T₀, T₁= 12 m + 3 m and T₅ = 60 m + 6 m with LVEF values at T₀ (64% ± 5%), T₁ (54% ± 6%) and T₅ (53% ± 8%). WB-CT-derived ECV values could provide a valid imaging marker for the early diagnosis of cardiotoxic damage in BC patients undergoing oncological treatments. We detected different patterns during the follow-up, with stably high values for DOX, whereas EPI-TRAS showed a peak within the first year, suggesting different mechanisms of cardiac damage.

Cardiac Biomarkers for the Detection and Management of Cancer Therapy-Related Cardiovascular Toxicity

Cardiotoxicity is one of the major side effects of anti-cancer therapy affecting the overall prognosis of patients and possibly leading to the discontinuation of chemotherapy. Traditional cardiovascular tests such as electrocardiography and transthoracic echocardiography have limited sensitivity and specificity for the early detection of myocardial injury. Cardiovascular imaging generally detects cancer therapy-related cardiac dysfunction (CTRCD) at advanced stages, whereas biomarkers are inexpensive, easily detected, reproducible, and capable of detecting even minimal cardiomyocyte damage or mild hemodynamic fluctuations. The presence of circulating cardiac biomarkers has been investigated as early indicators of cardiotoxicity and predictors of subsequent CTRCD. Currently, the most frequently used cardiac biomarkers are cardiac troponin (cTn) and natriuretic peptides (NPs). This review presents the evidence gathered so far regarding the usefulness and limitations of cardiac biomarkers in the field of cardio-oncology.

Investigation of the impact of rosuvastatin and telmisartan in doxorubicin-induced acute cardiotoxicity

Cardiac injury is the main dose-limiting factor for doxorubicin (Dox) use as an anticancer agent. The cardiotoxicity of Dox is linked to a number of complex mechanisms, including oxidative stress, mitochondrial damage, intracellular calcium dysregulation, and apoptosis/necrosis. This study investigates several aspects of Dox-induced cardiotoxicity. We investigated the effects of pre-treatment with rosuvastatin and telmisartan, which were used in different doses alone or combination, on the acute cardiotoxicity induced by Dox. The results of this study showed that Dox induced significant pathological changes in the cardiomyocytes. Adverse effects were observed on several biomarkers related to cardiac damage like cardiac troponin I (cTnI) and lactate dehydrogenase (LDH), oxidative stress like malondialdehyde (MDA), an inflammatory process like interleukin-17 (IL-17) with important histopathological changes. We illusterate the cardio-protective contribution of the two pharmacological agents against the acute cardiotoxic effects of Dox. This is manifested by the significant improvement in the biomarker levels and the associated histological damage. This study points out the beneficial use of both rosuvastatin and telmisartan alone or in combination as a clinical option for decreasing the acute toxicity of Dox on cardiomyocytes.

Potential effect of novel thiadiazole derivatives against radiation induced inflammation with low cardiovascular risk in rats

The aim of the present study is to explore new selective anti-inflammatory compounds with low cardiovascular risk. Twelve thiadiazole derivatives incorporating different amino acid moieties were newly synthesized (4–15) as potential anti-inflammatory agents with low cardiovascular risks through dual COX-2/MPO inhibition. Compounds were initially screened for their anti-inflammatory effect by assay of COX-2, the most potent (4–6, 8) were further tested for COX-1 inhibition, myeloperoxidase MPO activity as well as total nitric oxide content NO in heart of irradiated rats. Cardiac toxicity potential was evaluated by assay of creatine kinase-MB (CK-MB), troponin-I (Tn-I) and lactate dehydrogenase (LDH). Celcoxcib was used as reference drug. S-(5-((4-Methoxybenzylidene)amino)-2,3-dihydro-1,3,4-thiadiazol-2-yl)2-amino propanethioate (5) was the most potent anti-inflammatory with the least cardiotoxicity effect. It exhibited IC50 0.09 µM on COX-2 inhibition with very low activity on COX-1. Troponin I was elevated by 11% using compound 5 in non-irradiated rats. Moreover, compound (5) showed 73% reduction in MPO level. Results were supported by molecular docking into the active sites of COX-2 and MPO enzymes to have more insights about the possible dual inhibition of compound 5 of both enzymes.

Cardioprotective Strategies from Cardiotoxicity in Cancer Patients: A Comprehensive Review

Cardiotoxicity is a significant complication of chemotherapeutic agents in cancer patients. Cardiovascular incidents including LV dysfunction, heart failure (HF), severe arrhythmias, arterial hypertension, and death are associated with high morbidity and mortality. Risk stratification of cancer patients prior to initiation of chemotherapy is crucial, especially in high-risk patients for cardiotoxicity. The early identification and management of potential risk factors for cardiovascular side effects seems to contribute to the prevention or minimization of cardiotoxicity. Screening of cancer patients includes biomarkers such as cTnI and natriuretic peptide and imaging measurements such as LV function, global longitudinal strain, and cardiac MRI. Cardioprotective strategies have been investigated over the last two decades. These strategies for either primary or secondary prevention include medical therapy such as ACE inhibitors, ARBs, b-blockers, aldosterone antagonists, statins and dexrazoxane, physical therapy, and reduction of chemotherapeutic dosages. However, data regarding dosages, duration of medical therapy, and potential interactions with chemotherapeutic agents are still limited. Collaboration among oncologists, cardiologists, and cardio-oncologists could establish management cardioprotective strategies and approved follow-up protocols in patients with cancer receiving chemotherapy.

Could allicin alleviate trastuzumab-induced cardiotoxicity in a rat model through antioxidant, anti-inflammatory, and antihyperlipidemic properties?

AIMS

Although trastuzumab (TZB)-induced cardiotoxicity is well documented and allicin (one of the main active garlic ingredients) has ameliorating effects against numerous causes of toxicities; however, the influence of allicin on TZB-induced cardiotoxicity has not been investigated yet. Therefore, the current work explored the potential cardioprotective structural, biochemical, and molecular mechanisms of allicin against TZB-induced cardiotoxicity in a rat's model.

METHODS

Forty rats were divided into four equal groups and treated for five weeks. The control group (G1) received PBS, the allicin group (G2) received allicin (9 mg/kg/day), the TZB group (G3) received TZB (6 mg/kg/week), and the allicin+TZB group (G4) received 9 mg of allicin/kg/day +6 mg of TZB/kg/week. Heart specimens and blood samples were processed for histopathological, immunohistochemical, biochemical, and molecular investigations to determine the extent of cardiac injury in all groups.

KEY FINDINGS

The myocardium of G3 revealed significant increases in the numbers of inflammatory and apoptotic cells and the area percentage of collagen fibers and TNF-α immunoexpression compared with G1 and G2. Besides, qRT-PCR analysis exhibited significant reductions of SOD3, GPX1, and CAT expressions with significant increases in TNFα, IL-1β, IL-6, cTnI, cTnT, and LDH expressions. Additionally, flow cytometry analysis demonstrated a significant elevation in the apoptotic and ROS levels. In contrast, allicin+TZB cotherapy in G4 ameliorated all previous changes compared with G3.

