1
|
Muraoka N, Oyakawa T, Fujita A, Iida K, Yokota T, Kenmotsu H. Frequency of ischemic cardiac events in patients receiving long-term multikinase inhibitor: A report of three cases. Asia Pac J Oncol Nurs 2025; 12:100624. [PMID: 39712513 PMCID: PMC11658567 DOI: 10.1016/j.apjon.2024.100624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 11/16/2024] [Indexed: 12/24/2024] Open
Abstract
Objective To investigate the incidence and characteristics of ischemic cardiac events, specifically major adverse cardiac events (MACE), in patients undergoing long-term treatment with multikinase inhibitors (MKIs) such as lenvatinib and sorafenib. Methods A single-center retrospective analysis was conducted on 41 patients treated with lenvatinib or sorafenib for more than one year at our institution from 2015 to 2022. Patient records were reviewed to collect data on demographics, cancer type, cardiovascular risk factors, MKI treatment duration, and MACE incidence. MACE events, defined as acute heart failure, fatal arrhythmia, acute myocardial infarction, and coronary revascularization, were analyzed to determine potential correlations with MKI therapy. Results Among the 41 patients, three (7.3%) developed MACE, presenting as acute heart failure, fatal arrhythmia, and acute myocardial infarction, all associated with significant coronary artery stenosis. Notably, none of these patients had a prior history of cardiovascular disease. Despite variations in clinical presentation, all cases suggested a link between long-term MKI administration and accelerated coronary atherosclerosis. Factors involved in atherosclerosis were significantly older and tended to be more hypertensive in the non-MACE group. Conclusions Long-term MKI therapy may increase the risk of severe ischemic cardiac events, likely due to accelerated atherosclerosis. Clinicians and oncology nurses should monitor patients closely for early signs of angina, especially in an outpatient setting, to prevent acute cardiac events. Further large-scale studies are warranted to establish a clearer causal relationship between MKI therapy and cardiovascular risks.
Collapse
Affiliation(s)
- Nao Muraoka
- Division of Cardio-oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takuya Oyakawa
- Division of Cardio-oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ayano Fujita
- Division of Cardio-oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kei Iida
- Division of Internal Medicine, Mishima Tokai Hospital, Shizuoka, Japan
| | - Tomoya Yokota
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | | |
Collapse
|
2
|
Bloom MW, Ferrari AM, Stojanovska J, Harnden KK, Beckford Y, Skurka K, Barac A. Cardio-Oncology Program Building: A Practical Guide. Cardiol Clin 2025; 43:195-207. [PMID: 39551558 DOI: 10.1016/j.ccl.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2024]
Abstract
The organization of a cardio-oncology clinic and overall program is designed to provide comprehensive cardiovascular care to patients who are at risk of or have developed cardiovascular sequelae during or following cancer treatments. In this article, we summarize the core components of a contemporary cardio-oncology program, including its core members (cardiologists, oncologists, clinical pharmacists, advanced practice providers, nurses, and coordinators), key services (risk assessment, treatment planning, cardiac imaging, intervention, and management), and practical integration within the health care system.
Collapse
Affiliation(s)
| | - Alana M Ferrari
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Jadranka Stojanovska
- Department of Radiology, NYU Langone Hospital, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Yaisa Beckford
- Department of Cardiology, Inova Schar Heart and Vascular, Fairfax, VA, USA
| | - Kerry Skurka
- Cardio-Oncology Nurse/Program Consultant, International Cardio-Oncology (IC-OS) Society
| | - Ana Barac
- Department of Cardiology, Inova Schar Heart and Vascular, Fairfax, VA, USA.
| |
Collapse
|
3
|
Bredin P, Galvin Z, O'Kane GM. Role of immunotherapy in managing cancers prior to liver transplantation. Curr Opin Organ Transplant 2025; 30:3-11. [PMID: 39620576 DOI: 10.1097/mot.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICIs) have transformed the treatment landscape in advanced hepatocellular carcinoma and increasingly are being evaluated in earlier stage disease. Herein we explore the role of ICIs pre-liver transplant for liver cancers. RECENT FINDINGS Given the high response rates with combination approaches including locoregional treatments, more patients with liver confined disease, without vascular invasion, who have received ICIs are now being rendered eligible for potential liver transplant. This opportunity to expand the population who may benefit from liver transplant has also come with challenges recognizing the global shortage of organs. Post-liver transplant immunosuppression potentially competes with the immune-stimulating effects of ICIs and graft rejection has been a concern. ICIs may provide an opportunity to maintain patients on the waiting list but an understanding of who is likely to benefit is needed, to circumvent possible toxicities. In addition, ICIs are now considered standard of care, in combination with chemotherapy, for advanced cholangiocarcinoma, where the role of liver transplant is evolving. SUMMARY As the eligibility criteria globally for liver transplant in the setting of malignancy continues to expand, the integration of ICIs becomes increasingly important.
Collapse
Affiliation(s)
| | - Zita Galvin
- St Vincent's University Hospital, Elm Park
- University College Dublin, Ireland
| | - Grainne M O'Kane
- St Vincent's University Hospital, Elm Park
- University College Dublin, Ireland
| |
Collapse
|
4
|
Girardi L, Di Nisio M, Candeloro M, Valeriani E, Ageno W. Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs. Eur J Clin Invest 2025; 55:e14311. [PMID: 39262322 PMCID: PMC11628654 DOI: 10.1111/eci.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 08/23/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses. AIMS This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs. METHODS No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies. CONTENT The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context. CONCLUSIONS The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.
Collapse
Affiliation(s)
- Laura Girardi
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences“G. D'Annunzio” UniversityChieti‐PescaraItaly
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry“G. D'Annunzio” UniversityChietiItaly
| | - Emanuele Valeriani
- Department of General Surgery and Surgical SpecialtySapienza University of RomeRomeItaly
- Department of Infectious DiseaseUmberto I HospitalRomeItaly
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
- Department of MedicineRegional Hospital of Bellinzona, Ente Ospedaliero CantonaleBellinzonaSwitzerland
| |
Collapse
|
5
|
Weaver KE, Dressler EV, Klepin HD, Lee SC, Wells BJ, Smith S, Hundley WG, Lesser GJ, Nightingale CL, Turner JC, Lackey I, Heard K, Foraker R. Effectiveness of a Cardiovascular Health Electronic Health Record Application for Cancer Survivors in Community Oncology Practice: Results From WF-1804CD. J Clin Oncol 2025; 43:46-56. [PMID: 39571113 DOI: 10.1200/jco.24.00342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 08/07/2024] [Accepted: 09/26/2024] [Indexed: 12/22/2024] Open
Abstract
PURPOSE Guidelines recommend cardiovascular (CV) risk assessment and counseling for cancer survivors. This study evaluated the automated heart-health assessment (AH-HA) clinical decision support tool to promote provider-patient CV health (CVH) discussions in outpatient oncology. METHODS The AH-HA trial (WF-1804CD), coordinated by the Wake Forest National Cancer Institute Community Oncology Research Program Research Base, randomized practices to the AH-HA tool or usual care (UC) and enrolled survivors receiving routine care ≥6 months after curative cancer treatment. The tool displayed American Heart Association Life's Simple 7 CVH factors (BMI, physical activity, diet, smoking status, blood pressure, cholesterol, and glucose), populated from the electronic health record (EHR), alongside cancer treatments received with cardiotoxic potential. The primary end point was survivor-reported discussion of nonideal or missing CVH factors. A mixed-effects logistic regression model assessed the effect of AH-HA on CVH discussions, adjusting for practice. RESULTS Five UC and four AH-HA practices enrolled 645 survivors (82% breast, 8% endometrial, 5% colorectal, and 5% lymphoma, prostate, or multiple types) from October 1, 2020, to February 28, 2023. Most survivors were female (96%; 84% White/non-Hispanic, 8% Black; 3% Hispanic). Nearly all survivors (98%) in AH-HA practices reported a discussion for ≥1 nonideal or missing CVH factor compared with 55% in UC (P < .001). The average number of survivor-reported factors discussed was higher in AH-HA compared with UC (mean, 4.06 v 1.27; P < .001), as were EHR-documented discussions (3.83 v 0.77; P = .03). Survivors in AH-HA practices were also significantly more likely to report a recommendation to see a primary care provider (39%) compared with UC practices (25%, P = .02). Reported recommendations to see a cardiologist were low (approximately 6%) and did not differ between groups. CONCLUSION The AH-HA tool was effective at promoting CVH discussions during routine follow-up care for survivors and recommendations to consult primary care.
Collapse
Affiliation(s)
- Kathryn E Weaver
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Emily V Dressler
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Heidi D Klepin
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
- Section on Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Simon C Lee
- Department of Population Health, University of Kansas Medical Center and University of Kansas Cancer Center, Kansas City, KS
| | - Brian J Wells
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sydney Smith
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - W Gregory Hundley
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Glenn J Lesser
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
- Section on Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Chandylen L Nightingale
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Julie C Turner
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Ian Lackey
- John T. Milliken Department of Medicine, Washington University in St Louis School of Medicine, St. Louis, MO
| | | | - Randi Foraker
- John T. Milliken Department of Medicine, Washington University in St Louis School of Medicine, St. Louis, MO
| |
Collapse
|
6
|
Munir M, Sayed A, Addison D, Epperla N. Cardiovascular toxicities associated with novel cellular immune therapies. Blood Adv 2024; 8:6282-6296. [PMID: 39418640 DOI: 10.1182/bloodadvances.2024013849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 09/26/2024] [Accepted: 10/13/2024] [Indexed: 10/19/2024] Open
Abstract
ABSTRACT Over the past decade, T-cell-directed therapies, including chimeric antigen receptor T-cell (CAR-T) and bispecific T-cell engager (BTE) therapies, have reshaped the treatment of an expanding number of hematologic malignancies, whereas tumor-infiltrating lymphocytes, a recently approved cellular therapy, targets solid tumor malignancies. Emerging data suggest that these therapies may be associated with a high incidence of serious cardiovascular toxicities, including atrial fibrillation, heart failure, ventricular arrhythmias, and other cardiovascular toxicities. The development of these events is a major limitation to long-term survival after these treatments. This review examines the current state of evidence, including reported incidence rates, risk factors, mechanisms, and management strategies of cardiovascular toxicities after treatment with these novel therapies. We specifically focus on CAR-T and BTE therapies and their relation to arrhythmia, heart failure, myocarditis, bleeding, and other major cardiovascular events. Beyond the relationship between cytokine release syndrome and cardiotoxicity, we describe other potential mechanisms and highlight key unanswered questions and future directions of research.
Collapse
Affiliation(s)
- Malak Munir
- Department of Medicine, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Ahmed Sayed
- Department of Medicine, Ain Shams University Faculty of Medicine, Cairo, Egypt
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Daniel Addison
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH
| | - Narendranath Epperla
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, Salt Lake City, UT
| |
Collapse
|
7
|
Cho MH, Jung J, Koo HY, Jung W, Han K, Cho IY, Shin DW. Effects of Smoking Behavior Change on Diabetes Incidence after Cancer Development: A Nationwide Cohort Study. DIABETES & METABOLISM 2024:101604. [PMID: 39709168 DOI: 10.1016/j.diabet.2024.101604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 12/11/2024] [Accepted: 12/13/2024] [Indexed: 12/23/2024]
Abstract
AIM Cigarette smoking and diabetes mellitus (DM) increase risks of cardiovascular diseases and all-cause mortality in cancer survivors. An increased risk of DM incidence in cancer survivors has been observed and smoking is an important modifiable risk factor for DM development in the general population. Thus, we investigated the association between smoking behavior change after cancer diagnosis and DM incidence in cancer survivors. METHODS This retrospective cohort study using the Korean National Health Insurance System database included patients with newly diagnosed cancers between 2010 and 2016. Smoking behavior changes after cancer diagnosis were categorized as never smoker, ex-smoker, quitter, smoking starter, and persistent smoker. The associations between smoking behavior changes and DM incidence in overall and specific cancers were investigated using Cox regression analyses. RESULTS Of the 263,940 cancer survivors, 67.6% were never smokers, 16.0% were ex-smokers, 9.3% were quitters, 1.0% were smoking starters, and 6.2% were persistent smokers. During a mean follow-up of 4.0 years, 12,175 patients were diagnosed with DM after cancer development. Compared to the never smokers, the adjusted hazard ratios (95% confidential interval) of DM incidence were 1.06 (1.00-1.13) for ex-smokers, 1.45 (1.35-1.54) for quitters, 1.46 (1.25-1.71) for starters, and 1.57 (1.45-1.69) for persistent smokers. CONCLUSION Compared with never smokers, cancer survivors who engaged smoking at any point before or after cancer diagnosis showed an increased risk of DM incidence after cancer diagnosis. Cancer survivors should be advised to quit smoking promptly and to maintain abstinence throughout cancer survivorship.
Collapse
Affiliation(s)
- Mi Hee Cho
- Samsung C&T Medical Clinic, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinhyung Jung
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Hye Yeon Koo
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Family Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wonyoung Jung
- Department of Family Medicine / Obesity and Metabolic Health Center, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - In Young Cho
- Department of Family Medicine and Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
| | - Dong Wook Shin
- Department of Family Medicine and Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
| |
Collapse
|
8
|
Leven AS, Wagner N, Nienaber S, Messiha D, Tasdogan A, Ugurel S. Changes in tumor and cardiac metabolism upon immune checkpoint. Basic Res Cardiol 2024:10.1007/s00395-024-01092-8. [PMID: 39658699 DOI: 10.1007/s00395-024-01092-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/06/2024] [Accepted: 11/25/2024] [Indexed: 12/12/2024]
Abstract
Cardiovascular disease and cancer are the leading causes of death in the Western world. The associated risk factors are increased by smoking, hypertension, diabetes, sedentary lifestyle, aging, unbalanced diet, and alcohol consumption. Therefore, the study of cellular metabolism has become of increasing importance, with current research focusing on the alterations and adjustments of the metabolism of cancer patients. This may also affect the efficacy and tolerability of anti-cancer therapies such as immune-checkpoint inhibition (ICI). This review will focus on metabolic adaptations and their consequences for various cell types, including cancer cells, cardiac myocytes, and immune cells. Focusing on ICI, we illustrate how anti-cancer therapies interact with metabolism. In addition to the desired tumor response, we highlight that ICI can also lead to a variety of side effects that may impact metabolism or vice versa. With regard to the cardiovascular system, ICI-induced cardiotoxicity is increasingly recognized as one of the most life-threatening adverse events with a mortality of up to 50%. As such, significant efforts are being made to assess the specific interactions and associated metabolic changes associated with ICIs to improve both efficacy and management of side effects.
