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Lee S, Alsamarrai A, Xiao A, Wang TKM. Prevention of anthracycline and trastuzumab-induced decline in left ventricular ejection fraction with angiotensin-converting enzyme inhibitors or angiotensin receptor blocker: a narrative systematic review of randomised controlled trials. Intern Med J 2024; 54:1254-1263. [PMID: 38874281 DOI: 10.1111/imj.16437] [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: 11/11/2023] [Accepted: 05/13/2024] [Indexed: 06/15/2024]
Abstract
Cancer therapy-related cardiac dysfunction (CTRCD) is a complication of selected cancer therapy agents associated with decline in left ventricular ejection fraction (LVEF). Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have established benefits in heart failure with reduced ejection fraction, but their efficacy for preventing CTRCD remains controversial. This narrative systematic review assessed the efficacy and safety of ACEI/ARB in the prevention of cancer therapy LVEF decline. We systematically searched PubMed, Embase and Cochrane from January 1980 to June 2022. Studies of interest were randomised controlled trials of patients with normal LVEF and active malignancy receiving cancer therapy, randomised to receive either an ACEI or ARB compared with a control group. The outcome was the change in LVEF from baseline to the end of the follow-up period. Death, clinical heart failure and adverse drug reactions were recorded. A total of 3731 search records were screened and 12 studies were included, comprising a total of 1645 participants. Nine studies assessed the prevention of anthracycline-induced LVEF decline, of which five showed a beneficial effect (1%-14% higher LVEF in treated groups), whereas four studies showed no effect. Three studies assessed the prevention of trastuzumab-induced LVEF decline, of which one showed a beneficial effect (4% higher LVEF) in a subset of participants. There are mixed data regarding the efficacy of ACEI/ARB in preventing the LVEF decline in patients undergoing anthracycline or trastuzumab therapy, with evidence suggesting no clinically meaningful benefit observed in recent studies.
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Affiliation(s)
- Simon Lee
- Cardiology Department, Middlemore Hospital, Auckland, New Zealand
- Cardiology Department, Tauranga Hospital, Tauranga, New Zealand
| | - Ammar Alsamarrai
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Amy Xiao
- Cardiology Department, Middlemore Hospital, Auckland, New Zealand
| | - Tom K M Wang
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Li J, Lee ARYB, Tariq A, Lau G, Yau CE, Tan LL, Tyebally SM, Lee MX, Koo CY, Sia CH. Comparing Renin-Angiotensin-Aldosterone Blockade Regimens for Long-Term Chemotherapy-Related Cardiac Dysfunction: A Network Meta-Analysis. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07457-w. [PMID: 37314568 DOI: 10.1007/s10557-023-07457-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Cancer therapies including trastuzumab and anthracyclines are cardiotoxic and cause cardiac dysfunction. To prevent cardiotoxicity, pharmacological agents used in heart failure have been administered concomitantly with cardiotoxic cancer therapy, but few studies to date have performed a head-to-head comparison of these different agents. This systematic review and network meta-analysis of randomized-controlled trials aims to evaluate the efficacy of renin-angiotensin-aldosterone system (RAAS) blockers, namely angiotensin-converting enzyme inhibitors (ACE-Is), aldosterone receptor blockers (ARBs), and mineralocorticoid receptor antagonists (MRAs), in primary prevention against chemotherapy-related cardiac dysfunction in patients receiving anthracyclines and/or trastuzumab. METHODS A systematic search was performed in major web databases for studies from inception to 15 September 2022. A Bayesian network meta-analysis model was used to assess the relative effects of competing treatments on the primary outcomes of risk of significant decline in left ventricular ejection fraction (LVEF) and mean LVEF decline. Secondary outcomes included left ventricular diastolic function, global longitudinal strain, and cardiac biomarkers. This study is registered with PROSPERO, CRD42022357980. RESULTS AND CONCLUSION Nineteen studies reported the effects of 13 interventions (N = 1905 patients). Only enalapril (RR 0.05, 95% CI 0.00-0.20) was associated with reduced risk of patients developing significant decline in LVEF relative to placebo. Subgroup analysis showed that the beneficial effect of enalapril was driven by protection against anthracycline-associated toxicity. In addition, no RAAS-inhibiting agents showed efficacy in protection against treatment with both anthracycline and trastuzumab. The use of RAAS inhibition therapy did not conclusively impact on other markers of cardiac function, including left ventricular diastolic function and cardiac biomarkers.
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Affiliation(s)
- Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Areeba Tariq
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Grace Lau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Li Ling Tan
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore
| | - Sara Moiz Tyebally
- Department of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Matilda Xinwei Lee
- Department of Hematology-Oncology, National University Cancer Institute Singapore, Singapore, Singapore
| | - Chieh Yang Koo
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center Singapore, Singapore, Singapore.