SIGNIFICANCE

The current study proves that allicin could be used as a novel supplementary cardioprotective therapy to avoid TZB-induced cardiotoxicity via its anti-inflammatory, antifibrotic, antioxidant, antihyperlipidemic, and antiapoptotic properties.

Circulating biomarkers for management of cancer therapeutics related cardiac dysfunction

Cancer therapeutics related cardiac dysfunction (CTRCD) has emerged as a major cause of morbidity and mortality in cancer survivors. Effective clinical management of CTRCD is impeded by a lack of sensitive diagnostic and prognostic strategies. Circulating molecular markers could potentially address this need as they are often indicative of cardiac stress before cardiac damage can be detected clinically. A growing understanding of the underlying physiological mechanisms for CTRCD has inspired research efforts to identify novel pathophysiologically-relevant biomarkers that may also guide development of cardio-protective therapeutic approaches. The purpose of this review is to evaluate current circulating biomarkers of cardiac stress and their potential role in diagnosis and management of CTRCD. We also discuss some emerging avenues for CTRCD-focused biomarker investigations.

The Value of Left Atrial Volume Changes in Predicting Cardiotoxicity in Patients Undergoing Anthracycline Chemotherapy

In order to study the value of left atrial volume three-dimensional echocardiography in predicting cardiotoxicity in patients with multiple myeloma undergoing anthracycline chemotherapy, a total of 53 patients with multiple myeloma who are treated in the Department of Hematology of our hospital from January 2018 to December 2020 are selected as the research object, and all patients underwent three cycles (T1-T3) of chemotherapy. Before and after each cycle of chemotherapy, the patients are examined with 3D ultrasound and serology detection. These patients are divided into the cardiotoxicity group and noncardiotoxicity group. The serological indexes and three-dimensional echocardiographic parameters between two groups are compared. Multivariate logistic regression is used to determine the independent risk factors of cardiotoxicity in patients undergoing chemotherapy. And ROC curves are performed to evaluate the diagnostic value of related indicators in predicting cardiotoxicity. A total of 53 patients with multiple myeloma are included in this study. Serological indexes (T3 cTnI and T3 Pro-BNP), T2 LAVmin, T3 LAVmin, T2 LAVprep, and T3 LAVprep in the cardiotoxicity group are significantly higher than those in the noncardiotoxicity group. Multivariate logistic regression further found that T3 cTnI, T3 Pro-BNP, T2 LAVmin, T3 LAVmin, T2 LAVprep, T3 LAVprep could be used to predict the occurrence of cardiotoxicity (P < 0.05). The results of ROC curves showed that T3 LAVmin had the most diagnostic efficiency of cardiotoxicity (AUC = 0.938; sensitivity 75.72%; specificity 93.82%). Detection of changes in left atrial volume using three-dimensional ultrasound could be used as strong predictors of cardiotoxicity caused by anthracycline chemotherapy drugs in patients with multiple myeloma.

Soluble Urokinase Plasminogen Activator Receptor Is Associated With Subclinical Myocardial Impairment by Speckle Tracking Echocardiography in Lung Cancer Patients

Background

Plasma cardiac biomarkers have emerged as a cost-effective diagnostic tool aimed at early identification of cardiotoxicity. Soluble urokinase plasminogen activator receptor (suPAR) is a bone marrow cell derived signaling molecule that is associated with cardiovascular disease outcomes.

Objectives

We investigated associations between suPAR and global longitudinal strain (GLS) as a marker of early myocardial impairment in lung cancer patients.

Methods

We retrospectively analyzed 52 patients with stage IV non-small cell lung cancer with normal left ventricular ejection fraction (LVEF >55%) and without known heart disease or end-stage renal disease (ESRD). We studied associations between cardiac biomarkers and echocardiographic measures of systolic and diastolic function. GLS was analyzed using 2D speckle-tracking echocardiography via vendor-independent software (TomTec).

Results

Median plasma suPAR was 7.0 ng/mL (interquartile range: 5.4–9.0). Mean LVEF was 61.9 ± 8.3% and mean GLS was-19.3 ± 2.1%. Inter-observer reproducibility was excellent for GLS as determined by Intraclass Correlation Coefficient analysis, ICC = 0.81 (0.68–0.89). After multivariate analysis, suPAR was the only biomarker associated with GLS (p = 0.009). suPAR was also associated with diastolic parameters E velocity (p = 0.018), A velocity (p = 0.017), and E/E' ratio (p = 0.033). Interestingly, suPAR was not associated with LVEF (p = 0.916). In addition, suPAR and GLS were found to be age-independent predictors of all-cause mortality, though only GLS remained significant after multivariate adjustment.

Conclusions

In this cohort of stage IV non-small cell lung cancer patients with normal LVEF and without known heart disease or ESRD, suPAR was associated with GLS and diastolic impairment. suPAR is a readily available inexpensive biomarker; further research is required to evaluate the possible role of suPAR in screening for subclinical LV dysfunction in the high-risk oncological population.

Plasma biomarkers reflecting high oxidative stress in the prediction of myocardial injury due to anthracycline chemotherapy and the effect of carvedilol: insights from the CECCY Trial

Background: Anthracycline (ANT) is often used for breast cancer treatment but its clinical use is limited by cardiotoxicity (CTX). CECCY trial demonstrated that the β-blocker carvedilol (CVD) could attenuate myocardial injury secondary to ANT. Mieloperoxydase (MPO) is a biomarker of oxidative stress and galectin-3 (Gal-3) is a biomarker of fibrosis and cardiac remodeling. We evaluated the correlation between MPO and Gal-3 behavior with CTX.

Materials and Methods: A post hoc analysis was performed in the patients who were included in the CECCY trial. A total of 192 women had her blood samples stored during the study at –80°C until the time of assay in a single batch. Stored blood samples were obtained at baseline, 3 and 6 months after randomization. We excluded samples from 18 patients because of hemolysis. MPO and Gal-3 were measured using Luminex xMAP technology through MILLIPLEX MAP KIT (Merck Laboratories).