Collapse
Affiliation(s)
- Anna-Sophia Leven
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Natalie Wagner
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Stephan Nienaber
- Clinic III for Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Daniel Messiha
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre, University of Duisburg-Essen, Essen, Germany
| | - Alpaslan Tasdogan
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Essen, Germany
- National Center for Tumor Diseases (NCT)-West, Campus Essen, and Research Alliance Ruhr, Research Center One Health, University Duisburg-Essen, Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site Essen/Düsseldorf, Essen, Germany
- National Center for Tumor Diseases (NCT)-West, Campus Essen, and Research Alliance Ruhr, Research Center One Health, University Duisburg-Essen, Essen, Germany
| |
Collapse
|
9
|
Cook GJR, Alberts IL, Wagner T, Fischer BM, Nazir MS, Lilburn D. The impact of long axial field of view (LAFOV) PET on oncologic imaging. Eur J Radiol 2024; 183:111873. [PMID: 39647272 DOI: 10.1016/j.ejrad.2024.111873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 11/25/2024] [Accepted: 12/02/2024] [Indexed: 12/10/2024]
Abstract
The development of long axial field of view (LAFOV) positron emission tomography coupled with computed tomography (PET/CT) scanners might be considered the biggest step forward in PET imaging since it became a mainstream clinical modality. Despite increased capital and maintenance costs and data storage requirements, the improvement in image quality, significantly faster acquisition times and lower radiopharmaceutical administered activities, allow a high quality and more efficient clinical service. This step change in technology overcomes some of the limitations of standard short axial field of view scanners. It allows simultaneous imaging of all body systems, and with the ability to obtain high temporal resolution data, it increases potential research applications, particularly in multisystem disease or for dosimetry measurements of novel radiopharmaceuticals. The improvements in sensitivity and signal-to-noise facilitates the use of tracers with long half-lives and low administered activity (e.g. [89Zr]-labelled monoclonal antibodies) or very short half-lives (e.g. [82Rb]), opening up applications that hitherto have been challenging. It is early in the evolution of LAFOV PET/CT and the advantages these systems offer have still to be fully realised in providing additional impact in clinical practice. In this article we describe the potential advantages of LAFOV PET technology and some of the clinical and research applications where it has been applied as well as some of the future developments that may enhance the modality further.
Collapse
Affiliation(s)
- Gary J R Cook
- King's College London & Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College, London SE1 7EH, UK.
| | - Ian L Alberts
- Molecular Imaging and Therapy, BC Cancer Agency, Vancouver, BC, Canada; Department of Radiology, University of British Columbia, Vancouver, BC, Canada.
| | - Thomas Wagner
- Department of Nuclear Medicine, Royal Free London NHS Trust, London NW3 1TX, UK.
| | - B Malene Fischer
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark.
| | - Muhummad Sohaib Nazir
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London SE1 7EH, UK; Cardio-Oncology Centre of Excellence, Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - David Lilburn
- King's College London & Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College, London SE1 7EH, UK.
| |
Collapse
|
10
|
Pei J, Feng L, Mu Q, Wang Q, Wu Z, Wang Z, Liu Y. Exploring an novel diagnostic gene of trastuzumab-induced cardiotoxicity based on bioinformatics and machine learning. Sci Rep 2024; 14:30067. [PMID: 39627317 PMCID: PMC11615351 DOI: 10.1038/s41598-024-81335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Accepted: 11/26/2024] [Indexed: 12/06/2024] Open
Abstract
Trastuzumab (Tra)-induced cardiotoxicity (TIC) is a serious side effect of cancer chemotherapy, which can seriously harm the health of cancer patients. However, there is currently a lack of effective and reliable biomarkers for the early diagnosis of TIC in clinical practice. Therefore, we screened the TIC candidate diagnostic gene solute carrier family 6 member 6 (SLC6A6) by combining multi-machine learning algorithm based on bioinformatics. In addition, cross-validation showed that SLC6A6 had a consistent expression trend in multi-data-sets. To further explore the diagnostic capability of SLC6A6 in TIC, we constructed a nomogram diagnostic model based on SLC6A6 expression level, and receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis proved that SLC6A6 had good diagnostic capability. In order to further verify the TIC expression of SLC6A6 in the real world, we have constructed cell and animal models. Animal experiments showed that left ventricular ejection fraction (LVEF) was significantly decreased (from 65.01 ± 3.30% and 351.32 ± 3.51%, p < 0.0001) after Tra injection, and severe cardiac function was impaired. Similarly, RT-QPCR demonstrated that SLC6A6 was significantly downregulated in Tra-treated cardiomyocytes in vitro and in vivo. Our study suggests that the differential expression of SLC6A6 in vitro and in vivo models is associated with TIC, which may be a candidate diagnostic gene for the early occurrence and development of TIC and a potential therapeutic target.
Collapse
Affiliation(s)
- Jixiang Pei
- Department of Cardiology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Luxin Feng
- Department of Cardiology, Qingdao Huangdao Central Hospital, Qingdao, Shandong, China
| | - Qiang Mu
- Department of Breast Surgery, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Qitang Wang
- Department of Breast Surgery, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Ziying Wu
- Interventional Catheterization Lab, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Zhimei Wang
- Department of Gynecological Oncology, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao, China
| | - Yukun Liu
- Department of Breast Surgery, Qingdao Central Hospital, University of Health and Rehabilitation Sciences, Qingdao, China.
| |
Collapse
|
11
|
Salas MQ, Cascos E, López-García A, Pérez-López E, Baile-González M, López-Corral L, Pascual Cascón MJ, Luque M, Esquirol A, Heras Fernando I, Oiartzabal Ormtegi I, Sáez Marín AJ, Peña-Muñóz F, Fernández-Luis S, Domínguez-García JJ, Villar Fernández S, Fernández de Sanmamed Girón M, González Pinedo L, González-Rodríguez AP, Torrado T, García L, Filaferro S, Cedillo Á, Basalobre P, Ortí G, Jurado Chacón M. Cardiac events occurring after allogeneic hematopoietic cell transplantation with post-transplant cyclophosphamide. Study conducted on behalf of the GETH-TC. Bone Marrow Transplant 2024; 59:1694-1703. [PMID: 39277653 DOI: 10.1038/s41409-024-02414-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 08/27/2024] [Accepted: 09/04/2024] [Indexed: 09/17/2024]
Abstract
This multicenter study investigates the incidence and predictors of cardiac events (CE) following allo-HCT with PTCY in 453 AML patients. CE occurred in 57 (12.3%) patients within a median of 52 days (IQR: 13-289), with day 100 and 5-year cumulative incidences of 7.7% and 13.5%. Early (first 100 days) and late CE occurred at rates of 7.7% and 4.8%. The most prevalent CE were heart failure (n = 18, 31.6%), pericardial complications (n = 16, 28.1%), and arrhythmia (n = 14, 24.6%). The proportions of patients older than 55 years (64.9% vs. 46.1%, P = 0.010), with hypertension (36.8% vs. 18.4%, P = 0.001) and dyslipidemia (28.1% vs. 11.1%, P = 0.001) were higher in patients with CE. Patients undergoing haplo-HCT trend to have more CE (68.4% vs. 56.8%, P = 0.083). The multivariate regression analysis revealed that only hypertension (HR 1.88, P = 0.036) and dyslipidemia (HR 2.20, P = 0.018) were predictors for CE, with no differences according to donor type (haplo-HCT vs. others: HR 1.33, P = 0.323). Among the 57 patients with CE, the mortality rate was 12.2%. Notably, the diagnosis of CE negatively impacted NRM (HR 2.57, P = 0.011) and OS (HR 1.80, P = 0.009), underscoring necessity of aggressively treating cardiovascular risk factors, and implementing post-transplant cardiac monitoring protocols to prevent these complications.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Marta Luque
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | - Felipe Peña-Muñóz
- Institut Català d'Oncologia - Hospital Duran i Reynals, Barcelona, Spain
| | | | | | | | | | | | | | | | - Lucía García
- Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Silvia Filaferro
- Grupo Español de Trasplante de Progenitores Hematopoyéticos y Terapia Celular, Madrid, Spain
| | - Ángel Cedillo
- Grupo Español de Trasplante de Progenitores Hematopoyéticos y Terapia Celular, Madrid, Spain
| | - Pascual Basalobre
- Grupo Español de Trasplante de Progenitores Hematopoyéticos y Terapia Celular, Madrid, Spain
| | - Guillermo Ortí
- Grupo Español de Trasplante de Progenitores Hematopoyéticos y Terapia Celular, Madrid, Spain
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manuel Jurado Chacón
- Grupo Español de Trasplante de Progenitores Hematopoyéticos y Terapia Celular, Madrid, Spain
- Hospital Universitario Virgen de las Nieves de Granada, Granada, Spain
| |
Collapse
|
12
|
Gürdoğan M, Taylan G, Özkan U, Ebik M, Solak N, Gürlertop Y, Yalta K. Atrioventricular Block in the Setting of Immune Myocarditis: A Pragmatic Approach to Diagnosis and Treatment. Pacing Clin Electrophysiol 2024; 47:1617-1626. [PMID: 39549256 DOI: 10.1111/pace.15108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/01/2024] [Accepted: 10/27/2024] [Indexed: 11/18/2024]
Abstract
Immunotherapy has revolutionized cancer treatment in the last decade and has significantly improved patient survival. However, immunotherapy is associated with serious cardiac adverse events including myocarditis and conduction disturbances. In the literature, the mortality rate in patients with immunotherapy-associated myocarditis and complete AV block is reported to be approximately 60%. Current cardio-oncology guidelines provide a series of recommendations for the management of immune myocarditis (IM). However, there is no recommendation on whether or when pacemaker implantation should be performed in the setting of complete AV block associated with myocarditis. This gap in the literature has led to a trend in cardio-oncology practice to implant permanent pacemakers (PPMs) in a significant proportion of patients without waiting for a response to immunosuppressive therapy. However, in a significant proportion of patients undergoing PPM implantation, complete AV block resolves after immunosuppressive therapy. This suggests that in cases of complete AV block in the setting of IM, more robust clues are needed for PPM implantation. This review aims to present algorithms for the management of myocarditis and complete AV block, one of the most lethal complications of immunotherapy, to help fill this gap in the literature.
Collapse
Affiliation(s)
- Muhammet Gürdoğan
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Gökay Taylan
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Uğur Özkan
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Mustafa Ebik
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Nilay Solak
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Yekta Gürlertop
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| | - Kenan Yalta
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
| |
Collapse
|
13
|
Barcellini A, Rordorf R, Dusi V, Fontana G, Pepe A, Vai A, Schirinzi S, Vitolo V, Orlandi E, Greco A. Pilot study to assess the early cardiac safety of carbon ion radiotherapy for intra- and para-cardiac tumours. Strahlenther Onkol 2024; 200:1080-1087. [PMID: 39212688 DOI: 10.1007/s00066-024-02270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/03/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Modern photon radiotherapy effectively spares cardiac structures more than previous volumetric approaches. Still, it is related to non-negligible cardiac toxicity due to the low-dose bath of surrounding normal tissues. However, the dosimetric advantages of particle radiotherapy make it a promising treatment for para- and intra-cardiac tumours. In the current short report, we evaluate the cardiac safety profile of carbon ion radiotherapy (CIRT) for radioresistant intra- and para-cardiac malignancies in a real-world setting. METHODS We retrospectively analysed serum biomarkers (TnI, CRP and NT-proBNP), echocardiographic, and both 12-lead and 24-hour Holter electrocardiogram (ECG) data of consecutive patients with radioresistant intra- and para-cardiac tumours irradiated with CIRT between June 2019 and September 2022. In the CIRT planning optimization process, to minimize the delivered doses, we contoured and gave a high priority to the cardiac substructures. Weekly re-evaluative 4D computed tomography scans were carried out throughout the treatment. RESULTS A total of 16 patients with intra- and para-cardiac localizations of radioresistant tumours were treated up to a total dose of 70.4 Gy relative biological effectiveness (RBE) and a mean heart dose of 2.41 Gy(RBE). We did not record any significant variation of the analysed serum biomarkers after CIRT nor significant changes of echocardiographic features, biventricular strain, or 12-lead and 24-hour Holter ECG parameters during 6 months of follow-up. CONCLUSION Our pilot study suggests that carbon ion radiotherapy is a promising radiation technique capable of sparing off-target side effects at the cardiac level. A larger cohort, long-term follow-up and further prospective studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Amelia Barcellini
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100, Pavia, Italy
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
| | - Roberto Rordorf
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10126, Torino, Italy
| | - Giulia Fontana
- Clinical Department, CNAO National Center for Oncological Hadrontherapy, Via Erminio Borloni 1, 27100, Pavia, Italy.