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Mir A, Badi Y, Bugazia S, Nourelden AZ, Fathallah AH, Ragab KM, Alsillak M, Elsayed SM, Hagrass AI, Bawek S, Kalot M, Brumberger ZL. Efficacy and safety of cardioprotective drugs in chemotherapy-induced cardiotoxicity: an updated systematic review & network meta-analysis. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:10. [PMID: 36804940 PMCID: PMC9938608 DOI: 10.1186/s40959-023-00159-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/23/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Cancer patients receiving chemotherapy have an increased risk of cardiovascular complications. This limits the widespread use of lifesaving therapies, often necessitating alternate lower efficacy regimens, or precluding chemotherapy entirely. Prior studies have suggested that using common cardioprotective agents may attenuate chemotherapy-induced cardiotoxicity. However, small sample sizes and conflicting outcomes have limited the clinical significance of these results. HYPOTHESIS A comprehensive network meta-analysis using updated and high-quality data can provide more conclusive information to assess which drug or drug class has the most significant effect in the management of chemotherapy-induced cardiotoxicity. METHODS We performed a literature search for randomized controlled trials (RCTs) investigating the effects of cardioprotective agents in patients with chemotherapy-induced cardiotoxicity. We used established analytical tools (netmeta package in RStudio) and data extraction formats to analyze the outcome data. To obviate systematic bias in the selection and interpretation of RCTs, we employed the validated Cochrane risk-of-bias tools. Agents included were statins, aldosterone receptor antagonists (MRAs), ACEIs, ARBs, and beta-blockers. Outcomes examined were improvement in clinical and laboratory parameters of cardiac function including a decreased reduction in left ventricular ejection fraction (LVEF), clinical HF, troponin-I, and B-natriuretic peptide levels. RESULTS Our study included 33 RCTs including a total of 3,285 patients. Compared to control groups, spironolactone therapy was associated with the greatest LVEF improvement (Mean difference (MD) = 12.80, [7.90; 17.70]), followed by enalapril (MD = 7.62, [5.31; 9.94]), nebivolol (MD = 7.30, [2.39; 12.21]), and statins (MD = 6.72, [3.58; 9.85]). Spironolactone was also associated with a significant reduction in troponin elevation (MD = - 0.01, [- 0.02; - 0.01]). Enalapril demonstrated the greatest BNP reduction (MD = - 49.00, [- 68.89; - 29.11]), which was followed by spironolactone (MD = - 16.00, [- 23.9; - 8.10]). Additionally, patients on enalapril had the lowest risk of developing clinical HF compared to the control population (RR = 0.05, [0.00; 0.75]). CONCLUSION Our analysis reaffirmed that statins, MRAs, ACEIs, and beta-blockers can significantly attenuate chemotherapy-induced cardiotoxicity, while ARBs showed no significant effects. Spironolactone showed the most robust improvement of LVEF, which best supports its use among this population. Our analysis warrants future clinical studies examining the cardioprotective effects of cardiac remodeling therapy in cancer patients treated with chemotherapeutic agents.
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Affiliation(s)
- Ali Mir
- grid.273335.30000 0004 1936 9887Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY USA
| | - Yasra Badi
- grid.517786.aAll Saints University School of Medicine, Roseau, Dominica
| | - Seif Bugazia
- grid.490189.d0000 0004 0433 2862Henry Ford Macomb Hospital, Clinton Township, Macomb County, MI USA
| | | | | | - Khaled Mohamed Ragab
- grid.411806.a0000 0000 8999 4945Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohammed Alsillak
- grid.417218.90000 0004 0451 9790Woodhull Medical and Mental Health Center Program, Brooklyn, NY USA
| | - Sarah Makram Elsayed
- grid.412319.c0000 0004 1765 2101Faculty of Medicine, October 6 University, Giza, Egypt
| | | | - Sawyer Bawek
- grid.273335.30000 0004 1936 9887Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY USA
| | - Mohamad Kalot
- grid.273335.30000 0004 1936 9887Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY USA
| | - Zachary L. Brumberger
- grid.273335.30000 0004 1936 9887Department of Medicine, Division of Cardiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY USA
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Lee ARYB, Yau CE, Low CE, Li J, Tyebally SM, Lin W, Tan LL, Liao CT, Chang WT, Lee MX, Koo CY, Sia CH. Natural Progression of Left Ventricular Function following Anthracyclines without Cardioprotective Therapy: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15020512. [PMID: 36672461 PMCID: PMC9856944 DOI: 10.3390/cancers15020512] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Anthracyclines form the backbone of many systemic chemotherapy regimens but are accompanied by dose-limiting cardiotoxicity. We elucidate the progression and severity of cardiac function over time, in the absence of cardioprotection, which less is known about. METHODS This PRISMA-guideline-adherent review was registered on PROSPERO (CRD42022373496). RESULTS 26 studies met the eligibility criteria including a total of 910 patients. The overall reduction in post-anthracycline pooled mean left ventricular ejection fraction (LVEF) in placebo arms of the included randomised-controlled trials was 4.5% (95% CI, 2.6 to 6.4). The trend in LVEF showed a progressive decline until approximately 180 days, after which there was no significant change. Those receiving a cumulative anthracycline dose of 300 mg/m2 experienced a more profound reduction. The overall pooled risk of a 10% absolute decline in LVEF from baseline, or a decline to an LVEF below 50%, was 17% (95% CI: 11 to 24; I2 = 71%). Sensitivity analyses of baseline LVEF and trastuzumab treatment status did not yield significant differences. CONCLUSION While the mean LVEF decline in patients without cardioprotective therapy was clinically small, a vulnerable subset experienced significant impairment. Further research to best identify those who benefit most from cardioprotective therapies when receiving anthracyclines is required.