Results: 26 patients (14.9%) had a decrease of at least 10% in LVEF at 6 months after the initiation of chemotherapy. Among these, there was no significant difference in the MPO and Gal-3 when compared to the group without drop in LVEF (p = 0.85 for both MPO and Gal-3). Blood levels of MPO [baseline: 13.2 (7.9, 24.8), 3 months: 17.7 (11.1, 31.1), 6 months: 19.2 (11.1, 37.8) ng/mL] and Gal-3 [baseline: 6.3 (5.2, 9.6), 3 months: 12.3 (9.8, 16.0), 6 months: 10.3 (8.2, 13.1) ng/mL] increased after ANT chemotherapy, and the longitudinal changes were similar between the placebo and CVD groups (p for interaction: 0.28 and 0.32, respectively). In an exploratory analysis, as there is no normal cutoff value established for Gal-3 and MPO in the literature, the MPO and Gal-3 results were splited in two groups: above and below median. In the placebo group, women with high (above median) baseline MPO blood levels demonstrated a greater increase in TnI blood levels than those with low baseline MPO blood levels (p = 0.041). Compared with placebo, CVD significantly reduced TnI blood levels in women with high MPO blood levels (p < 0.001), but did not reduce the TnI levels in women with low baseline MPO blood levels (p = 0.97; p for interaction = 0.009). There was no significant interaction between CVD treatment and baseline Gal-3 blood levels (p for interaction = 0.99).

Conclusions: In this subanalysis of the CECCY trial, MPO and Gal-3 biomarkers did not predict the development of CTX. However, MPO blood levels above median was associated with more severe myocardial injury and identified women who were most likely to benefit from carvedilol for primary prevention (NCT01724450).

Garlic Extract Alleviates Trastuzumab-Induced Hepatotoxicity in Rats Through Its Antioxidant, Anti-Inflammatory, and Antihyperlipidemic Effects

Background

Trastuzumab is a new biological drug that has been used to treat breast and gastric cancer; however, its cardiotoxicity and hepatotoxicity limit its use. Garlic has antioxidant, anti-inflammatory, antihyperlipidemic, and anticancer effects. The present study aimed to evaluate the effects of garlic on trastuzumab-induced hepatotoxicity in a rat model.

Methods

Twenty rats were divided into four equal groups as vehicle control (G1), garlic (G2), trastuzumab (G3), and trastuzumab+garlic (G4). All rats were sacrificed after eight weeks of treatment, followed by blood collection and excision of liver tissues for further analyses. The liver specimens were processed for histopathological (HP), immunohistochemical (expression of TNF-α and PCNA), immunofluorescent expression of Chk2 and p53, biochemical, and flow cytometry investigations to evaluate the extent of hepatocyte injury. The biochemical analysis was conducted for the activity of tissue antioxidants (GPX1, CAT, and SOD2), serum lipid profile, and liver enzymes, whereas ROS was performed by flow cytometry.

Results

The results revealed remarkable structural changes in hepatocytes of G3 with significant increases in the numbers of inflammatory cells and positive PCNA cells, area % of collagen fibers, and immuno-expression of TNF-α, as well as a significant reduction in the nuclear expression of Chk2. In addition, significant reductions were noticed in the antioxidant enzymes (SOD2, CAT, and GPX1) activity of G3. In contrast, the levels of lipid profile tests (triglycerides, total cholesterol, LDLC, and HDLC), liver enzymes (ALT, AST, and ALP), and ROS revealed significant increases in rats of G3. Likewise, garlic administration in G4 restored all mentioned changes to their average levels deviated by trastuzumab.

Conclusion

Based on the current results, garlic demonstrates hepatoprotective effects against trastuzumab-induced toxicity in rats. The study suggested for the first time that the coadministration of garlic with trastuzumab for treating breast or gastric cancer can augment their efficacy with minimal toxicity.

Adjuvant breast cancer treatments cardiotoxicity and modern methods of detection and prevention of cardiac complications

The most common cancer diagnosis in female population is breast cancer, which affects every year about 2.0 million women worldwide. In recent years, significant progress has been made in oncological therapy, in systemic treatment, and in radiotherapy of breast cancer. Unfortunately, the improvement in the effectiveness of oncological treatment and prolonging patients' life span is associated with more frequent occurrence of organ complications, which are side effects of this treatment. Current recommendations suggest a periodic monitoring of the cardiovascular system in course of oncological treatment. The monitoring includes the assessment of occurrence of risk factors for cardiovascular diseases in combination with the evaluation of the left ventricular systolic function using echocardiography and electrocardiography as well as with the analysis of the concentration of cardiac biomarkers. The aim of this review was critical assessment of the breast cancer therapy cardiotoxicity and the analysis of methods its detections. The new cardio-specific biomarkers in serum, the development of modern imaging techniques (Global Longitudinal Strain and Three-Dimensional Left Ventricular Ejection Fraction) and genotyping, and especially their combined use, may become a useful tool for identifying patients at risk of developing cardiotoxicity, who require further cardiovascular monitoring or cardioprotective therapy.

Cardiovascular Oncology: The Need for a Multidisciplinary Approach

Improved cancer survivorship has led to an increase in cardiovascular (CV) complications in the oncologic population, mainly associated with therapeutic regimens. Hence, cardio-oncology has grown toward unifying the cancer care process in which the best prevention, early detection, treatment, and CV surveillance are offered to patients. This multidisciplinary approach allows us to optimize and agree upon clinical decisions to enhance clinical outcomes. Atrial fibrillation is one of the hot topics in the field because it is still challenging in cancer patients. The optimal antithrombotic therapy remains unclear. Nevertheless, evidence supports that specific recommendations are needed due to a hemorrhagic/thrombotic disbalance present within this subgroup of patients and a low rate of anticoagulation treatments compared with the general population. Further, cardiotoxicity management is currently transforming. Increasingly, early detection of subclinical alterations is raising awareness. When medical therapy is initiated early, fewer patients progress to ventricular dysfunction and the rate of patients completing cancer therapy gradually increases. New approaches are demonstrating better outcomes and these strategies will expectedly be established in clinical practice. Cardio-oncology enables us to find the best balance between cancer treatment and CV health protection. Nowadays, more and more physicians are being instructed in this discipline, which gradually exhibits a greater presence in conferences and scientific journals. However, given the need for physicians thoroughly trained in cardio-oncology, this subspecialty must be promoted further.

Genetic Polymorphisms Affecting Cardiac Biomarker Concentrations in Children with Cancer: an Analysis from the "European Paediatric Oncology Off-patents Medicines Consortium" (EPOC) Trial

BACKGROUND AND OBJECTIVES

Doxorubicin plays an essential role in the treatment of paediatric cancers. Defining genotypes with a higher risk for developing anthracycline-induced cardiotoxicity could help to reduce cardiotoxicity.

METHODS

Data originated from a phase II study assessing the pharmacokinetics of doxorubicin in 100 children. Studied patients (0-17 years) were treated for solid tumours or leukaemia. Two cycles of doxorubicin were studied. Concentrations of natriuretic peptides proANP, BNP and NT-proBNP and cardiac troponins T and I were measured at five time points before, during and after two cycles of doxorubicin treatment. Genotypes of 17 genetic polymorphisms in genes encoding for anthracycline metabolizing enzymes and drug transporters were determined for each patient. We analysed the influence of genotypes on cardiac biomarker concentrations at different time points by a Kruskal-Wallis test. To perform a pairwise comparison significant genetic polymorphisms with more than two genotypes were analysed by a post hoc test.