| | - Antonella Pepe
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
- Division of Cardiology, Cardio-Thoracic Department, San Carlo Borromeo Hospital (ASST Santi Paolo e Carlo), 20100, Milano, Italy
| | - Alessandro Vai
- Medical Physics Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
| | - Sandra Schirinzi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Viviana Vitolo
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy
| | - Alessandra Greco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| |
Collapse
|
14
|
Jaber Chehayeb R, Singh J, Matute-Martinez C, Chen NW, Guajardo AF, Lin D, Jayakrishnan R, Christofides A, Leveille E, Im Y, Biancon G, VanOudenhove J, Ibrahim E, Ardasheva A, Jha A, Hwa J, Halene S, Kwan JM. Clonal hematopoiesis of indeterminate potential is associated with increased risk of immune checkpoint inhibitor myocarditis in a prospective study of a cardio-oncology cohort. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:84. [PMID: 39587635 PMCID: PMC11590368 DOI: 10.1186/s40959-024-00289-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Accepted: 11/12/2024] [Indexed: 11/27/2024]
Abstract
BACKGROUND Clonal hematopoiesis of indeterminate potential (CHIP) has been shown to increase all-cause mortality and risk of cardiomyopathy in patients with solid malignancies. CHIP has also been shown to increase T cell activation in heart failure patients. It is unclear whether CHIP can affect the risk of immune checkpoint inhibitor (ICI) myocarditis in patients with cancer treated with immunotherapy. METHODS We enrolled patients with solid tumors in a prospective study, determined CHIP status at time of enrollment through blood whole exome sequencing, and assessed incidence of ICI myocarditis from time of enrollment through December 1st, 2023. We performed a competing risk cox regression to evaluate the role of CHIP in ICI myocarditis, accounting for patient demographics, cardiac comorbidities, cardiotoxic cancer therapy, and dual ICI use in our covariates. We also generated cumulative incidence curves using subdistribution hazards to evaluate development of ICI myocarditis stratified by CHIP vs no CHIP. Chart review was performed to evaluate patient co-morbidities, lab values, imaging findings and outcomes. RESULTS Among the 88 patients receiving ICI therapy, average age was 67 ± 14 years, of which 50% harbored CHIP variants. Among all comorbidities, including diabetes, heart failure and obstructive coronary artery disease, only coronary artery calcifications were significantly increased in patients with CHIP. There were no statistically significant differences in cancer therapy or cardiovascular drugs between patients with and without CHIP. Among examined outcomes, patients with CHIP had a statistically higher rate of ICI myocarditis (overall: 57%, CHIP: 73% (32/44), no CHIP: 41% (18/44), p = 0.003) and death (CHIP: 60%, no CHIP 31%, p = 0.011). In a multivariate competing risk analysis, CHIP status doubled the risk of developing ICI myocarditis, similar to the risk of dual ICI use (CHIP status HR 2.74, 95% CI: 1.44-5.22, p = 0.002 vs dual ICI use HR 2.39, 95% CI: 1.11-5.14, p = 0.026). CONCLUSIONS This study is the first to show that CHIP independently increases risk of ICI myocarditis, with implications for risk stratification of patients prior to ICI initiation and frequency of cardiac monitoring.
Collapse
Affiliation(s)
| | | | - Carlos Matute-Martinez
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, 06511, USA
| | | | | | | | | | | | | | - Yunju Im
- University of Nebraska Medical Center, Omaha, USA
| | - Giulia Biancon
- Section of Hematology, Department of Internal Medicine and Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer VanOudenhove
- Section of Hematology, Department of Internal Medicine and Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Eiman Ibrahim
- Section of Hematology, Department of Internal Medicine and Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Anastasias Ardasheva
- Section of Hematology, Department of Internal Medicine and Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | | | - John Hwa
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, 06511, USA
| | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine and Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer M Kwan
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, 06511, USA.
- Yale School of Medicine, 300 George St #770B, New Haven, CT, 06511, USA.
| |
Collapse
|
15
|
Yu R, Lin J, Fu T, Huang X, Xu F, Yang C, Fu Y, Fei H, Lin L. Diastolic dysfunction and risks of heart failure and death in long-term adult cancer survivors. BMC Med 2024; 22:544. [PMID: 39563317 PMCID: PMC11575149 DOI: 10.1186/s12916-024-03773-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 11/13/2024] [Indexed: 11/21/2024] Open
Abstract
BACKGROUND Cancer survivors face elevated risks of heart failure (HF) and death, with cardiac dysfunction being a significant concern. Current evaluations often emphasize systolic function while insufficiently addressing diastolic function. This study aims to investigate the prevalence of diastolic dysfunction and assess its prognostic implications in long-term cancer survivors. METHODS We analyzed participants from the Atherosclerosis Risk in Communities (ARIC) Study with complete echocardiographic assessments and documented cancer histories. Diastolic function was classified by guideline criteria: normal (≤ 1 abnormal parameter), indeterminate (2 abnormal parameters), and dysfunction (≥ 3 abnormal parameters). The primary outcomes were incident HF and all-cause death. Diastolic dysfunction prevalence was compared between cancer survivors and non-cancer participants after propensity score matching. Cox regression, Kaplan-Meier, and restricted cubic spline (RCS) analyses were used to assess associated risks. RESULTS A total of 5322 participants were included, with 18.4% (N = 979) being cancer survivors. The mean age of cancer survivors at echocardiography was 76.3 (5.10) years, with a median of 12.17 years since diagnosis. There were no significant differences in diastolic dysfunction prevalence (12.26% vs 10.73%, P = 0.29) after matching. Cox regression revealed a graded association between diastolic dysfunction and risks of HF and death. Fully adjusted hazard ratios were 2.59 (95% CI: 1.59-4.20, P < 0.001) for indeterminate diastolic function and 4.41 (95% CI: 2.40-8.12, P < 0.001) for diastolic dysfunction in HF; and 1.68 (95% CI: 1.26-2.25, P < 0.001) for indeterminate and 2.21 (95% CI: 1.51-3.22, P < 0.001) for diastolic dysfunction in all-cause death. These results were consistent across subgroup and sensitivity analyses and supported by Kaplan-Meier curves. RCS analyses demonstrated dose-response relationships between individual diastolic parameters and outcomes. CONCLUSIONS Diastolic dysfunction is prevalent among long-term cancer survivors and is stepwise associated with adverse outcomes. These findings underscore the essential need for ongoing monitoring of diastolic function in this population.
Collapse
Affiliation(s)
- Rongjian Yu
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Juze Lin
- Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Tingting Fu
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xuhui Huang
- Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Fei Xu
- Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Caizhi Yang
- The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Yuanfeng Fu
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hongwen Fei
- Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
| | - Lizhu Lin
- The First Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China.
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
| |
Collapse
|
16
|
Mallidi J, Baylis R, Song EJ. Management of Cancer Therapy-Related Cardiac Dysfunction: A Case-Based Review. Am J Cardiol 2024; 231:20-31. [PMID: 39233062 DOI: 10.1016/j.amjcard.2024.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 08/22/2024] [Accepted: 08/25/2024] [Indexed: 09/06/2024]
Abstract
With an ever-expanding repertoire of cancer therapies, cardiologists increasingly encounter patients with cancer therapy-related cardiac dysfunction. This can range from asymptomatic mild left ventricular dysfunction to severe symptomatic congestive heart failure. A multidisciplinary approach involving oncologists and cardiologists is needed in the management of these patients. This case-based review provides a practical guide for clinicians regarding the diagnosis and management of cancer therapy-related cardiac dysfunction associated with commonly used cancer treatments: anthracyclines, human epidermal receptor 2-targeted therapies, and immune checkpoint inhibitors.
Collapse
Affiliation(s)
- Jaya Mallidi
- Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital; Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California.
| | - Richard Baylis
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Evelyn J Song
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| |
Collapse
|
17
|
Aslan D, Ozoner S, Inanc M, Yildiz OG, Inanc MT. Evaluation of early cardiotoxicity in HER2-positive breast cancer patients receiving radiotherapy and concurrent trastuzumab. Ir J Med Sci 2024:10.1007/s11845-024-03835-x. [PMID: 39495473 DOI: 10.1007/s11845-024-03835-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 10/26/2024] [Indexed: 11/05/2024]
Abstract
BACKGROUND Overexpression of human epidermal growth factor receptor 2 (HER-2) is associated with aggressive disease in breast cancer. Trastuzumab and radiotherapy are standard treatments for patients with HER-2 + breast cancer, but they may increase the risk of cardiotoxicity. AIM This study aimed to assess early cardiotoxicity in patients receiving radiotherapy (RT) and concurrent trastuzumab. METHOD The study included 116 patients with HER-2 + breast cancer who received concurrent treatment with trastuzumab and RT (52 right-side; 64 left-side). Five left ventricular ejection fraction (LVEF) measurements were performed: one before treatment and four subsequent measurements taken at three-month intervals. LVEF was also assessed before (preRT-EF) and after (postRT-EF) radiotherapy. RESULTS The baseline LVEF was 62.27 ± 5.5%, while the 12-month LVEF was 59.8 ± 5.8% (p < 0.05). In subgroups, post-RT LVEF values were significantly lower than pre-RT LVEF values (p < 0.05). No significant difference was found between the reduction in LVEF for patients receiving 50 Gy and 60 Gy doses. Moreover, the contribution of regional lymph node irradiation to the decrease in LVEF could not be demonstrated. A positive correlation was found between the total trastuzumab dose and the decrease in LVEF from preRT to postRT. Additionally, a positive correlation was observed between the total taxane dose and the reduction in LVEF from baseline to 9 months, both in the overall group and in the left breast cancer group. CONCLUSION In our study,it was found that not only trastuzumab but also taxane-based agents could be cardiotoxic. However, no connection was found between RT doses and the decrease in LVEF.
Collapse
Affiliation(s)
- Dicle Aslan
- Department of Radiation Oncology, Erciyes University, Faculty of Medicine, 38140, Kayseri, Türkiye.
| | - Sadik Ozoner
- Department of Radiation Oncology, Mugla Education and Research Hospital, Mugla, Türkiye
| | - Mevlude Inanc
- Department of Medical Oncology, Erciyes University, Faculty of Medicine, Kayseri, Türkiye
| | - Oguz Galip Yildiz
- Department of Radiation Oncology, Erciyes University, Faculty of Medicine, 38140, Kayseri, Türkiye
| | - Mehmet Tugrul Inanc
- Department of Cardiology, Erciyes University, Faculty of Medicine, Kayseri, Türkiye
| |
Collapse
|
18
|
Picardi M, Vincenzi A, Giordano C, Fazio LD, Pugliese N, Scarpa A, Vigliar E, Troncone G, Russo D, Mascolo M, Esposito G, Prastaro M, Santoro C, Esposito R, Tocchetti CG, Mainolfi C, Fonti R, Vecchio SD, Carchia M, Quagliano C, Salemme A, Damiano V, Bianco R, Trastulli F, Ronconi F, Annunziata M, Pane F. Liposomal Doxorubicin, Vinblastine and Dacarbazine Plus Consolidation Radiotherapy of Residual Nodal Masses for Frontline Treatment in Older Adults With Advanced Stage Classic Hodgkin Lymphoma: Improved Outcome in a Multi-Center Real-Life Study. Hematol Oncol 2024; 42:e70003. [PMID: 39552192 PMCID: PMC11590052 DOI: 10.1002/hon.70003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 09/05/2024] [Accepted: 11/04/2024] [Indexed: 11/19/2024]
Abstract
In elderly patients with high-risk classic Hodgkin lymphoma (c-HL), we evaluated the impact of a new modality treatment without bleomycin, that is, liposomal doxorubicin (NPLD)-based regimen plus consolidation radiotherapy of residual nodal masses (RNMs), on overall survival (OS) and progression free survival (PFS). In this retrospective study (2013-2023) conducted in tertiary hospitals in the bay of Naples (Italy), 50 older adults (median age, 69 years; range, 60-89) with advanced stage c-HL received frontline treatment with MVD ± irradiation. MVD consisted of 25 mg/m2 of NPLD along with standard Vinblastine and Dacarbazine for a total of 6 cycles (twelve iv administrations, every 2 weeks) followed by radiation of RNMs with size ≥ 2.5 cm at computed tomography. Patients underwent MVD with a median dose intensity of 92%. At 2-deoxy-2[F-18] fluoro-D-glucose positron emission tomography (FDG-PET), 90% of patients (45/50 patients; one failed to perform final FDG-PET due to early death) reached complete responses. Altogether, 17 patients (34%) received consolidation radiotherapy of RNMs with Deauville score ≥ 3. At 5-year median follow-up, the OS and PFS of the entire population were 87.5% (95% confidence interval [CI], 78.7-97.4) and 81.6% (95% CI, 71.4-93.2), respectively. Eleven patients (22%) experienced grade ≥ 3 adverse events, and 4 of them required hospitalization. Our data suggest that in older adults with high-risk c-HL NPLD-driven strategy (without bleomycin) plus consolidation radiotherapy (if needed) may be a promising up-front option, to test in phase II clinical trials for improving survival incidence.
Collapse
Affiliation(s)
- M. Picardi
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - A. Vincenzi
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - C. Giordano
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - L. De Fazio
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - N. Pugliese
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - A. Scarpa
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - E. Vigliar
- Department of Public HealthFederico II University Medical School NaplesNaplesItaly
| | - G. Troncone
- Department of Public HealthFederico II University Medical School NaplesNaplesItaly
| | - D. Russo
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - M. Mascolo
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - G. Esposito
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - M. Prastaro
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - C. Santoro
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - R. Esposito
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - C. G. Tocchetti
- Departments of Translational Medical SciencesFederico II University Medical SchoolNaplesItaly
| | - C. Mainolfi
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - R. Fonti
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - S. Del Vecchio
- Department of Advanced Biomedical SciencesFederico II University Medical SchoolNaplesItaly
| | - M. Carchia
- Department of Public HealthFederico II University Medical School NaplesNaplesItaly
| | - C. Quagliano
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - A. Salemme
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - V. Damiano
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - R. Bianco
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| | - F. Trastulli
- Hematology UnitAntonio Cardarelli Hospital of National ImportanceNaplesItaly
| | - F. Ronconi
- Hematology UnitAntonio Cardarelli Hospital of National ImportanceNaplesItaly
| | - M. Annunziata
- Hematology UnitAntonio Cardarelli Hospital of National ImportanceNaplesItaly
| | - F. Pane
- Department of Clinical Medicine and SurgeryFederico II University Medical SchoolNaplesItaly
| |
Collapse
|
19
|
Schuuring MJ, Treskes RW, Castiello T, Jensen MT, Casado-Arroyo R, Neubeck L, Lyon AR, Keser N, Rucinski M, Marketou M, Lambrinou E, Volterrani M, Hill L. Digital solutions to optimize guideline-directed medical therapy prescription rates in patients with heart failure: a clinical consensus statement from the ESC Working Group on e-Cardiology, the Heart Failure Association of the European Society of Cardiology, the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology, the ESC Digital Health Committee, the ESC Council of Cardio-Oncology, and the ESC Patient Forum. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:670-682. [PMID: 39563907 PMCID: PMC11570396 DOI: 10.1093/ehjdh/ztae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/14/2024] [Accepted: 08/13/2024] [Indexed: 11/21/2024]
Abstract
The 2021 European Society of Cardiology guideline on diagnosis and treatment of acute and chronic heart failure (HF) and the 2023 Focused Update include recommendations on the pharmacotherapy for patients with New York Heart Association (NYHA) class II-IV HF with reduced ejection fraction. However, multinational data from the EVOLUTION HF study found substantial prescribing inertia of guideline-directed medical therapy (GDMT) in clinical practice. The cause was multifactorial and included limitations in organizational resources. Digital solutions like digital consultation, digital remote monitoring, digital interrogation of cardiac implantable electronic devices, clinical decision support systems, and multifaceted interventions are increasingly available worldwide. The objectives of this Clinical Consensus Statement are to provide (i) examples of digital solutions that can aid the optimization of prescription of GDMT, (ii) evidence-based insights on the optimization of prescription of GDMT using digital solutions, (iii) current evidence gaps and implementation barriers that limit the adoption of digital solutions in clinical practice, and (iv) critically discuss strategies to achieve equality of access, with reference to patient subgroups. Embracing digital solutions through the use of digital consults and digital remote monitoring will future-proof, for example alerts to clinicians, informing them of patients on suboptimal GDMT. Researchers should consider employing multifaceted digital solutions to optimize effectiveness and use study designs that fit the unique sociotechnical aspects of digital solutions. Artificial intelligence solutions can handle larger data sets and relieve medical professionals' workloads, but as the data on the use of artificial intelligence in HF are limited, further investigation is warranted.