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Affiliation(s)
| | - Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
| | - Sara Moiz Tyebally
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Weiqin Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Li-Ling Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Chia-Te Liao
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, 3000 Leuven, Belgium
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan
| | - Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 117597, Singapore
| | - Chieh-Yang Koo
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore 609606, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore
- Correspondence: ; Tel.: +65-6779-5555
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Vuong JT, Stein-Merlob AF, Cheng RK, Yang EH. Novel Therapeutics for Anthracycline Induced Cardiotoxicity. Front Cardiovasc Med 2022; 9:863314. [PMID: 35528842 PMCID: PMC9072636 DOI: 10.3389/fcvm.2022.863314] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/14/2022] [Indexed: 01/04/2023] Open
Abstract
Anthracyclines remain an essential component of the treatment of many hematologic and solid organ malignancies, but has important implications on cardiovascular disease. Anthracycline induced cardiotoxicity (AIC) ranges from asymptomatic LV dysfunction to highly morbid end- stage heart failure. As cancer survivorship improves, the detection and treatment of AIC becomes more crucial to improve patient outcomes. Current treatment modalities for AIC have been largely extrapolated from treatment of conventional heart failure, but developing effective therapies specific to AIC is an area of growing research interest. This review summarizes the current evidence behind the use of neurohormonal agents, dexrazoxane, and resynchronization therapy in AIC, evaluates the clinical outcomes of advanced therapy and heart transplantation in AIC, and explores future horizons for treatment utilizing gene therapy, stem cell therapy, and mechanism-specific targets.
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Affiliation(s)
- Jacqueline T. Vuong
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Ashley F. Stein-Merlob
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Richard K. Cheng
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Eric H. Yang
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Eric H. Yang,
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6
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Morelli MB, Bongiovanni C, Da Pra S, Miano C, Sacchi F, Lauriola M, D’Uva G. Cardiotoxicity of Anticancer Drugs: Molecular Mechanisms and Strategies for Cardioprotection. Front Cardiovasc Med 2022; 9:847012. [PMID: 35497981 PMCID: PMC9051244 DOI: 10.3389/fcvm.2022.847012] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/03/2022] [Indexed: 12/13/2022] Open
Abstract
Chemotherapy and targeted therapies have significantly improved the prognosis of oncology patients. However, these antineoplastic treatments may also induce adverse cardiovascular effects, which may lead to acute or delayed onset of cardiac dysfunction. These common cardiovascular complications, commonly referred to as cardiotoxicity, not only may require the modification, suspension, or withdrawal of life-saving antineoplastic therapies, with the risk of reducing their efficacy, but can also strongly impact the quality of life and overall survival, regardless of the oncological prognosis. The onset of cardiotoxicity may depend on the class, dose, route, and duration of administration of anticancer drugs, as well as on individual risk factors. Importantly, the cardiotoxic side effects may be reversible, if cardiac function is restored upon discontinuation of the therapy, or irreversible, characterized by injury and loss of cardiac muscle cells. Subclinical myocardial dysfunction induced by anticancer therapies may also subsequently evolve in symptomatic congestive heart failure. Hence, there is an urgent need for cardioprotective therapies to reduce the clinical and subclinical cardiotoxicity onset and progression and to limit the acute or chronic manifestation of cardiac damages. In this review, we summarize the knowledge regarding the cellular and molecular mechanisms contributing to the onset of cardiotoxicity associated with common classes of chemotherapy and targeted therapy drugs. Furthermore, we describe and discuss current and potential strategies to cope with the cardiotoxic side effects as well as cardioprotective preventive approaches that may be useful to flank anticancer therapies.