RESULTS

The Kruskal-Wallis tests and the post hoc-tests showed a significant association for seven genetic polymorphisms (ABCB1-rs1128503, ABCB1-rs1045642, ABCC1-rs4148350, CBR3-rs8133052, NQO2-in/del, SLC22A16-rs714368 and SLC22A16-rs6907567) with the concentration of at least one biomarker at one or more time points. We could not identify any polymorphism with a consistent effect on any biomarker over the whole treatment period.

CONCLUSIONS

In this study of patients treated with doxorubicin for different tumour entities, seven genetic polymorphisms possibly influencing the pharmacokinetics and pharmacodynamics of doxorubicin could lead occasionally to differences in the concentration of cardiac biomarkers. Since, the role of cardiac biomarkers for monitoring anthracycline-induced cardiotoxicity has not yet been clarified, further trials with a long follow-up time are required to assess the impact of these genetic polymorphisms on chemotherapy-related cardiotoxicity.

TRIAL REGISTRATION

EudraCT number: 2009-011454-17.

Assessment and Management of Cardiotoxicity in Hematologic Malignancies

With the increasing overall survival of cancer patients due to recent discoveries in oncology, the incidence of side effects is also rising, and along with secondary malignancies, cardiotoxicity is one of the most concerning side effects, affecting the quality of life of cancer survivors. There are two types of cardiotoxicity associated with chemotherapy; the first one is acute, life-threatening but, fortunately, in most of the cases, reversible; and the second one is with late onset and mostly irreversible. The most studied drugs associated with cardiotoxicity are anthracyclines, but many new agents have demonstrated unexpected cardiotoxic effect, including those currently used in multiple myeloma treatment (proteasome inhibitors and immunomodulatory agents), tyrosine kinase inhibitors used in the treatment of chronic myeloid leukemia and some forms of acute leukemia, and immune checkpoint inhibitors recently introduced in treatment of refractory lymphoma patients. To prevent irreversible myocardial damage, early recognition of cardiac toxicity is mandatory. Traditional methods like echocardiography and magnetic resonance imaging are capable of detecting structural and functional changings, but unable to detect early myocardial damage; therefore, more sensible biomarkers like troponins and natriuretic peptides have to be introduced into the current practice. Baseline assessment of patients allows the identification of those with high risk for cardiotoxicity, while monitoring during and after treatment is important for early detection of cardiotoxicity and prompt intervention.

Prognostic value of pretreatment cardiovascular biomarkers in head and neck squamous cell carcinoma

OBJECTIVES

To examine the prognostic significance of pretreatment C-reactive protein (CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP), and cardiac troponin T (cTnT) levels on all-cause mortality 3 years after head and neck squamous cell carcinoma (HNSCC) diagnosis.

SUBJECTS AND METHODS

Data from 118 consecutive HNSCC patients, treated between 2012 and 2015, were evaluated prospectively. The impact of CRP, high-sensitive (hs)-cTnT, and NT-proBNP levels on the 3-year overall survival was estimated using the Kaplan-Meier method and Cox proportional hazard models.

RESULTS

During the 36-month follow-up, 37 patients (31.35%) died. Multivariate analysis revealed that elevated CRP (Hazard ratio: 3.71, 95% CI: 1.44-9.53, p = .007) and NT-proBNP levels (Hazard ratio: 5.04, 95% CI: 2.02-12.55, p = .001) were associated with negative prognosis, independent on age, sex, smoking and alcohol status, TNM classification, tumor site, body mass index (BMI), systolic blood pressure (SBP), and treatment modality (except for radiotherapy). hs-cTnT had no influence over the prognosis, but it was correlated with TNM classification and SBP. CRP was significantly correlated with BMI and TNM classification, and NT-proBNP with SBP and hs-cTnT.

CONCLUSIONS

Pretreatment CRP and NT-proBNP levels were identified as independent prognostic markers for poor clinical outcome 3 years after HNSCC diagnosis.

Toxicities Associated with Immunotherapy and Approach to Cardiotoxicity with Novel Cancer Therapies

In recent years, major advances in oncology especially the advent of targeted agents and immunotherapies (immune checkpoint inhibitors [ICIs] and chimeric antigen receptor [CAR] T-cell therapy) have led to improved quality of life and survival rates in patients with cancer. This article focuses on the clinical features, and grading and management of toxicities associated with ICIs and CAR T-cell therapy. In addition, because cardiotoxicity is one of the most harmful effects of anticancer therapeutics, we describe the risk factors and mechanisms of cardiovascular injury associated with newer agents, screening technologies for at-risk patients, and preventive and treatment strategies.

Identification of Clinical and Laboratory Variables Associated with Cardiotoxicity Events Due to Doxorubicin in Breast Cancer Patients: A 1-Year Follow-Up Study

Cardiovascular adverse events in patients with breast cancer undergoing chemotherapy (CT) are frequent due to the high cardiotoxic potential of treatments, especially doxorubicin (DOXO). This study aimed to evaluate the association of plasma levels of various biomarkers with cardiotoxicity in women with breast cancer on DOXO-based chemotherapy. In this single center prospective cohort, 80 breast cancer patients who used DOXO as a first-line treatment for cancer were evaluated. Patients were assessed at three time points: before CT (T0), 1 week after (T1) and 12 months after DOXO treatment (T2). The predominant histological classification was ductal carcinoma, n = 72 (90.0%); the most frequent molecular classification was Human epidermal growth factor receptor-type 2 positive (HER2+), n = 34 (43.0%). In patients submitted to complementary treatment with trastuzumab (n = 23), there was no association with cardio-specific biomarkers. Evaluating the clinical variables and the laboratory parameters in T1 and T2 in relation to T0, the reduction any time of N-terminal-pro hormone B-type natriuretic peptide (NT-proBNP), triglycerides and hematocrit levels showed an association with higher cardiotoxicity risk. In addition, increased levels of troponin I (cTnI) and glycated hemoglobin (HbA₁c) showed an independent association with the occurrence of cardiotoxicity. These results suggest that the evaluation of these laboratory tests should be included routinely to identify breast cancer patients under DOXO treatment at cardiotoxicity risk.

The Role of Biomarkers in Cardio-Oncology

In the field of cardio-oncology, it is well recognised that despite the benefits of chemotherapy in treating and possibly curing cancer, it can cause catastrophic damage to bystander tissues resulting in a range of potentially of life-threatening cardiovascular toxicities, and leading to a number of damaging side effects including heart failure and myocardial infarction. Cardiotoxicity is responsible for significant morbidity and mortality in the long-term in oncology patients, specifically due to left ventricular dysfunction. There is increasing emphasis on the early use of biomarkers in order to detect the cardiotoxicity at a stage before it becomes irreversible. The most important markers of cardiac injury are cardiac troponin and natriuretic peptides, whilst markers of inflammation such as interleukin-6, C-reactive protein, myeloperoxidase, Galectin-3, growth differentiation factor-15 are under investigation for their use in detecting cardiotoxicity early. In addition, microRNAs, genome-wide association studies and proteomics are being studied as novel markers of cardiovascular injury or inflammation. The aim of this literature review is to discuss the evidence base behind the use of these biomarkers for the detection of cardiotoxicity.