Collapse
Affiliation(s)
- Mark Johan Schuuring
- Department of Biomedical Signals and Systems, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
- Department of Cardiology, Medical Spectrum Twente, 7512 KZ Enschede, The Netherlands
| | | | - Teresa Castiello
- Department of Cardiovascular Imaging, King's College London, Croydon Health Service London, London, UK
| | | | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lis Neubeck
- Centre for Cardiovascular Health, Edinburgh Napier University, Edinburgh, UK
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, Guys and St. Thomas NHS Foundation Trust, London, UK
| | - Nurgul Keser
- Faculty of Medicine, Department of Cardiology-Istanbul, Istanbul Health Sciences University, Istanbul, Turkey
| | - Marcin Rucinski
- Poland, ESC Patient Forum, European Society of Cardiology, Sophia Antipolis Cedex, France
| | - Maria Marketou
- Cardiology Department, Heraklion University Hospital, Stavrakia, Heraklion, Greece
| | | | | | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| |
Collapse
|
20
|
Bak M, Park H, Lee SH, Lee N, Ahn MJ, Ahn JS, Jung HA, Park S, Cho J, Kim J, Park SJ, Chang SA, Lee SC, Park SW, Kim EK. The Risk and Reversibility of Osimertinib-Related Cardiotoxicity in a Real-World Population. J Thorac Oncol 2024:S1556-0864(24)02377-3. [PMID: 39395664 DOI: 10.1016/j.jtho.2024.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/30/2024] [Accepted: 10/05/2024] [Indexed: 10/14/2024]
Abstract
INTRODUCTION Although osimertinib, a third-generation EGFR tyrosine kinase inhibitor, as the first-line therapy for metastatic NSCLC was found to have substantial survival benefits, concerns have arisen regarding its potential cardiotoxicity, particularly in real-world clinical settings. We aimed to investigate the incidence, risk factors, and reversibility of osimertinib-related cardiotoxicity. METHODS We analyzed 1126 patients with NSCLC treated with osimertinib from May 2016 to April 2023 in two cancer centers. Osimertinib-related cardiotoxicity was defined as a composite of osimertinib-related cardiac dysfunction (ORCD), newly developed arrhythmia, and cardiac death. Total follow-up duration was 20.6 (10.8-35.2) months. RESULTS The osimertinib was administered for a median of 12.4 months. The incidence of osimertinib-related cardiotoxicity was 4.7%. Advanced age (adjusted hazard ratio with 95% confidence interval: 1.07 [1.04-1.09], p < 0.001), a history of heart failure (3.35 [1.67-9.64], p = 0.025), atrial fibrillation (3.42 [1.27-9.22], p = 0.015), and baseline low left ventricle strain (0.87 [0.79-0.96], p = 0.005) were independently associated with development of cardiotoxicity. The recovery rate of ORCD was 82.4%, which did not differ between patients who discontinued medication and those who did not. CONCLUSIONS In real-world practice, the incidence of osimertinib-related cardiotoxicity was 4.7%, including 3.4% for ORCD requiring cardiologic intervention, which is higher than previously reported. Given the long-term medication of osimertinib and increased mortality associated with cardiotoxicity, vigilant monitoring is crucial, especially in patients with advanced age, history of heart failure, atrial fibrillation, or decreased baseline left ventricular strain.
Collapse
Affiliation(s)
- Minjung Bak
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyukjin Park
- Department of Cardiology, Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Se-Hoon Lee
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nuri Lee
- Department of Cardiology, Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Myung-Ju Ahn
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Ahn
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Ae Jung
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sehhoon Park
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinhyun Cho
- Division of Hematology and Oncology, Department of Medicine, Inha University Hospital, Inchon, Republic of Korea
| | - Jihoon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
21
|
Terluk A, Stefani L, Boyd A, Vo K, Byth K, Hui R, Richards D, Thomas L. Redefining anthracycline-related subclinical cardiotoxicity: 'Absolute' and 'relative' change in longitudinal strain. ESC Heart Fail 2024; 11:3210-3221. [PMID: 38887181 PMCID: PMC11424371 DOI: 10.1002/ehf2.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/16/2024] [Accepted: 05/12/2024] [Indexed: 06/20/2024] Open
Abstract
AIMS Anthracycline chemotherapy (AC) for breast cancer can cause cancer therapy-related cardiac dysfunction (CTRCD) with resultant heart failure, traditionally defined as a reduction in left ventricular (LV) ejection fraction on echocardiography. In recent years, global longitudinal systolic strain (GLS) has been used to identify subclinical cardiac dysfunction prior to development of overt CTRCD. Recent harmonized guidelines have incorporated GLS into definitions for CTRCD to identify cardiac dysfunction and inform decisions regarding cardioprotective strategies. METHODS AND RESULTS We evaluated subclinical dysfunction in breast cancer patients treated with AC and determined the echocardiographic and patient factors associated with significant GLS changes. One hundred fourteen HER2 negative patients treated with AC were prospectively recruited and underwent serial echocardiograms (LVEF and LVGLS) at three time points (prior to AC, 3 months, and 1 year). CTRCD was defined as an asymptomatic reduction in LVEF of 10% or symptomatic drop of 5% to LVEF <53%. Subclinical LV dysfunction was defined as a reduction of ≥10% in GLS compared with baseline, recognizing that this cut off identified an 'at risk cohort' rather than patients with established CTRCD. No participant demonstrated CTRCD by reduction in LVEF. Forty-three patients (38%) demonstrated a ≥10% relative reduction in GLS at 12 months; 20/43 (47%) had a reduced absolute GLS to <16%, and were older, had hypertension, increased LV mass, lower baseline e' velocity and GLS. GLS ≥20.5% at baseline yielded a sensitivity of 79% and specificity of 87% for a normal GLS (i.e., ≥16%) at 1 year despite a ≥10% reduction from baseline. CONCLUSIONS We present a stepwise evaluation for subclinical LV dysfunction using both a relative reduction in GLS combined with an absolute reduction in GLS. We believe our findings may re-stratify patients with a high baseline GLS into a lower risk group despite transient relative GLS decrements ≥10%.
Collapse
Affiliation(s)
- Andrew Terluk
- Westmead Clinical School, The University of Sydney, Camperdown, Australia
| | - Luke Stefani
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney, Sydney, Australia
| | - Anita Boyd
- Westmead Private Cardiology, Westmead, Australia
| | - Kim Vo
- Westmead Private Cardiology, Westmead, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, Australia
- NHMRC Clinical Trials Centre, University of Sydney. Sydney, Sydney, Australia
| | - Rina Hui
- Westmead Clinical School, The University of Sydney, Camperdown, Australia
- Department of Oncology, Westmead Hospital, Sydney, Australia
| | - David Richards
- Westmead Applied Research Centre, The University of Sydney, Sydney, Australia
| | - Liza Thomas
- Westmead Clinical School, The University of Sydney, Camperdown, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney, Sydney, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, Australia
- NHMRC Clinical Trials Centre, University of Sydney. Sydney, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| |
Collapse
|
22
|
Nikolova AP, Ky B. Immune Checkpoint Inhibitors Myocarditis: The Nuts and Bolts. JACC. HEART FAILURE 2024; 12:1794-1796. [PMID: 39207325 DOI: 10.1016/j.jchf.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/11/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024]
Affiliation(s)
| | - Bonnie Ky
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
23
|
Bhasin V, Vakilpour A, Scherrer-Crosbie M. Statins for the Primary Prevention of Anthracycline Cardiotoxicity: A Comprehensive Review. Curr Oncol Rep 2024; 26:1197-1204. [PMID: 39002055 PMCID: PMC11480194 DOI: 10.1007/s11912-024-01579-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE OF REVIEW The aim of this review is two-fold: (1) To examine the mechanisms by which statins may protect from anthracycline-induced cardiotoxicity and (2) To provide a comprehensive overview of the existing clinical literature investigating the role of statins for the primary prevention of anthracycline-induced cardiotoxicity. RECENT FINDINGS The underlying cardioprotective mechanisms associated with statins have not been fully elucidated. Key mechanisms related to the inhibition of Ras homologous (Rho) GTPases have been proposed. Data from observational studies has supported the beneficial role of statins for the primary prevention of anthracycline-induced cardiotoxicity. Recently, several randomized controlled trials investigating the role of statins for the primary prevention of anthracycline-induced cardiotoxicity have produced contrasting results. Statins have been associated with a lower risk of cardiac dysfunction in cancer patients receiving anthracyclines. Further investigation with larger randomized control trials and longer follow-up periods are needed to better evaluate the long-term role of statin therapy and identify the subgroups who benefit most from statin therapy.
Collapse
Affiliation(s)
- Varun Bhasin
- Division of Cardiovascular Medicine and Thalheimer Center for Cardio-Oncology, Perelman Center for Advanced Medicine and Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, USA
| | - Azin Vakilpour
- Division of Cardiovascular Medicine and Thalheimer Center for Cardio-Oncology, Perelman Center for Advanced Medicine and Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, USA
| | - Marielle Scherrer-Crosbie
- Division of Cardiovascular Medicine and Thalheimer Center for Cardio-Oncology, Perelman Center for Advanced Medicine and Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA, USA.
| |
Collapse
|
24
|
Cannata A, McDonagh T. Preventing Cancer Therapy-Related Cardiotoxicity: Should We be PROACTive or Reactive? JACC CardioOncol 2024; 6:697-698. [PMID: 39479315 PMCID: PMC11520225 DOI: 10.1016/j.jaccao.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2024] Open
Affiliation(s)
- Antonio Cannata
- School of Cardiovascular Medicine & Sciences, King’s College London British Heart Foundation Centre of Excellence, London, United Kingdom
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Theresa McDonagh
- School of Cardiovascular Medicine & Sciences, King’s College London British Heart Foundation Centre of Excellence, London, United Kingdom
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
25
|
Bloom M, Alvarez-Cardona JA, Ganatra S, Barac A, Pusic I, Lenihan D, Dent S. How to utilize current guidelines to manage patients with cancer at high risk for heart failure. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:63. [PMID: 39342407 PMCID: PMC11438295 DOI: 10.1186/s40959-024-00259-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 08/19/2024] [Indexed: 10/01/2024]
Abstract
Heart failure (HF) in patients with cancer is associated with high morbidity and mortality. The success of cancer therapy has resulted in an exponential rise in the population of cancer survivors, however cardiovascular disease (CVD) is now a major life limiting condition more than 5 years after cancer diagnosis [Sturgeon, Deng, Bluethmann, et al 40(48):3889-3897, 2019]. Prevention and early detection of CVD, including cardiomyopathy (CM) and HF is of paramount importance. The European Society of Cardiology (ESC) published guidelines on Cardio-Oncology (CO) [Lyon, López-Fernández, Couch, et al 43(41):4229-4361, 2022] detailing cardiovascular (CV) risk stratification, prevention, monitoring, diagnosis, and treatment throughout the course and following completion of cancer therapy. Here we utilize a case to summarize aspects of the ESC guideline relevant to HF clinicians, with a focus on risk stratification, early detection, prevention of CM and HF, and the role for guideline directed medical therapy in patients with cancer.