Real-time three-dimensional echocardiography predicts cardiotoxicity induced by postoperative chemotherapy in breast cancer patients

BACKGROUND

The anthracycline chemotherapeutic drugs are cardiotoxic. Studies have found some indicators related to cardiotoxicity. However, there is currently no accurate indicator that can predict cardiac toxicity early.

AIM

To explore the diagnostic value of real-time three-dimensional echocardiography (RT3DE) in predicting cardiac toxicity in breast cancer patients undergoing chemotherapy.

METHODS

Female breast cancer patients who underwent radical mastectomy and postoperative chemotherapy at the Affiliated Hanzhou First People’s Hospital, Zhejiang University School of Medicine were recruited. All patients were routinely administered with chemotherapy for four cycles (T1-T4) after surgery. Two-dimensional (2D) echocardiography, RT3DE, and serological examinations were performed after each cycle of chemotherapy. Patients were divided into a toxic group and a non-toxic group based on whether patients had Δ left ventricular ejection fraction > 10% after one year of chemotherapy. Repeated measurement analysis of variance was used to compare the changes in 2D echocardiographic indicators, serological indicators, and RT3DE indicators before and after chemotherapy. Multivariate logistic regression was used to identify independent predictive indicators for cardiac toxicity in postoperative chemotherapy patients. Receiver operating characteristics (ROC) curve analysis was performed to analyze the diagnostic value of potential indicators in the diagnosis of cardiotoxicity.

RESULTS

A total of 107 female breast cancer patients were included in the study. T4 maximum peak velocity in early diastole (E peak)/mitral annulus lateral tissue Doppler (e' peak) (E/e'), serological indicators [T4 cardiac troponin I (cTnI) and T4 pro-brain natriuretic peptide (Pro-BNP)], T3 minimum left atrial volume (LAV), T4 LAVmin, T3 LAV before the start of the P wave (LAVprep), and T4 LAVprep in the toxicity group were significantly higher than those in the non-toxic group. Multivariate logistic regression found that T4 cTnI, T4 Pro-BNP, T3 LAVmin, T4 LAVmin, T3 LAVprep, and T4 LAVprep had potential predictive value for cardiac toxicity (P < 0.05). ROC results showed that T4 LAVmin had the highest accuracy for diagnosing cardiac toxicity [area under the curve (AUC) = 0.947; sensitivity = 78.57%; specificity = 94.62%], followed by T4 LAVprep (AUC = 0.899; sensitivity = 100%; specificity = 66.67%). The accuracies of LAVprep and LAVprep in predicting cardiac toxicity were higher than those of T3 LAVmin and T3 LAVprep.

CONCLUSION

RT3DE of left atrial volume can be used to predict the cardiotoxicity caused by chemotherapy, and it is expected to guide the clinical adjustment of dose and schedule in time.

Cardio-oncology, the myth of Sisyphus, and cardiovascular disease in breast cancer survivors

The number of breast cancer (BC) survivors has been increasing lately, due to the improvement in early detection strategies and oncological treatments. However, BC survivors are 3 times as likely to develop heart failure (HF) within 5 years of cancer diagnosis, and 7/100 of them will develop HF in a median follow-up of 8.5 years. Furthermore, HF in BC survivors has a worse prognosis compared to other causes of HF. Anthracyclines and trastuzumab have been proven to improve survival. However, they are also considered as the main causative factors of HF in BC survivors. Old patients, those with a pre-existing cardiovascular (CV) risk factors/disease, prior exposure to chemotherapy and radiotherapy are at increased risk. Serial evaluation of troponins and cardiac imaging parameters using echocardiography and cardiovascular magnetic resonance can significantly contribute to the early diagnosis of cardiac involvement before overt HF will develop. Assessment and immediate treatment of traditional CV risk factors is the first step for cardiotoxicity prevention. In BC survivors with known heart disease, the clinical stabilization is strongly recommended for cardiotoxicity prevention. Finally, in high-risk CV patients, primary prevention including cardioprotectants and/or CV drugs should be applied. According to recent studies, the early start of ACE inhibitors and β-blockers and the modification of anti-cancer treatment can prevent the decline in left ventricular ejection fraction. However, further multicenter studies are needed to establish both prevention and treatment protocols to successfully overcome HF development in BC survivors.

Research progress of biomarkers in early detection of chemotherapy-induced cardiotoxicity

With the advances of drug therapy, the prognosis of cancer patients has seen remarkable improvements, and cancer-related mortality has decreased significantly. However, the followed drug-related cardiotoxicity becomes a serious threat to patients' living quality and survival rate. Cardiovascular toxicity associated with some chemotherapy drugs is reversible and dose-dependent. If early identification is possible, early cardiovascular protection measures or adjustment of chemotherapy regimens can be taken to improve the prognosis of patients. Therefore, early prevention and monitoring of chemotherapy-related cardiotoxicity are critical for cancer patients and survivors. Among them, biomarkers are an important method for the early identification of myocardial injury.

Cardiotoxicity - the first cause of morbidity and mortality in pediatric patients survivors of acute lymphoblastic leukemia

Acute lymphoblastic leukemia is the most common hematological malignancy at pediatric age. Cardiotoxicity holds the first place among the causes of morbidity and mortality in these patients. Anthracyclines are cytostatic drugs frequently associated with cardiotoxicity. Early diagnosis of cardiac impairment during the treatment of pediatric patients is extremely important, both for modulating future chemotherapy and for administering cardioprotective agents. Long term monitoring after chemotherapy helps to identify the risk of late cardiotoxicity among cancer survivors. There are several biomarkers, already in use or still under study, which may represent an operator-independent alternative for echocardiography in the diagnosis of cardiotoxicity. In case of cardiac damage, the clinician has options for treating or limiting the progression, either with the use of already approved agents, such as Dexrazoxane, or by administrating other cardioprotective drugs. International experts are still attempting to establish the best algorithm for early detection of cardiotoxicity, as well as the most efficient treatment plan in case of already existing myocardial damage in these patients. We present a review on treatment-related cardiotoxicity, including mechanisms of development, useful biomarkers and treatment options, after carefully analyzing specialty literature.

Circulating biomarkers and cardiac function over 3 years after chemotherapy with anthracyclines: the ICOS-ONE trial

AIMS

A multicentre trial, ICOS-ONE, showed increases above the upper limit of normality of cardiac troponin (cTn) in 27% of patients within 12 months after the end of cancer chemotherapy (CT) with anthracyclines, whether cardiac protection with enalapril was started at study entry in all (prevention arm) or only upon first occurrence on supra-normal cTn (troponin-triggered arm). The aims of the present post hoc analysis were (i) to assess whether anthracycline-based treatment could induce cardiotoxicity over 36 month follow-up and (ii) to describe the time course of three cardiovascular biomarkers (i.e. troponin I cTnI-Ultra, B-type natriuretic peptide BNP, and pentraxin 3 PTX3) and of left ventricular (LV) function up to 36 months.

METHODS AND RESULTS

Eligible patients were those prescribed first-in-life CT, without evidence of cardiovascular disease, normal cTn, LV ejection fraction (EF) >50%, not on renin-angiotensin aldosterone system antagonists. Patients underwent echocardiography and blood sampling at 24 and 36 months. No differences were observed in biomarker concentration between the two study arms, 'prevention' vs. 'troponin-triggered'. During additional follow-up 13 more deaths occurred, leading to a total of 23 (9.5%), all due to a non-cardiovascular cause. No new occurrences of LV-dysfunction were reported. Two additional patients were admitted to the hospital for cardiovascular causes, both for acute pulmonary embolism. No first onset of raised cTnI-Ultra was reported in the extended follow-up. BNP remained within normal range: at 36 months was 23.4 ng/L, higher (N.S.) than at baseline, 17.6 ng/L. PTX3 peaked at 5.2 ng/mL 1 month after CT and returned to baseline values thereafter. cTnI-Ultra peaked at 26 ng/L 1 month after CT and returned to 3 ng/L until the last measurement at 36 months. All echocardiographic variables remained stable during follow-up with a median LVEF of 63% and left atrial volume index about 24 mL/m² .

CONCLUSIONS

First-in-life CT with median cumulative dose of anthracyclines of 180 mg/m² does not seem to cause clinically significant cardiac injury, as assessed by circulating biomarkers and echocardiography, in patients aged 51 years (median), without pre-existing cardiac disease. This may suggest either a 100% efficacy of enalapril (given as preventive or troponin-triggered) or a reassuringly low absolute cardiovascular risk in this cohort of patients, which may not require intensive cardiologic follow-up.

Identification of differential gene expression related to epirubicin-induced cardiomyopathy in breast cancer patients

BACKGROUND

Epirubicin is a potent chemotherapeutic agent for the treatment of breast cancer. However, it may lead to cardiotoxicity and cardiomyopathy, and no reliable biomarker was available for the early prediction of epirubicin-induced cardiomyopathy.

METHODS

Global gene expression changes of peripheral blood cells were studied using high-throughput RNA sequencing in three pair-matched breast cancer patients (patients who developed symptomatic cardiomyopathy paired with patients who did not) before and after the full session of epirubicin-based chemotherapy. Functional analysis was conducted using gene ontology and pathway enrichment analysis.

RESULTS

We identified 13 significantly differentially expressed genes between patients who developed symptomatic epirubicin-induced cardiomyopathy and their paired control who did not. Among them, the upregulated Bcl-associated X protein was related to "apoptosis," while the downregulated 5'-aminolevulinate synthase 2 (ALAS2) was related to both "glycine, serine, and threonine metabolism" and "porphyrin and chlorophyll metabolism" in pathway enrichment analysis.

CONCLUSIONS

ALAS2 and the metabolic pathways which were involved may play an important role in the development of epirubicin-induced cardiomyopathy. ALAS2 may be useful as an early biomarker for epirubicin-induced cardiotoxicity detection.

Optimal management of coronary artery disease in cancer patients

Owing to early diagnosis and rapid development of treatments for cancers, the five-year survival rate of all cancer types has markedly improved worldwide. Over time, however, there has been an increase in the number of cancer patients who develop coronary artery disease (CAD) due to different causes. First, many risk factors are shared between cancer and CAD. Second, inflammation and oxidative stress are common underlying pathogeneses in both disorders. Lastly, cancer therapy can result in endothelial injury, coronary artery spasm, and coagulation, thereby increasing the risk of CAD. As more cancer patients are being diagnosed with CAD, specialized cardiac care should be established to minimize the cardiovascular mortality of cancer survivors.

Acute reversible left ventricular systolic dysfunction associated with 5-fluorouracil therapy: a rare and increasingly recognised cardiotoxicity of a commonly used drug

5-Fluorouracil (5-FU) is the third most common chemotherapeutic agent for treating solid cancers and the second most common to cause cardiotoxicity. We present a rare case of acute reversible severe left ventricular systolic dysfunction associated with 5-FU. A 54-year-old woman with a history of stage IV gastric cancer presented with features of transient ischaemic attack after receiving the first dose of FLOT (5-FU, leucovorin, oxaliplatin and docetaxel). During the diagnostic workup, it was found that her ejection fraction was severely reduced to 15% with features of global hypokinesis, which later improved back to 65% within 13 days. These cases challenge our current understanding of the underlying mechanisms of this cardiotoxicity. Additionally, even though the patient did not experience any cardiac symptoms, it is important to monitor these patients closely as they are at high risk for fatal complications like arrhythmia and thrombus formation.

Genetic Variants Associated With Cancer Therapy-Induced Cardiomyopathy

BACKGROUND

Cancer therapy-induced cardiomyopathy (CCM) is associated with cumulative drug exposures and preexisting cardiovascular disorders. These parameters incompletely account for substantial interindividual susceptibility to CCM. We hypothesized that rare variants in cardiomyopathy genes contribute to CCM.

METHODS

We studied 213 patients with CCM from 3 cohorts: retrospectively recruited adults with diverse cancers (n=99), prospectively phenotyped adults with breast cancer (n=73), and prospectively phenotyped children with acute myeloid leukemia (n=41). Cardiomyopathy genes, including 9 prespecified genes, were sequenced. The prevalence of rare variants was compared between CCM cohorts and The Cancer Genome Atlas participants (n=2053), healthy volunteers (n=445), and an ancestry-matched reference population. Clinical characteristics and outcomes were assessed and stratified by genotypes. A prevalent CCM genotype was modeled in anthracycline-treated mice.

RESULTS

CCM was diagnosed 0.4 to 9 years after chemotherapy; 90% of these patients received anthracyclines. Adult patients with CCM had cardiovascular risk factors similar to the US population. Among 9 prioritized genes, patients with CCM had more rare protein-altering variants than comparative cohorts ( P≤1.98e-04). Titin-truncating variants (TTNtvs) predominated, occurring in 7.5% of patients with CCM versus 1.1% of The Cancer Genome Atlas participants ( P=7.36e-08), 0.7% of healthy volunteers ( P=3.42e-06), and 0.6% of the reference population ( P=5.87e-14). Adult patients who had CCM with TTNtvs experienced more heart failure and atrial fibrillation ( P=0.003) and impaired myocardial recovery ( P=0.03) than those without. Consistent with human data, anthracycline-treated TTNtv mice and isolated TTNtv cardiomyocytes showed sustained contractile dysfunction unlike wild-type ( P=0.0004 and P<0.002, respectively).