Collapse
Affiliation(s)
- Michelle Bloom
- Leon H. Charney Division of Cardiology, New York University School of Medicine, NYU Langone Health, New York, NY, USA
| | - Jose A Alvarez-Cardona
- Leon H. Charney Division of Cardiology, New York University School of Medicine, NYU Langone Health, New York, NY, USA
| | - Sarju Ganatra
- Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Department of Medicine, Beth Israel Lahey Health, Burlington, MA, USA
| | - Ana Barac
- Inova Schar Heart and Vascular and Inova Inova Schar Cancer, Falls Church, VA, USA
| | - Iskra Pusic
- Division of Oncology, Department of Medicine, Washington University, St. Louis, MO, USA
| | - Daniel Lenihan
- International Cardio-Oncology Society, FL and Cape Cardiology Group, Cape Girardeau, Tampa, MO, USA
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, DUMC 3446, Durham, NC, 27710, USA.
| |
Collapse
|
26
|
Borowiec A, Ozdowska P, Rosinska M, Zebrowska AM, Jagiello-Gruszfeld A, Jasek S, Waniewska J, Kotowicz B, Kosela-Paterczyk H, Lampka E, Pogoda K, Cieszanowski A, Nowecki Z, Walewski J. Coronary artery calcium score and other risk factors in patients at moderate and high risk of cancer therapy-related cardiovascular toxicity. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:64. [PMID: 39342402 PMCID: PMC11437645 DOI: 10.1186/s40959-024-00266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND The presence and burden of coronary artery calcium (CAC) is a strong predictor of cardiovascular events. Current guidelines of the European Society of Cardiology (ESC) for cardio-oncology do not recommend the use of the CAC score to determine the status of risk in cancer patients. The aim of this study is to evaluate the presence and burden of CAC on cardiac tomography and the distribution of the cardiovascular toxicity risk factors in patients with moderate and high baseline risk of cancer therapy-related cardiovascular toxicity. METHODS The study prospectively included cancer patients, diagnosed and qualified for systemic treatment with anthracycline chemotherapy. Clinical data and blood samples were collected from all patients. Additionally, the echocardiography and coronary computed tomography (CCTA) with the calculation of the coronary artery calcium (CAC) score were performed. RESULTS A total of 80 patients (mean age 60.5 years, 75 female) were included in the study. The majority of patients (62, 77.5%) had breast cancer, 11 (13.8%) were diagnosed with sarcoma, and 7 (8.8%) with lymphoma. There were 42 (52.5%) patients classified as having moderate (MR) and 38 (47.5%) as having high risk (HR) of cancer therapy-related cardiovascular toxicity according to current ESC guidelines. In comparison with moderate risk, high risk patients were older and more likely to have hypertension, hyperlipidaemia and chronic kidney disease. The mean coronary artery calcium score was significantly higher in the HR group (150.4 vs. 24.8; p = 0.000). Furthermore, cardiac biomarkers were also higher in high-risk patients (p = 0.000). In echocardiographic parameters global longitudinal strain (GLS) was lower (p = 0.012), and diastolic dysfunction was more common in the HR group. However, the left ventricle ejection fraction (LVEF) was similar in the MR and HR groups. CONCLUSIONS In patients at high and moderate risk for cancer therapy-related cardiovascular toxicity, cardiovascular toxicity risk factors were common and more prevalent in the high-risk group. The coronary artery calcium score was also significantly higher in the high-risk group. Assessing the presence and burden of coronary artery calcium is an attractive option to assess additional cardiovascular risk in cancer patients.
Collapse
Affiliation(s)
- Anna Borowiec
- Department of Cancer & Cardio-Oncology Diagnostics, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland.
| | - Patrycja Ozdowska
- Department of Cancer & Cardio-Oncology Diagnostics, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Magdalena Rosinska
- Department of Computational Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Agnieszka Maria Zebrowska
- Department of Cancer & Cardio-Oncology Diagnostics, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Unit for Screening Studies in Inherited Cardiovascular Diseases, The Cardinal Stefan, Wyszynski National Institute of Cardiology, Warsaw, Poland
| | | | - Sławomir Jasek
- Department of Cancer & Cardio-Oncology Diagnostics, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Joanna Waniewska
- Department of Radiology I, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Beata Kotowicz
- Cancer Biomarker and Cytokines Laboratory Unit, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Hanna Kosela-Paterczyk
- Department of Soft Tissue/Bone Sarcoma and Melanoma, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Elzbieta Lampka
- Department of Lymphoid Malignancies, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Katarzyna Pogoda
- Department of Brest Cancer & Reconstructive Surgery, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Andrzej Cieszanowski
- Second Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Nowecki
- Department of Brest Cancer & Reconstructive Surgery, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jan Walewski
- Department of Lymphoid Malignancies, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| |
Collapse
|
27
|
Lavalle C, Mariani MV, Severino P, Palombi M, Trivigno S, D'Amato A, Silvetti G, Pierucci N, Di Lullo L, Chimenti C, Summaria F, Ronco C, Badagliacca R, Miraldi F, Vizza CD. Efficacy of Modern Therapies for Heart Failure with Reduced Ejection Fraction in Specific Population Subgroups: A Systematic Review and Network Meta-Analysis. Cardiorenal Med 2024; 14:570-580. [PMID: 39284285 DOI: 10.1159/000541393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 08/19/2024] [Indexed: 10/25/2024] Open
Abstract
INTRODUCTION The efficacy and safety of emerging therapies for heart failure with reduced ejection fraction (HFrEF) have never been compared in specific subgroups of patients. METHODS PubMed, Cochrane Registry, Web of Science, Scopus, and EMBASE libraries were used to extract data. We used the following keywords: (heart failure with reduced ejection fraction OR HFrEF) AND (treatment OR therapy) OR (cardiovascular death) OR (hospitalization for heart failure). We compared randomized clinical trials for HFrEF emerging therapies focusing on the elderly (patients >65 years old and >75 years old), chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) < 60 mL/min), patients with diabetes mellitus (DM), coronary heart disease (CAD), New York Heart Association (NYHA) class III/IV, women, patients on sacubitril/valsartan (S/V). The primary outcome was the efficacy composite endpoint of cardiovascular death (CVD) and HF hospitalization (HFH). RESULTS S/V significantly reduced the primary outcome in patients >65 years old (RR: 0.80; 95% CI: 0.68-0.94) and with CKD (RR: 0.79; 95% CI: 0.69-0.90); dapagliflozin in patients >65 (RR: 0.72; 95% CI: 0.60-0.86) and >75 years old (RR: 0.68; 95% CI: 0.53-0.87), in those with CKD (RR: 0.72; 95% CI: 0.59-0.88), DM (RR: 0.75; 95% CI: 0.63-0.89), and CAD (RR: 0.77; 95% CI: 0.65-0.92); empagliflozin in patients >65 years old (RR: 0.78; 95% CI: 0.66-0.93), those with DM (RR: 0.72; 95% CI: 0.60-0.86), CAD (RR: 0.82; 95% CI: 0.68-0.99), women (RR: 0.59; 95% CI: 0.44-0.79), and in patients on S/V (RR: 0.64; 95% CI: 0.45-0.91); vericiguat in patients with CKD (RR: 0.84; 95% CI: 0.73-0.97) and NYHA class III/IV (RR: 0.87; 95% CI: 0.77-0.98); omecamtiv mecarbil in patients with CAD (RR: 0.90; 95% CI: 0.82-0.99) and NYHA III/IV (RR: 0.88; 95% CI: 0.80-0.97). CONCLUSION Emerging HFrEF therapies show a clinical benefit with the reduction of the primary composite endpoint of CVD and HFH, with each drug being more effective in specific patient population.
Collapse
Affiliation(s)
- Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marta Palombi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Sara Trivigno
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giacomo Silvetti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Nicola Pierucci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Azienda USL Roma 6, Rome, Italy
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Claudio Ronco
- Department of Nephrology and Dialysis, International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
28
|
Nazir MS, Lyon AR, Southworth R. Iron replacement in anthracycline-related cardiac dysfunction: fuel on the fire? Eur Heart J 2024; 45:3132-3134. [PMID: 38982980 DOI: 10.1093/eurheartj/ehae411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Affiliation(s)
- Muhummad Sohaib Nazir
- School of Biomedical Engineering and Imaging Sciences, King's College London, Guy's and St Thomas' Hospital, London SE1 7EU, UK
- Cardio-Oncology Centre of Excellence, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Alexander R Lyon
- Cardio-Oncology Centre of Excellence, Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Richard Southworth
- School of Biomedical Engineering and Imaging Sciences, King's College London, Guy's and St Thomas' Hospital, London SE1 7EU, UK
| |
Collapse
|
29
|
Akhter N, Hibler EA. Under Pressure to Optimize the Cardiac Care of Breast Cancer Survivors. JACC. ADVANCES 2024; 3:101209. [PMID: 39238852 PMCID: PMC11375246 DOI: 10.1016/j.jacadv.2024.101209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Affiliation(s)
- Nausheen Akhter
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth A Hibler
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
30
|
Feat-Vetel J, Suffee N, Bachelot F, Dos Santos M, Mougenot N, Delage E, Saliou F, Martin S, Brunet I, Sicard P, Monceau V. X-ray Radiotherapy Impacts Cardiac Dysfunction by Modulating the Sympathetic Nervous System and Calcium Transients. Int J Mol Sci 2024; 25:9483. [PMID: 39273430 PMCID: PMC11394929 DOI: 10.3390/ijms25179483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/15/2024] Open
Abstract
Recent epidemiological studies have shown that patients with right-sided breast cancer (RBC) treated with X-ray irradiation (IR) are more susceptible to developing cardiovascular diseases, such as arrhythmias, atrial fibrillation, and conduction disturbances after radiotherapy (RT). Our aim was to investigate the mechanisms induced by low to moderate doses of IR and to evaluate changes in the cardiac sympathetic nervous system (CSNS), atrial remodeling, and calcium homeostasis involved in cardiac rhythm. To mimic the RT of the RBC, female C57Bl/6J mice were exposed to X-ray doses ranging from 0.25 to 2 Gy targeting 40% of the top of the heart. At 60 weeks after RI, Doppler ultrasound showed a significant reduction in myocardial strain, ejection fraction, and atrial function, with a significant accumulation of fibrosis in the epicardial layer and apoptosis at 0.5 mGy. Calcium transient protein expression levels, such as RYR2, NAK, Kir2.1, and SERCA2a, increased in the atrium only at 0.5 Gy and 2 Gy at 24 h, and persisted over time. Interestingly, 3D imaging of the cleaned hearts showed an early reduction of CSNS spines and dendrites in the ventricles and a late reorientation of nerve fibers, combined with a decrease in SEMA3a expression levels. Our results showed that local heart IR from 0.25 Gy induced late cardiac and atrial dysfunction and fibrosis development. After IR, ventricular CSNS and calcium transient protein expression levels were rearranged, which affected cardiac contractility. The results are very promising in terms of identifying pro-arrhythmic mechanisms and preventing arrhythmias during RT treatment in patients with RBC.
Collapse
Affiliation(s)
- Justyne Feat-Vetel
- Laboratoire de Pharmacologie Expérimentale et Moléculaire (LPEM), Service d'Ingénierie Moléculaire Pour la Santé (SIMoS), Département Médicaments et Technologies Pour la Santé (DMTS), CEA, 91191 Gif-sur-Yvette, France
| | - Nadine Suffee
- UMR 1166, Unité de Recherche sur les Maladies Cardiovasculaires et Métaboliques, INSERM, 75013 Paris, France
| | - Florence Bachelot
- PSE-SANTE/SESANE/LRTOX, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| | - Morgane Dos Santos
- PSE-SANTE/SERAMED/LRAcc, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| | - Nathalie Mougenot
- UMS28, INSERM, Sorbonne Université, Plateforme PECMV, 75005 Paris, France
| | - Elise Delage
- CellTechs Laboratory, SupBiotech, 94800 Villejuif, France
- Service d'Etude des Prions et des Infections Atypiques, Institut François Jacob, Commissariat à l'Energie Atomique et aux Energies Alternatives, Université Paris Saclay, 91405 Fontenay-aux-Roses, France
| | - Florian Saliou
- PSE-SANTE/SESANE/LRTOX, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| | - Sabrina Martin
- Center for Interdisciplinary Research in Biology (CIRB), College de France, 75001 Paris, France
| | - Isabelle Brunet
- Center for Interdisciplinary Research in Biology (CIRB), College de France, 75001 Paris, France
| | - Pierre Sicard
- PhyMedExp, IPAM/Biocampus, INSERM, CNRS, Université de Montpellier, 34095 Montpellier, France
| | - Virginie Monceau
- PSE-SANTE/SESANE/LRTOX, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| |
Collapse
|
31
|
Smiseth OA, Rider O, Cvijic M, Valkovič L, Remme EW, Voigt JU. Myocardial Strain Imaging: Theory, Current Practice, and the Future. JACC Cardiovasc Imaging 2024:S1936-878X(24)00301-2. [PMID: 39269417 DOI: 10.1016/j.jcmg.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 09/15/2024]
Abstract
Myocardial strain imaging by echocardiography or cardiac magnetic resonance (CMR) is a powerful method to diagnose cardiac disease. Strain imaging provides measures of myocardial shortening, thickening, and lengthening and can be applied to any cardiac chamber. Left ventricular (LV) global longitudinal strain by speckle-tracking echocardiography is the most widely used clinical strain parameter. Several CMR-based modalities are available and are ready to be implemented clinically. Clinical applications of strain include global longitudinal strain as a more sensitive method than ejection fraction for diagnosing mild systolic dysfunction. This applies to patients suspected of having heart failure with normal LV ejection fraction, to early systolic dysfunction in valvular disease, and when monitoring myocardial function during cancer chemotherapy. Segmental LV strain maps provide diagnostic clues in specific cardiomyopathies, when evaluating LV dyssynchrony and ischemic dysfunction. Strain imaging is a promising modality to quantify right ventricular function. Left atrial strain may be used to evaluate LV diastolic function and filling pressure.
Collapse
Affiliation(s)
- Otto A Smiseth
- Institute for Surgical Research, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway.
| | - Oliver Rider
- Oxford Centre for Clinical Magnetic Resonance Research, RDM Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Marta Cvijic
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research, RDM Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom; Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Espen W Remme
- Institute for Surgical Research, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway; The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Leuven, Belgium
| |
Collapse
|
32
|
Felix N, Nogueira PC, Silva IM, Costa TA, Campello CA, Stecca C, Lopes RD. Cardio-protective effects of statins in patients undergoing anthracycline-based chemotherapy: An updated meta-analysis of randomized controlled trials. Eur J Intern Med 2024; 126:43-48. [PMID: 38643042 DOI: 10.1016/j.ejim.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/28/2024] [Accepted: 04/10/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Several interventions have been tested for cardio-protection against anthracycline-induced cancer therapy-related cardiovascular dysfunction (CTRCD). The role of statins in this setting remains unclear. METHODS We systematically searched PubMed, Embase, Cochrane Library, Clinicaltrials.gov, and Web of Science for randomized controlled trials (RCTs) comparing statins versus control (placebo or no intervention) for preventing anthracycline-induced CTRCD. We applied a random-effects model to pool risk ratios (RR) and mean differences (MD) with 95 % confidence intervals (CI). RESULTS We included seven RCTs comprising 887 patients with planned chemotherapy with anthracycline-based regimens, of whom 49.8 % were randomized to statins. Relative to placebo, statins significantly reduced the incidence of cardiotoxicity/CTRCD (RR 0.46; 95 % CI 0.29 to 0.72; p < 0.001). The left ventricular end-systolic volume was also lower in patients treated with statin (MD -3.12 mL; 95 % CI -6.13 to -0.12 mL; p = 0.042). There was no significant difference between groups in post-anthracycline left ventricular ejection fraction (LVEF) overall. CONCLUSION In this meta-analysis of RCTs, statins were significantly associated with a lower incidence of anthracycline-induced CTRCD and attenuated changes in the left ventricular end-systolic volume. Thus, our findings suggest that statins should be considered as a cardio-protection strategy for patients with planned anthracycline-based chemotherapy.