CONCLUSIONS

Unrecognized rare variants in cardiomyopathy-associated genes, particularly TTNtvs, increased the risk for CCM in children and adults, and adverse cardiac events in adults. Genotype, along with cumulative chemotherapy dosage and traditional cardiovascular risk factors, improves the identification of patients who have cancer at highest risk for CCM.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01173341; AAML1031; NCT01371981.

Prevention, monitoring and treatment of cardiovascular adverse events in myeloma patients receiving carfilzomib A consensus paper by the European Myeloma Network and the Italian Society of Arterial Hypertension

BACKGROUND

The novel proteasome inhibitor carfilzomib alone or in combination with other agents is already one of the standard therapies for relapsed and/or refractory multiple myeloma (MM) patients and produces impressive response rates in newly diagnosed MM as well. However, carfilzomib-related cardiovascular adverse events (CVAEs) - including hypertension (all grades: 12.2%; grade ≥3: 4.3%), heart failure (all grades: 4.1%; grade ≥3: 2.5%) and ischemic heart disease (all grades: 1.8%; grade ≥3: 0.8%) - may lead to treatment suspensions. At present, there are neither prospective studies nor expert consensus on the prevention, monitoring and treatment of CVAEs in myeloma patients treated with carfilzomib.

METHODS

An expert panel of the European Myeloma Network in collaboration with the Italian Society of Arterial Hypertension and with the endorsement of the European Hematology Association aimed to provide recommendations to support health professionals in selecting the best management strategies for patients, considering the impact on outcome and the risk-benefit ratio of diagnostic and therapeutic tools, thereby achieving myeloma response with novel combination approaches whilst preventing CVAEs.

RESULTS

Patients scheduled to receive carfilzomib need a careful cardiovascular evaluation before treatment and an accurate follow-up during treatment.

CONCLUSIONS

A detailed clinical assessment before starting carfilzomib treatment is essential to identify patients at risk for CVAEs, and accurate monitoring of blood pressure and of early signs and symptoms suggestive of cardiac dysfunction remains pivotal to safely administer carfilzomib without treatment interruptions or dose reductions.

Cardiac Toxicity and Anthracyclines: Mechanism, Interventions, and the Trouble With Troponin

As cancer survivorship increases, clinicians need to become educated regarding the long-term effect of cancer treatments. Cancer therapeutics–related cardiac dysfunction (CTRCD) is one such sequela that contributes to significant morbidity and mortality. Unfortunately, screening and management practices regarding CTRCD are inconsistent within guidelines and practice. This review will first look at anthracycline-related cardiac dysfunction occurrence and pathophysiology. Current guidelines for CTRCD screening will be discussed, including the use of 2D echocardiograms along with newer technology such as 3D echocardiography and global systolic longitudinal myocardial strain (GLS) measurements. Biomarkers like serum troponin demonstrate promise as an early indicator of cardiomyocyte injury and a potential means of risk stratification; however, guidelines vary regarding how best to incorporate elevated serum troponin levels into management plans. Growing evidence indicates the clinical need for early detection of CTRCD in order to initiate preventative pharmacologic management and improve patient outcomes.

Physiopathology and diagnosis of cardiotoxicity in patients submitted to chemotherapy treatment

Cardiovascular diseases and neoplastic diseases are the two main causes of morbidity and mortality in the world. Treated cancer patients usually develop cardiac diseases late in life due to chemotherapy- induced heart damage. The type of damage caused to the heart depends on the type of agent used during cancer treatment. It is expectable to observe ventricular impairment in patients treated with anthracyclines, while pyrimidines and some signalling inhibitors may damage the coronary circulation. Several techniques can be used to help diagnose early cardiac affections, such as biomarkers and auxiliary diagnostic tests. The information obtained can help physicians adjust chemotherapy doses, thus avoiding unnecessary heart damage. Although there is not yet a broad offer of cardioprotective drugs specific to these cases, some pharmacological agents used in common cardiology can also be applied here, such as beta-blockers and angiotensinogen- converting enzyme inhibitors.

The breast cancer patient in the cardioncology unit

The breakthroughs of breast cancer management have led to a significant improvement in patient survival. However, to obtain this outcome a considerable price has been paid regarding cardiovascular side effects. Indeed, cardiovascular disease is the main cause of mortality in patients with breast cancer over fifty years of age, contributing more than cancer mortality in older cancer survivors. Thus, the identification and the management of patients with breast cancer at risk for cardiovascular events has become critical in order to reduce morbidity and mortality from cardiovascular toxicity due to cancer therapy, which may blunt its effectiveness. Today, cardioncology is a novel and recognized medical discipline, which aims to encourage a close interaction between cardiology and oncology, explore new strategies, collect evidence-based indications, and develop interdisciplinary expertise with the ultimate goal of minimize the risk of developing cardiovascular disease during and after anticancer therapy, prevent the breast cancer patient cured today from becoming the heart patient of tomorrow, and avoiding the possibility that pre-existent cardiac disease be a barrier leading to a reduction of a patient's therapeutic opportunities. In this review we discussed the advantages of a cardioncology approach in terms of risk stratification, monitoring for early diagnosis, prevention, and early treatment of cardiotoxicity.

Updates in Anthracycline-Mediated Cardiotoxicity

Cardiotoxicity is one of the main adverse effects of chemotheraphy, affecting the completion of cancer therapies and the short- and long-term quality of life. Anthracyclines are currently used to treat many cancers, including the various forms of leukemia, lymphoma, melanoma, uterine, breast, and gastric cancers. World Health Organization registered anthracyclines in the list of essential medicines. However, anthracyclines display a major cardiotoxicity that can ultimately culminate in congestive heart failure. Taking into account the growing rate of cancer survivorship, the clinical significance of anthracycline cardiotoxicity is an emerging medical issue. In this review, we focus on the key progenitor cells and cardiac cells (cardiomyocytes, fibroblasts, and vascular cells), focusing on the signaling pathways involved in cellular damage, and the clinical biomarkers in anthracycline-mediated cardiotoxicity.

Cardio-oncology: an overview on outpatient management and future developments

Recent advances in the early detection and treatment of cancer have led to increasing numbers of cancer survivors worldwide. Nonetheless, despite major improvements in the outcome of these patients, long-term side effects of radio- and chemotherapy affect both patient survival and quality of life, independent of the oncological prognosis. Chemotherapy-related cardiac dysfunction is one of the most notorious short-term side effects of anticancer treatment, occurring in ~10% of patients. Progression to overt heart failure carries a strikingly poor prognosis with a 2-year mortality rate of 60%. Early detection of left ventricular damage by periodic monitoring and prompt initiation of heart failure treatment is key in improving cardiovascular prognosis. To meet the growing demand for a specialised interdisciplinary approach for the prevention and management of cardiovascular complications induced by cancer treatment, a new discipline termed cardio-oncology has evolved. However, an uniform, multidisciplinary approach is currently lacking in the Netherlands. This overview provides an introduction and comprehensive summary of this emerging discipline and offers a practical strategy for the outpatient management of this specific patient population.