Collapse
Affiliation(s)
- Nicole Felix
- Federal University of Campina Grande, Campina Grande, Brazil
| | - Paula C Nogueira
- Hospital da Mulher, São Paulo, Brazil; Grupo Fleury, São Paulo, Brazil.
| | | | | | | | | | | |
Collapse
|
33
|
Di Lisi D, Madaudo C, Ortello A, Rubino L, Scelfo D, Sinagra FP, Comparato F, Triolo OF, Rossetto L, Galassi AR, Novo G. Assessment of cancer therapy-related cardiac dysfunction in breast cancer women using a new speckle tracking echocardiography index: The GAVS. Echocardiography 2024; 41:e15881. [PMID: 39007868 DOI: 10.1111/echo.15881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 06/15/2024] [Accepted: 06/23/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Recently, peak atrial longitudinal strain (PALS) has emerged as a possible predictor of Cancer therapy-related cardiac dysfunction (CTRCD) in cancer patients (CP), in addition to left ventricular global longitudinal strain (GLS). Thus, considering the link between left atrium and left ventricle, the aim of this study was to assess the global atrio-ventricular strain (GAVS) in CP, to detect early cardiotoxicity. METHODS A prospective study was carried out enrolling 131 breast cancer women (mean age 51.4 ± 10.4 years) receiving anti-cancer treatment. Clinical and echocardiographic evaluation was performed at baseline (T0), 3 (T1), 6 (T2) and 12 months (T3) after starting treatment. CTRCD was defined according to the 2022 ESC Cardio-Oncology guidelines. RESULTS Forty-four patients developed CTRCD (3 moderate and 41 mild CTRCD group A) and 87 patients did not (group B). In group A, significant changes in GLS, PALS, GAVS, LASi (left atrial stiffness index) and LVEF/GLS occurred earlier than LVEF, that reduced significantly only at T3 (p-value < .05). Significant changes in LASi, PALS and GAVS occurred even in group B but reduction in GAVS (-21% vs. -5%) and PALS (-24% vs. -12%) was significantly greater in group A compared to group B (p-value = .04). CONCLUSIONS Our study confirms high sensitivity of speckle tracking echocardiography in detecting subclinical myocardial damage in CP and the usefulness of a multiparametric echocardiographic evaluation including PALS and GLS (GAVS) for having a global evaluation of the phenomenon cardiotoxicity.
Collapse
Affiliation(s)
- Daniela Di Lisi
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
| | - Cristina Madaudo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Antonella Ortello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Luigi Rubino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Domenico Scelfo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Francesco Paolo Sinagra
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Francesco Comparato
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | | | - Ludovico Rossetto
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
| | - Alfredo Ruggero Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Giuseppina Novo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Palermo, Italy
| |
Collapse
|
34
|
Chen J, Wei J, Xia P, Liu Y, Belew MD, Toohill R, Wu BJ, Cheng Z. Inhibition of cyclin-dependent kinase 7 mitigates doxorubicin cardiotoxicity and enhances anticancer efficacy. Cardiovasc Res 2024; 120:1024-1036. [PMID: 38646672 PMCID: PMC11288736 DOI: 10.1093/cvr/cvae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 01/16/2024] [Accepted: 02/29/2024] [Indexed: 04/23/2024] Open
Abstract
AIMS The anthracycline family of anticancer agents such as doxorubicin (DOX) can induce apoptotic death of cardiomyocytes and cause cardiotoxicity. We previously reported that DOX-induced apoptosis is accompanied by cardiomyocyte cell cycle re-entry. Cell cycle progression requires cyclin-dependent kinase 7 (CDK7)-mediated activation of downstream cell cycle CDKs. This study aims to determine whether CDK7 can be targeted for cardioprotection during anthracycline chemotherapy. METHODS AND RESULTS DOX exposure induced CDK7 activation in mouse heart and isolated cardiomyocytes. Cardiac-specific ablation of Cdk7 attenuated DOX-induced cardiac dysfunction and fibrosis. Treatment with the covalent CDK7 inhibitor THZ1 also protected against DOX-induced cardiomyopathy and apoptosis. DOX treatment induced activation of the proapoptotic CDK2-FOXO1-Bim axis in a CDK7-dependent manner. In response to DOX, endogenous CDK7 directly bound and phosphorylated CDK2 at Thr160 in cardiomyocytes, leading to full CDK2 kinase activation. Importantly, inhibition of CDK7 further suppressed tumour growth when used in combination with DOX in an immunocompetent mouse model of breast cancer. CONCLUSION Activation of CDK7 is necessary for DOX-induced cardiomyocyte apoptosis and cardiomyopathy. Our findings uncover a novel proapoptotic role for CDK7 in cardiomyocytes. Moreover, this study suggests that inhibition of CDK7 attenuates DOX-induced cardiotoxicity but augments the anticancer efficacy of DOX. Therefore, combined administration of CDK7 inhibitor and DOX may exhibit diminished cardiotoxicity but superior anticancer activity.
Collapse
MESH Headings
- Animals
- Doxorubicin/toxicity
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/enzymology
- Myocytes, Cardiac/pathology
- Myocytes, Cardiac/metabolism
- Cardiotoxicity
- Cyclin-Dependent Kinases/metabolism
- Cyclin-Dependent Kinases/antagonists & inhibitors
- Apoptosis/drug effects
- Protein Kinase Inhibitors/pharmacology
- Cyclin-Dependent Kinase 2/metabolism
- Cyclin-Dependent Kinase 2/antagonists & inhibitors
- Mice, Inbred C57BL
- Cyclin-Dependent Kinase-Activating Kinase
- Female
- Phenylenediamines/pharmacology
- Signal Transduction/drug effects
- Phosphorylation
- Mice, Knockout
- Cardiomyopathies/chemically induced
- Cardiomyopathies/enzymology
- Cardiomyopathies/prevention & control
- Cardiomyopathies/pathology
- Cardiomyopathies/metabolism
- Antibiotics, Antineoplastic/toxicity
- Pyrimidines/pharmacology
- Humans
- Fibrosis
- Cell Line, Tumor
- Mammary Neoplasms, Experimental/drug therapy
- Mammary Neoplasms, Experimental/pathology
- Mammary Neoplasms, Experimental/enzymology
- Mammary Neoplasms, Experimental/metabolism
- Ventricular Function, Left/drug effects
Collapse
Affiliation(s)
- Jingrui Chen
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Jing Wei
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Peng Xia
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Yuening Liu
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Mahder Dawit Belew
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Ryan Toohill
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Boyang Jason Wu
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| | - Zhaokang Cheng
- Department of Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd., Spokane, WA 99202-2131, USA
| |
Collapse
|
35
|
Parmentier S, Koschmieder S, Henze L, Griesshammer M, Matzdorff A, Bakchoul T, Langer F, Alesci RS, Duerschmied D, Thomalla G, Riess H. Antithrombotic Therapy in Cancer Patients with Cardiovascular Diseases: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society for Thrombosis and Hemostasis Research (GTH e.V.). Hamostaseologie 2024. [PMID: 39009011 DOI: 10.1055/a-2337-4025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
Active cancer by itself but also chemotherapy is associated with an increased risk of cardiovascular disease (CVD) and especially coronary artery disease (CAD) and atrial fibrillation (AF). The frequency of CVD, CAD, and AF varies depending on comorbidities (particularly in older patients), cancer type, and stage, as well as the anticancer therapeutic being taken. Many reports exist for anticancer drugs being associated with CVD, CAD, and AF, but robust data are often lacking. Because of this, each patient needs an individual structured approach concerning thromboembolic and bleeding risk, drug-drug interactions, as well as patient preferences to evaluate the need for anticoagulation therapy and targeting optimal symptom control. Interruption of specific cancer therapy should be avoided to reduce the potential risk of cancer progression. Nevertheless, additional factors like thrombocytopenia and anticoagulation in the elderly and frail patient with cancer cause additional challenges which need to be addressed in daily clinical management. Therefore, the aim of these recommendations is to summarize the available scientific data on antithrombotic therapy (both antiplatelet and anticoagulant therapy) in cancer patients with CVD and in cases of missing data providing guidance for optimal careful decision-making in daily routine.
Collapse
Affiliation(s)
- Stefani Parmentier
- Tumorzentrum, St. Claraspital Tumorzentrum, St. Claraspital, Basel, Basel-Stadt, Switzerland
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Larissa Henze
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
- Department of Internal Medicine II, Hematology, Oncology and Palliative Medicine, Asklepios Hospital Harz, Goslar, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, Schwedt, Germany
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Florian Langer
- Center for Oncology, University Cancer Center Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Center Eppendorf, Hamburg, Germany
| | - Rosa Sonja Alesci
- IMD Blood Coagulation Center, Hochtaunus/Frankfurt, Bad Homburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Hemostaseology, Angiology and Medical Intensive Care, Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Riess
- Division of Hematology, Oncology and Tumorimmunology, Department of Medical, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
36
|
Szponar J, Niziński P, Dudka J, Kasprzak-Drozd K, Oniszczuk A. Natural Products for Preventing and Managing Anthracycline-Induced Cardiotoxicity: A Comprehensive Review. Cells 2024; 13:1151. [PMID: 38995002 PMCID: PMC11240786 DOI: 10.3390/cells13131151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/13/2024] Open
Abstract
Doxorubicin (DOX) is an anthracycline anticancer agent that is highly effective in the treatment of solid tumors. Given the multiplicity of mechanisms involved in doxorubicin-induced cardiotoxicity, it is difficult to identify a precise molecular target for toxicity. The findings of a literature review suggest that natural products may offer cardioprotective benefits against doxorubicin-induced cardiotoxicity, both in vitro and in vivo. However, further confirmatory studies are required to substantiate this claim. It is of the utmost importance to direct greater attention towards the intricate signaling networks that are of paramount importance for the survival and dysfunction of cardiomyocytes. Notwithstanding encouraging progress made in preclinical studies of natural products for the prevention of DOX-induced cardiotoxicity, these have not yet been translated for clinical use. One of the most significant obstacles hindering the development of cardioprotective adjuvants based on natural products is the lack of adequate bioavailability in humans. This review presents an overview of current knowledge on doxorubicin DOX-induced cardiotoxicity, with a focus on the potential benefits of natural compounds and herbal preparations in preventing this adverse effect. As literature search engines, the browsers in the Scopus, PubMed, Web of Science databases and the ClinicalTrials.gov register were used.
Collapse
Affiliation(s)
- Jarosław Szponar
- Clinical Department of Toxicology and Cardiology, Toxicology Clinic, Stefan Wyszyński Regional Specialist Hospital, Medical University of Lublin, 20-718 Lublin, Poland;
| | - Przemysław Niziński
- Department of Pharmacology, Medical University of Lublin, Radziwiłłowska 11 Street, 20-080 Lublin, Poland;
| | - Jarosław Dudka
- Chair and Department of Toxicology, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland;
| | - Kamila Kasprzak-Drozd
- Department of Inorganic Chemistry, Medical University of Lublin, Chodźki 4a, 20-093 Lublin, Poland;
| | - Anna Oniszczuk
- Department of Inorganic Chemistry, Medical University of Lublin, Chodźki 4a, 20-093 Lublin, Poland;
| |
Collapse
|
37
|
Vigen R, Ayers C, Berry J, Rohatgi A, Nambi V, Ballantyne CM, Omland T, de Filippi CR, de Lemos J. Individual and Joint Associations of High-Sensitivity Troponin I and High-Sensitivity Troponin T with Cardiac Phenotypes and Outcomes in the General Population: An Analysis From the Dallas Heart Study. J Am Heart Assoc 2024; 13:e034549. [PMID: 38842289 PMCID: PMC11255706 DOI: 10.1161/jaha.124.034549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND High-sensitivity troponin I (hs-cTnI) and T (hs-cTnT) provide complementary information regarding cardiovascular disease risk. The explanation for their distinct risk profiles is incompletely understood. METHODS AND RESULTS hs-cTnI and hs-cTnT were measured in Dallas Heart Study participants. Associations of hs-cTnI and hs-cTnT with demographics and phenotypes were assessed using linear regression. Associations with incident heart failure, atherosclerotic cardiovascular disease, global cardiovascular disease, and cardiovascular and all-cause mortality were assessed using Cox models. Among 3276 participants (56% women, 50% Black persons, median age 43 years), the correlation between hs-cTnI and hs-cTnT was modest (Spearman rho=0.35). Variables associated with hs-cTnI but not hs-cTnT included hypertension, higher body mass index and total cholesterol, and lower high-density lipoprotein and cholesterol efflux capacity. Older age, male sex, and diabetes were positively associated, and smoking was negatively associated, with hs-cTnT but not hs-cTnI. Hs-cTnI and hs-cTnT were associated with heart failure (hazard ratio [HR] per SD log hs-cTnI 1.53 [95% CI, 1.30-1.81] and HR per SD log hs-cTnT 1.65 [95% CI, 1.40-1.95]), global cardiovascular disease (HR, 1.22 [95% CI, 1.10-1.34] and HR, 1.27 [95% CI, 1.15-1.32]), and all-cause mortality (HR, 1.12 [95% CI, 1.01-1.25], and HR, 1.17 [95% CI, 1.06-1.29]). After adjustment for N-terminal pro-B-type natriuretic peptide and the alternative troponin, both remained associated with heart failure (HR per SD log hs-cTnI 1.32 [95% CI, 1.1-1.58] and HR per log hs-cTnT 1.27 [95% CI, 1.06-1.51]). CONCLUSIONS Hs-cTnI and hs-cTnT are modestly correlated, demonstrate differential associations with cardiac and metabolic phenotypes, and provide complementary information regarding heart failure risk.
Collapse
Affiliation(s)
- Rebecca Vigen
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Colby Ayers
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Jarett Berry
- Department of Internal MedicineUniversity of Texas at Tyler Health Science CenterTylerTXUSA
| | - Anand Rohatgi
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Vijay Nambi
- Department of Medicine and Center for Cardiometabolic Disease PreventionBaylor College of MedicineHoustonTXUSA
| | - Christie M. Ballantyne
- Department of Medicine and Center for Cardiometabolic Disease PreventionBaylor College of MedicineHoustonTXUSA
| | - Torbjorn Omland
- K.G. Jebsen Center of Cardiac BiomarkersInstitute of Clinical MedicineUniversity of OsloOsloNorway
- Department of CardiologyAkershus University HospitalLørenskogNorway
| | | | - James de Lemos
- Division of CardiologyDepartment of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTXUSA
| |
Collapse
|
38
|
Gupta P, Canonico ME, Faaborg-Andersen C, Prabhu N, Kondapalli L, Quintana RA. Updates in the management of cancer therapy-related hypertension. Curr Opin Cardiol 2024; 39:235-243. [PMID: 38391284 DOI: 10.1097/hco.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive review of hypertension among patients with cancer. Several cancer therapies cause hypertension which has resulted in a growing and vulnerable population of patients with difficult to control hypertension which has significant downstream effects. RECENT FINDINGS Hypertension affects up to 50% of cancer patients and higher comorbidity when compared to the general population. Many anticancer therapies can cause hypertension through their treatment effect. Antihypertensive treatment is crucial given cardiovascular mortality is a leading cause of death among cancer patients. It is already known that hypertension is poorly controlled in the general population, and there are additional challenges in management among patients with cancer. Patients with cancer suffer from multimorbidity, are on multiple medications creating concern for drug interactions, and often have blood pressure lability, which can worsen clinical inertia among patients and their providers. It is crucial to effectively treat hypertension in cancer patients to mitigate downstream adverse cardiovascular events. SUMMARY In recent years, there have been significant changes in management guidelines of hypertension and simultaneously as influx of new cancer therapeutics. We provide an update on hypertension treatment among patients with cancer on different chemotherapeutic agents.
Collapse
Affiliation(s)
- Prerna Gupta
- Department of Medicine, Division of Cardiology, University of Colorado
| | - Mario Enrico Canonico
- Department of Medicine, Division of Cardiology, University of Colorado
- CPC Clinical Research, Aurora, Colorado
| | - Christian Faaborg-Andersen
- Department of Medicine, Massachusetts General Hospital / Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Prabhu
- Department of Medicine, Division of Cardiology, University of Colorado
| | | | | |
Collapse
|
39
|
Kim H, Hong B, Kim S, Kang SM, Park J. Chemotherapy-related cardiotoxicity and its symptoms in patients with breast cancer: a scoping review. Syst Rev 2024; 13:167. [PMID: 38937811 PMCID: PMC11212164 DOI: 10.1186/s13643-024-02588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Chemotherapy-related cardiotoxicity is a significant concern because it is a major cause of morbidity. This study aimed to provide in-depth information on the symptoms of chemotherapy-related cardiotoxicity (CRCT) by exploring literature that concurrently reports the types and symptoms of CRCT in patients with breast cancer. METHODS A scoping review was performed according to an a priori protocol using the Joanna Briggs Institute's guidelines. The participants were patients with breast cancer. The concept was the literature of specifically reported symptoms directly matched with CRCT and the literature, in English, from 2010, and the context was open. The search strategy included four keywords: "breast cancer," "chemotherapy," "cardiotoxicity," and "symptoms." All types of research designs were included; however, studies involving patients with other cancer types, animal subjects, and symptoms not directly related to CRCT were excluded. Data were extracted and presented including tables and figures. RESULTS A total of 29 articles were included in the study, consisting of 23 case reports, 4 retrospective studies, and 2 prospective studies. There were no restrictions on the participants' sex; however, all of them were women, except for one case report. The most used chemotherapy regimens were trastuzumab, capecitabine, and doxorubicin or epirubicin. The primary CRCT identified were myocardial dysfunction and heart failure, followed by coronary artery disease, pulmonary hypertension, and other conditions. Major tests used to diagnose CRCT include echocardiography, electrocardiography, serum cardiac enzymes, coronary angiography, computed tomography, and magnetic resonance imaging. In all case reports, CRCT was diagnosed through an incidental checkup according to the patient's symptom presentation; however, only 10 of these studies showed a baseline checkup before chemotherapy. The five most common CRCT symptoms were dyspnea, chest pain, peripheral edema, fatigue, and palpitations, which were assessed by patient-reported symptom presentation rather than using a symptom assessment tool. Dyspnea with trastuzumab treatment and chest pain with capecitabine treatment were particularly characteristic. The time for first symptom onset after chemotherapy ranged from 1 hour to 300 days, with anthracycline-based regimens requiring 3-55 days, trastuzumab requiring 60-300 days, and capecitabine requiring 1-7 days. CONCLUSIONS This scoping review allowed data mapping according to the study design and chemotherapy regimens. Cardiac assessments for CRCT diagnosis were performed according to the patient's symptoms. There were approximately five types of typical CRCT symptoms, and the timing of symptom occurrence varied. Therefore, developing and applying a CRCT-specific and user-friendly symptom assessment tool are expected to help healthcare providers and patients manage CRCT symptoms effectively.
Collapse
Affiliation(s)
- Hyunjoo Kim
- Graduate School, College of Nursing, Yonsei University, 50 Yonsei-ro, Seoul, South Korea
- Severance Cardiovascular Hospital, Yonsei University, 50-1 Yonsei-ro, Seoul, South Korea
| | - Bomi Hong
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, 50-1 Yonsei-ro, Seoul, South Korea
| | - Sanghee Kim
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seoul, South Korea
| | - Seok-Min Kang
- Department of Internal Medicine, Division of Cardiology, Heart Failure Center, Severance Hospital, Yonsei University, 50-1 Yonsei-ro, Seoul, South Korea
| | - Jeongok Park
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seoul, South Korea.
| |
Collapse
|
40
|
Wu S, Rhee JW, Iukuridze A, Bosworth A, Chen S, Atencio L, Manubolu V, Bhandari R, Jamal F, Mei M, Herrera A, Rodriguez F, Forman S, Nakamura R, Wong FL, Budoff M, Armenian SH. Coronary artery calcium and cardiovascular outcomes in patients with lymphoma undergoing autologous hematopoietic cell transplantation. Cancer 2024; 130:2205-2214. [PMID: 38358333 DOI: 10.1002/cncr.35252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/17/2023] [Accepted: 01/17/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Patients undergoing autologous hematopoietic cell transplantation (HCT) have a >2-fold risk of developing cardiovascular disease (CVD; heart failure, myocardial infarction, and stroke), compared to the general population. Coronary artery calcium (CAC) is predictive of CVD in nononcology patients but is not as well studied in patients who underwent HCT and survivors of HCT.The objective of this study was to examine the association between CAC and CVD risk and outcomes after HCT in patients with lymphoma. METHODS This was a retrospective cohort study of 243 consecutive patients who underwent a first autologous HCT for lymphoma between 2009 and 2014. CAC (Agatston score) was determined from chest computed tomography obtained <60 days from HCT. Multivariable Cox regression analysis was used to calculate hazard ratio (HR) estimates and 95% confidence intervals (CIs), adjusted for covariates (age, conventional risk factors [e.g., hypertension and dyslipidemia], and cancer treatment). RESULTS The median age at HCT was 55.7 years (range, 18.5-75.1 years), 59% were male, and 60% were non-Hispanic White. The prevalence of CAC was 37%. The 5-year CVD incidence for the cohort was 12%, and there was an incremental increase in the incidence according to CAC score: 0 (6%), 1-100 (20%), and >100 (32%) (p = .001). CAC was significantly associated with CVD risk (HR, 3.0; 95% CI, 1.2-7.5) and worse 5-year survival (77% vs. 50%; p < .001; HR, 2.0; 95% CI, 1.1-3.4), compared to those without CAC. CONCLUSIONS CAC is independently associated with CVD and survival after HCT. This highlights the importance of integrating readily available imaging information in risk stratification and decision-making in patients undergoing HCT, which sets the stage for strategies to optimize outcomes after HCT.
Collapse
Affiliation(s)
- Stephanie Wu
- Department of Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - June-Wha Rhee
- Department of Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Aleksi Iukuridze
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Alysia Bosworth
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Sitong Chen
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Liezl Atencio
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Venkat Manubolu
- Department of Cardiology, Lundquist Institute, Torrance, California, USA
| | - Rusha Bhandari
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
- Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Faizi Jamal
- Department of Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Matthew Mei
- Department of Hematology & Hematopoietic Transplantation, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Alex Herrera
- Department of Hematology & Hematopoietic Transplantation, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Fatima Rodriguez
- Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA
| | - Stephen Forman
- Department of Hematology & Hematopoietic Transplantation, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Transplantation, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - F Lennie Wong
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Matthew Budoff
- Department of Cardiology, Lundquist Institute, Torrance, California, USA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, California, USA
- Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| |
Collapse
|
41
|
Emami AH, Alizadehasl A, Sayad M, Shavandi F, Firoozbakhsh P, Meshgi S, Roudini K, Dokhani N. Diagnosis and management of cancer therapy-related myocarditis in a young female: A case report and review of literature. BMC Cardiovasc Disord 2024; 24:299. [PMID: 38858610 PMCID: PMC11163803 DOI: 10.1186/s12872-024-03960-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND The treatment of choice for Extra-osseous Ewing's sarcoma/primitive neuroectodermal tumor (ES/PNET), a rare neoplasm, is the VAC/IE regimen. This regimen includes Doxorubicin, Vincristine, Cyclophosphamide, Ifosfamide, and Etoposide, all of which have cardiotoxic effects. Myocarditis, a potentially threatening side effect following cancer therapy, can be accurately managed and diagnosed. CASE PRESENTATION In the current study, we report the case of a 19-year-old female with a mass on the abdominal wall, diagnosed with ES/PNET. She was treated with the VAC/IE regimen. A month after the last session of chemotherapy, she experienced dyspnea. Upon evaluation, a high level of troponin and a low left ventricular ejection fraction (LVEF) were detected via transthoracic echocardiography. She was treated with anti-heart failure drugs, but the response was unsatisfactory. The possibility of Cancer therapy-related myocarditis was suspected, and cardiac magnetic resonance imaging (CMR) confirmed acute myocarditis. This patient exhibited a significant response to intravenous immunoglobulin (IVIG), with her LVEF improving from 30-35% to 50% within three months. CONCLUSION In this case, based on negative tests and the absence of viral signs and symptoms, Cancer therapy-related myocarditis is highly suspected as the cause of myocarditis. This case underscores the importance of accurately utilizing CMR as a non-invasive method for diagnosing myocarditis. It effectively highlights the identification of reversible myocarditis with appropriate treatment and the notable response to IVIG, suggesting its potential as a favorable treatment for myocarditis in younger patients.
Collapse
Affiliation(s)
- Amir Hossein Emami
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Sayad
- Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farnaz Shavandi
- Student Research Committee, Hamadan University of Medical Sciences, School of Medicine, Hamadan, Iran
| | - Parisa Firoozbakhsh
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahla Meshgi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kamran Roudini
- Department of internal medicine, Hematology and Medical oncology ward, Cancer research center, Imam Khomeini hospital complex, Tehran University of medical sciences, cancer institute, Tehran, Iran
| | - Negar Dokhani
- Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
42
|
Miaris N, Kasinos N. The role of cardiovascular magnetic resonance in cancer therapy-related cardiotoxicity. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1393-1394. [PMID: 38613606 DOI: 10.1007/s10554-024-03090-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 03/21/2024] [Indexed: 04/15/2024]
Affiliation(s)
- Nikolaos Miaris
- Imaging Department, Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Harefield, UK.
- 'Dimitrios Belntekos' Department of Echocardiography Training, 'Tzaneio' General Hospital of Piraeus, Piraeus, Greece.
| | - Nearchos Kasinos
- 'Dimitrios Belntekos' Department of Echocardiography Training, 'Tzaneio' General Hospital of Piraeus, Piraeus, Greece
| |
Collapse
|
43
|
Wu L, Du Y, Wang L, Zhang Y, Ren J. Inhibition of METTL3 ameliorates doxorubicin-induced cardiotoxicity through suppression of TFRC-mediated ferroptosis. Redox Biol 2024; 72:103157. [PMID: 38631119 PMCID: PMC11033199 DOI: 10.1016/j.redox.2024.103157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/28/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Doxorubicin (DOX) is a chemotherapeutic drug, while its clinical use is greatly limited by the life-threatening cardiotoxicity. N6-methyladenosine (m6A) RNA modification participates in varieties of cellular processes. Nonetheless, it remains elusive whether m6A modification and its methyltransferase METTL3 are involved in the progression of DOX-induced cardiotoxicity (DIC). METHODS Mice were administrated with DOX (accumulative dosage of 20 mg/kg) repeatedly to establish a chronic DIC model. Cardiomyocyte-specific conditional METTL3 knockout mice were employed to evaluate the effects of altered m6A RNA modification on DIC. The effects of METTL3 on cardiomyocyte ferroptosis were also examined in response to DOX stimulation. RESULTS DOX led to increased levels in m6A modification and METTL3 expression in cardiomyocytes in a c-Jun-dependent manner. METTL3-knockout mice exhibited improved cardiac function, remodeling and injury following DOX insult. Besides, inhibition of METTL3 alleviated DOX-induced iron accumulation and ferroptosis in cardiomyocytes, whereas METTL3 overexpression exerted the opposite effects. Mechanistically, METTL3 promoted m6A modification of TFRC mRNA, a critical gene governing iron uptake, and enhanced its stability through recognition of the m6A reader protein, IGF2BP2. Moreover, pharmacological administration of a highly selective METTL3 inhibitor STM2457 effectively ameliorated DIC in mice. CONCLUSION METTL3 plays a cardinal role in the etiology of DIC by regulating cardiac iron metabolism and ferroptosis through TFRC m6A modification. Inhibition of METTL3 might be a potential therapeutic avenue for DIC.