Role of ACE inhibitors in anthracycline-induced cardiotoxicity: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Several measures including drugs have been tried to reduce anthracycline cardiotoxicity. The lack of randomized trials prompted this study to assess the role of an angiotensin converting enzyme (ACE) inhibitor (enalapril) in anthracycline-induced cardiotoxicity in children with hematological malignancies.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted on 84 patients with leukemia (41) and lymphoma (43) who received anthracyclines (doxorubicin and/or daunorubicin) at cumulative dose ≥200 mg/m² . The patients were randomized to receive either enalapril [group A (n = 44)] or placebo [group B (n = 40)] for 6 months. Left ventricular ejection fraction (LVEF) and cardiac biomarkers (cardiac troponin I [cTnI], probrain natriuretic peptide [proBNP], and creatine kinase MB [CK-MB]) were assessed at baseline and 6 months. The primary outcome was a measured decrease in LVEF (≥20%). Secondary outcome measures were changes in cardiac biomarkers and the development of heart failure or arrhythmias.

RESULTS

LVEF decreased in both groups at 6 months, more so in group B (62.25 ± 5.49 vs 56.15 ± 4.79, P < 0.001). A ≥20% decrease was seen in 3 patients in group B but none in group A (P = 0.21). Cardiac biomarkers increased more in group B at 6 months, and the increase was significant for proBNP (49.60 ± 35.97 vs 98.60 ± 54.24, P < 0.001) and cTnI (0.01 ± 0.00 vs 0.011 ± 0.003, P = 0.035) but not significant for CK-MB (1.08 ± 0.18 vs 1.21 ± 0.44, P = 0.079). In group A, 9.1% of the patients showed an increase in proBNP level ≥100 compared with 37.5% in group B (P < 0.001). No patient developed heart failure or arrhythmia.

CONCLUSION

Enalapril has a role in reducing cardiac toxicity after anthracycline administration.

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.

Toxicity and Safety Evaluation of Doxorubicin-Loaded Cockleshell-Derived Calcium Carbonate Nanoparticle in Dogs

Doxorubicin (DOX) is a potent anticancer agent with cytotoxic effects which limit its clinical usage. This effect is due to its nonselective nature causing injury to the cells as a result of reactive free oxygen radical's release. Cockleshell-derived calcium carbonate nanoparticle (CS-CaCO3NP) is a pH-responsive carrier with targeted delivery potentials. This study aimed at evaluating the toxicity effects of repeated dose administration of DOX-loaded CS-CaCO3NP in healthy dogs. Fifteen dogs with an average body weight of 15 kg were randomized equally into 5 groups. Dogs were subjected to 5 doses at every 3-week interval with (i) normal saline, (ii) DOX, 30 mg/m2, and the experimental groups: CS-CaCO3NP-DOX at (iii) high dose, 50 mg/m2, (iv) clinical dose, 30 mg/m2, and (v) low dose, 20 mg/m2. Radiographs, electrocardiography, and blood samples were collected before every treatment for haematology, serum biochemistry, and cardiac injury assessment. Heart and kidney tissues were harvested after euthanasia for histological and ultrastructural evaluation. The cumulative dose of DOX 150 mg/m2 over 15 weeks revealed significant effects on body weight, blood cells, functional enzymes, and cardiac injury biomarkers with alterations in electrocardiogram, myocardium, and renal tissue morphology. However, the dogs given CS-CaCO3NP-DOX 150 mg/m2 and below did not show any significant change in toxicity biomarker as compared to those given normal saline. The study confirmed the safety of repeated dose administration of CS-CaCO3NP-DOX (30 mg/m2) for 5 cycles in dogs. This finding offers opportunity to dogs with cancer that might require long-term administration of DOX without adverse effects.

Role of Biomarkers in Prediction of Cardiotoxicity During Cancer Treatment

Purpose of review

As cancer survivor rates improve with early screening and modern treatment options, cardiotoxicity is becoming an increasing problem. It is imperative for physicians to recognize adverse events early so that appropriate measures can be taken before advanced and permanent cardiac dysfunction ensues. In this review, we will evaluate the literature surrounding current cardiac biomarkers in the detection of cardiotoxicity during cancer treatment as well as discuss the role of emerging novel biomarkers.

Recent findings

Troponin and brain natriuretic peptides show promise in the detection of subclinical cardiotoxicity during cancer treatment. In addition to identifying late complications among cancer survivors, they have the potential to predict patients who are at risk of developing cardiotoxicity prior to the initiation of cancer therapy. However, there are also conflicting data due to varying study design.

Summary

Although biomarkers are an attractive option in the detection of cardiotoxicity among cancer patients, current recommendations surrounding its role are based on expert consensus opinion. Further research with appropriately designed prospective trials is required to guide optimal clinical practice.

Anthracycline-induced cardiotoxicity: A multicenter randomised trial comparing two strategies for guiding prevention with enalapril: The International CardioOncology Society-one trial

BACKGROUND

Troponin changes over time have been suggested to allow for an early diagnosis of cardiac injury ensuing cancer chemotherapy; cancer patients with troponin elevation may benefit of therapy with enalapril. It is unknown whether a preventive treatment with enalapril may further increase the benefit.

METHODS

The International CardioOncology Society-one trial (ICOS-ONE) was a controlled, open-label trial conducted in 21 Italian hospitals. Patients were randomly assigned to two strategies: enalapril in all patients started before chemotherapy (CT; 'prevention' arm), and enalapril started only in patients with an increase in troponin during or after CT ('troponin-triggered' arm). Troponin was assayed locally in 2596 blood samples, before and after each anthracycline-containing CT cycle and at each study visit; electrocardiogram and echocardiogram were done at baseline, and at 1, 3, 6 and 12-month follow-up. Primary outcome was the incidence of troponin elevation above the threshold.

FINDINGS

Of the 273 patients, 88% were women, mean age 51 ± 12 years. The majority (76%) had breast cancer, 3% had a history of hypertension and 4% were diabetic. Epirubicin and doxorubicin were most commonly prescribed, with median cumulative doses of 360 [270-360] and 240 [240-240] mg/m², respectively. The incidence of troponin elevation was 23% in the prevention and 26% in the troponin-triggered group (p = 0.50). Three patients (1.1%) -two in the prevention, one in the troponin-triggered group-developed cardiotoxicity, defined as 10% point reduction of LV ejection fraction, with values lower than 50%.

INTERPRETATION

Low cumulative doses of anthracyclines in adult patients with low cardiovascular risk can raise troponins, without differences between the two strategies of giving enalapril. Considering a benefit of enalapril in the prevention of LV dysfunction, a troponin-triggered strategy may be more convenient.