Collapse
Affiliation(s)
- Lin Wu
- Department of Cardiology and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, 200032, China; National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China
| | - Yuxin Du
- Department of Cardiology and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, 200032, China; National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China
| | - Litao Wang
- Department of Cardiology and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, 200032, China; National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China
| | - Yingmei Zhang
- Department of Cardiology and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, 200032, China; National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China.
| | - Jun Ren
- Department of Cardiology and Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, 200032, China; National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China.
| |
Collapse
|
44
|
Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GMT, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: a 2023 update. Bone Marrow Transplant 2024; 59:717-741. [PMID: 38413823 DOI: 10.1038/s41409-023-02190-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the volume of HCT performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long-term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pre-, peri- and post-transplant exposures and other underlying risk-factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and updated in 2012. To review contemporary literature and update the recommendations while considering the changing practice of HCT and cellular therapy, an international group of experts was again convened. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed but cGVHD management is not covered in detail. These guidelines emphasize special needs of patients with distinct underlying HCT indications or comorbidities (e.g., hemoglobinopathies, older adults) but do not replace more detailed group, disease, or condition specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
Collapse
Affiliation(s)
- Seth J Rotz
- Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, MA, USA
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
| | - Peggy Burkhard
- National Bone Marrow Transplant Link, Southfield, MI, USA
| | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
- QEII Health Sciences Center, Halifax, NS, Canada
| | - Gregory M T Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, NSW, Australia
- St Vincent's Clinical School Sydney, University of New South Wales, Sydney, NSW, Australia
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, WA, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, WA, Australia
- PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, UK
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, ACCENT VV, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Susan K Stewart
- Blood & Marrow Transplant Information Network, Highland Park, IL, 60035, USA
| | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, TN, USA
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
45
|
Morris DA. Left atrial strain as a potential parameter to detect cancer therapy-related cardiac dysfunction: An editorial commentary and systematic review. Echocardiography 2024; 41:e15824. [PMID: 38757453 DOI: 10.1111/echo.15824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Affiliation(s)
- Daniel A Morris
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
| |
Collapse
|
46
|
Lammers EMJ, Nijdam A, Zijlstra JM, Janus CPM, de Weijer RJ, Appelman Y, Manintveld OC, Teske AJ, van Leeuwen FE, Aleman BMP. Cardiovascular screening outcomes in the Dutch survivorship care program for Hodgkin lymphoma survivors. J Cancer Surviv 2024:10.1007/s11764-024-01561-y. [PMID: 38649650 DOI: 10.1007/s11764-024-01561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 03/02/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Hodgkin lymphoma (HL) survivors are at increased risk of cardiovascular disease (CVD) due to former lymphoma treatment. In 2013, cardiovascular screening for 5-year HL survivors according to national guidelines was implemented in Dutch survivorship clinics. We aim to assess the following: (1) adherence to screening guidelines and (2) the yield of (risk factors for) CVD in the screening program. METHODS The study population consisted of 5-year HL survivors who received survivorship care at three University Medical Centers from 2013 to 2016 through 2021. Patient characteristics, cardiovascular screening procedures, and outcomes were collected from the medical records. RESULTS In 186 survivors eligible for cardiovascular screening (mean age 47.8 years, 60.8% female), the following diagnostics were performed: complete blood tests (81.0%, median frequency: yearly instead of advised 5-yearly evaluation), electrocardiogram (93.0%), echocardiography (94.6%). Fifty-five percent of survivors had at least one modifiable cardiovascular risk factor (i.e., current smoking, overweight, new/insufficiently controlled hypertension, dyslipidemia, or diabetes). Screening detected ≥ 1 CVD in 31.1% of survivors. Among survivors with available echocardiography report (n = 106), screening detected new aortic and/or mitral valve dysfunction(s) in 51.0% (with grades 3-4 in 4.9%) and impaired left ventricular ejection fraction in 10.3%. CONCLUSIONS Adherence to the screening guidelines in the Dutch HL survivorship care program was reasonable to good and a substantial number of actionable (risk factors for) CVD were diagnosed. IMPLICATIONS FOR CANCER SURVIVORS Our findings inform HL survivors at high risk of late cardiotoxicity about cardiovascular screening findings and demonstrate appropriate therapeutic actions after diagnosis of (risk factors for) CVD.
Collapse
Affiliation(s)
- Eline M J Lammers
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annelies Nijdam
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC Location Vrije Universiteit, Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Roel J de Weijer
- Department of Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Arco J Teske
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| |
Collapse
|
47
|
Mandala E, Lafara K, Kokkinovasilis D, Kalafatis I, Koukoulitsa V, Katodritou E, Lafaras C. Applied Cardio-Oncology in Hematological Malignancies: A Narrative Review. Life (Basel) 2024; 14:524. [PMID: 38672794 PMCID: PMC11050930 DOI: 10.3390/life14040524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Applied cardio-oncology in hematological malignancies refers to the integration of cardiovascular care and management for patients with blood cancer, particularly leukemia, lymphoma, and multiple myeloma. Hematological cancer therapy-related cardiotoxicity deals with the most common cardiovascular complications of conventional chemotherapy, targeted therapy, immunotherapy, chimeric antigen receptor T (CAR-T) cell and tumor-infiltrating lymphocyte therapies, bispecific antibodies, and hematopoietic stem cell transplantation. This narrative review focuses on hematological cancer-therapy-related cardiotoxicity's definition, risk stratification, multimodality imaging, and use of cardiac biomarkers to detect clinical and/or subclinical myocardial dysfunction and electrical instability. Moreover, the most common cardiotoxic profiles of the main drugs and/or therapeutic interventions in patients with hematological malignancies are described thoroughly.
Collapse
Affiliation(s)
- Evdokia Mandala
- Division of Hematology, Forth Department of Medicine, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (E.M.); (K.L.); (D.K.)
| | - Kyranna Lafara
- Division of Hematology, Forth Department of Medicine, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (E.M.); (K.L.); (D.K.)
| | - Dimitrios Kokkinovasilis
- Division of Hematology, Forth Department of Medicine, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (E.M.); (K.L.); (D.K.)
| | - Ioannis Kalafatis
- Cardiology-Oncology Unit, Theagenion Cancer Hospital, 54639 Thessaloniki, Greece; (I.K.); (V.K.)
| | - Vasiliki Koukoulitsa
- Cardiology-Oncology Unit, Theagenion Cancer Hospital, 54639 Thessaloniki, Greece; (I.K.); (V.K.)
| | - Eirini Katodritou
- Department of Hematology, Theagenion Cancer Hospital, 54639 Thessaloniki, Greece;
| | - Christos Lafaras
- Cardiology-Oncology Unit, Theagenion Cancer Hospital, 54639 Thessaloniki, Greece; (I.K.); (V.K.)
| |
Collapse
|
48
|
Rossetto L, Di Lisi D, Madaudo C, Sinagra FP, Di Palermo A, Triolo OF, Gambino G, Ortello A, Galassi AR, Novo G. Right ventricle involvement in patients with breast cancer treated with chemotherapy. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:24. [PMID: 38616279 PMCID: PMC11017635 DOI: 10.1186/s40959-024-00224-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Anthracyclines can cause left ventricular (LV) dysfunction. There is little data about right ventricular (RV) damage during chemotherapy. AIM This study aimed to investigate the toxic effects of chemotherapy, analyzing its impact on right ventricular function. MATERIAL AND METHODS A prospective study was conducted, enrolling 83 female patients (55 ± 11 years old) affected by breast cancer treated with anthracyclines. Cardiological evaluation, HFA risk score assessment and comprehensive echocardiogram, including speckle tracking analysis and 3D analysis, were performed before starting chemotherapy (T0) and at 3 (T1), 6 (T2) and 12 months (T3) after beginning treatment. RV function was assessed with tricuspid annular plane excursion (TAPSE), S' wave of the tricuspid annulus, fractional area change (FAC), RV global longitudinal strain (RV-GLS), free wall strain (RV-FWLS) and RV 3D ejection fraction (RV-3DEF). Subclinical LV CTRCD was defined as a reduction of GLS > 15% compared to baseline. Subclinical RV cardiotoxicity was defined as the co-presence of a relative decrease of 10% from baseline in RV-3DEF and a relative reduction of 15% from baseline RV-FWLS. RESULTS After chemotherapy, we found a significant reduction in 2D-LVEF (p = < 0.001) and 3D-LVEF (p = < 0.001), in LV-GLS and RVLS (p = < 0.001), in FAC and TAPSE, also RV-3DEF reduced significantly (p = 0.002). 39% of patients developed LV subclinical CTRCD; 28% of patients developed RV subclinical cardiotoxicity. LV and RV changes occurred concomitantly, and no RV echocardiographic parameters were found to predict the development of LV CTRCD and vice-versa. CONCLUSION After anthracyclines-based chemotherapy, LV and RV subclinical damage occurs, and it can be detected early by speckle-tracking and 3D echocardiography.
Collapse
Affiliation(s)
- Ludovico Rossetto
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Daniela Di Lisi
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy.
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy.
| | - Cristina Madaudo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Francesco Paolo Sinagra
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Antonio Di Palermo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Oreste Fabio Triolo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Grazia Gambino
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Antonella Ortello
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Alfredo Ruggero Galassi
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| | - Giuseppina Novo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE) "G. D'Alessandro", University of Palermo, Via del Vespro, 129, Palermo, Italy
| |
Collapse
|
49
|
Lorca R, Fernández M, Avanzas P, Pascual I, Álvarez-Velasco R, Silva I, Gutiérrez L, Gómez J, Muñiz M, Álvarez C, Esteban E, López-Fernández T. "Inherited cardiovascular disease mindset" can identify concealed inherited conditions at cardio-oncology evaluation: An opportunistic screening. Int J Cardiol 2024; 401:131825. [PMID: 38309590 DOI: 10.1016/j.ijcard.2024.131825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/27/2024] [Accepted: 01/31/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Baseline cardiovascular (CV) risk stratification is recommended in all cancer patients. Integrating all clinical information (personal/family history, ECG and echocardiogram) can properly identify high-risk patients. We aimed to evaluate the concealed inherited CV conditions detected in mandatory CV screening performed at a Cardio-Oncology Unit. METHODS retrospective study of all consecutive cancer patients referred to the Cardio-Oncology Unit for CV evaluation (2020-2023). Inherited CV conditions diagnosis and genetic testing was performed according to guidelines. RESULTS 1984 cancer patients underwent CV screening. Sanger sequencing was indicated in 1 patient, excluding the genetic family disease. NGS sequencing was performed in 11 cancer patients with normal left ventricular ejection fraction (LVEF): 2 due to aortic syndrome evaluation (identifying 1 vascular Ehrler-Danlos syndrome due to COL3A1 p.Arg242Ter), 4 channelopathies (2 Long QT syndrome and 2 Brugada's), 4 hypertrophic cardiomyopathies and 1 non-dilated left ventricular cardiomyopathy (NDLVC). Among the 12 patients with reduced LVEF, one was diagnosed with NDLVC, and chemotherapy-induced dilated cardiomyopathy was only ascribable in 3 of them. CONCLUSION Integrating clinical information at mandatory baseline CV toxicity risk cardio-oncology evaluation, can identify high-risk cancer patients with concealed inherited conditions. Keeping an "inherited cardiovascular disease-oriented mindset" to implement opportunist screenings is encouraged.
Collapse
Affiliation(s)
- Rebeca Lorca
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain; Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33003 Oviedo, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), 28029 Madrid, Spain.
| | - María Fernández
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain; Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain.
| | - Isaac Pascual
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain; Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain
| | - Rut Álvarez-Velasco
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Iria Silva
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Luis Gutiérrez
- Área del Corazón, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain
| | - Juan Gómez
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, 33011 Oviedo, Spain; Unidad de Cardiopatías Familiares, Área del Corazón y Departamento de Genética Molecular, Hospital Universitario Central Asturias, 33011 Oviedo, Spain; Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORs), 28029 Madrid, Spain
| | - María Muñiz
- Oncología Médica, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - Carlos Álvarez
- Oncología Médica, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - Emilio Esteban
- Departamento de Medicina, Universidad de Oviedo, 33003 Oviedo, Spain; Oncología Médica, Hospital Universitario Central Asturias, 33011 Oviedo, Spain
| | - Teresa López-Fernández
- Cardiology Department, La Paz University Hospital, IdiPAZ Research Institute, Madrid, Spain
| |
Collapse
|
50
|
Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GM, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International Recommendations for Screening and Preventative Practices for Long-Term Survivors of Transplantation and Cellular Therapy: A 2023 Update. Transplant Cell Ther 2024; 30:349-385. [PMID: 38413247 PMCID: PMC11181337 DOI: 10.1016/j.jtct.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the number of HCTs performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pretransplantation, peritransplantation, and post-transplantation exposures and other underlying risk factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and then updated in 2012. An international group of experts was convened to review the contemporary literature and update the recommendations while considering the changing practices of HCT and cellular therapy. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed, but cGVHD management is not covered in detail. These guidelines emphasize the special needs of patients with distinct underlying HCT indications or comorbidities (eg, hemoglobinopathies, older adults) but do not replace more detailed group-, disease-, or condition-specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
Collapse
Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Neel S Bhatt
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, Massachusetts
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, Arizona
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, California
| | | | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Gregory Mt Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, St Vincent's Clinical School Sydney, University of New South Wales, School of Medicine Sydney, University of Notre Dame Australia, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, PathWest Laboratory Medicine WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Department of Public Health and Primary Care, ACCENT VV, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, Tennessee
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|