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Affiliation(s)
| | - Chiara Bongiovanni
- National Laboratory of Molecular Biology and Stem Cell Engineering, National Institute of Biostructures and Biosystems (INBB), Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Silvia Da Pra
- National Laboratory of Molecular Biology and Stem Cell Engineering, National Institute of Biostructures and Biosystems (INBB), Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Carmen Miano
- National Laboratory of Molecular Biology and Stem Cell Engineering, National Institute of Biostructures and Biosystems (INBB), Bologna, Italy
| | - Francesca Sacchi
- National Laboratory of Molecular Biology and Stem Cell Engineering, National Institute of Biostructures and Biosystems (INBB), Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Mattia Lauriola
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Gabriele D’Uva
- National Laboratory of Molecular Biology and Stem Cell Engineering, National Institute of Biostructures and Biosystems (INBB), Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
- *Correspondence: Gabriele D’Uva,
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7
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LCZ696 ameliorates doxorubicin-induced cardiomyocyte toxicity in rats. Sci Rep 2022; 12:4930. [PMID: 35322164 PMCID: PMC8943022 DOI: 10.1038/s41598-022-09094-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/17/2022] [Indexed: 12/11/2022] Open
Abstract
Doxorubicin (DOX)-based chemotherapy induces cardiotoxicity, which is considered the main bottleneck for its clinical application. In this study, we investigated the potential benefit of LCZ696, an angiotensin receptor-neprilysin inhibitor against DOX-induced cardiotoxicity in rats and H9c2 cells and determined whether the mechanism underlying any such effects involves its antioxidant activity. Male Sprague-Dawley rats were randomly separated into four groups, each consisting of 15 rats (DOX (1.5 mg/kg/day intraperitoneally for 10 days followed by non-treatment for 8 days); DOX + valsartan (31 mg/kg/day by gavage from day 1 to day 18); DOX + LCZ696 (68 mg/kg/day by gavage from day 1 to day 18); and control (saline intraperitoneally for 10 days). DOX-induced elevation of cardiac troponin T levels on day 18 was significantly reduced by LCZ696, but not valsartan. The DOX-induced increase in myocardial reactive oxygen species (ROS) levels determined using dihydroethidium was significantly ameliorated by LCZ696, but not valsartan, and was accompanied by the suppression of DOX-induced increase in p47phox. LCZ696 recovered the DOX-induced decrease in phosphorylation of adenosine monophosphate-activated protein kinase and increased the ratio of Bax and Bcl-2. In H9c2 cardiomyocytes, LCZ696 reduced DOX-induced mitochondrial ROS generation and improved cell viability more than valsartan. Our findings indicated that LCZ696 ameliorated DOX-induced cardiotoxicity in rat hearts in vivo and in vitro, possibly by mediating a decrease in oxidative stress.
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Lang JK, Karthikeyan B, Quiñones-Lombraña A, Blair RH, Early AP, Levine EG, Sharma UC, Blanco JG, O'Connor T. CBR3 V244M is associated with LVEF reduction in breast cancer patients treated with doxorubicin. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2021; 7:17. [PMID: 33975650 PMCID: PMC8111996 DOI: 10.1186/s40959-021-00103-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/22/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The CBR3 V244M single nucleotide polymorphism has been linked to the risk of anthracycline-related cardiomyopathy in survivors of childhood cancer. There have been limited prospective studies examining the impact of CBR3 V244M on the risk for anthracycline-related cardiotoxicity in adult cohorts. OBJECTIVES This study evaluated the presence of associations between CBR3 V244M genotype status and changes in echocardiographic parameters in breast cancer patients undergoing doxorubicin treatment. METHODS We recruited 155 patients with breast cancer receiving treatment with doxorubicin (DOX) at Roswell Park Comprehensive Care Center (Buffalo, NY) to a prospective single arm observational pharmacogenetic study. Patients were genotyped for the CBR3 V244M variant. 92 patients received an echocardiogram at baseline (t0 month) and at 6 months (t6 months) of follow up after DOX treatment. Apical two-chamber and four-chamber echocardiographic images were used to calculate volumes and left ventricular ejection fraction (LVEF) using Simpson's biplane rule by investigators blinded to all patient data. Volumetric indices were evaluated by normalizing the cardiac volumes to the body surface area (BSA). RESULTS Breast cancer patients with CBR3 GG and AG genotypes both experienced a statistically significant reduction in LVEF at 6 months following initiation of DOX treatment for breast cancer compared with their pre-DOX baseline study. Patients homozygous for the CBR3 V244M G allele (CBR3 V244) exhibited a further statistically significant decrease in LVEF at 6 months following DOX therapy in comparison with patients with heterozygous AG genotype. We found no differences in age, pre-existing cardiac diseases associated with myocardial injury, cumulative DOX dose, or concurrent use of cardioprotective medication between CBR3 genotype groups. CONCLUSIONS CBR3 V244M genotype status is associated with changes in echocardiographic parameters suggestive of early anthracycline-related cardiomyopathy in subjects undergoing chemotherapy for breast cancer.
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Affiliation(s)
- Jennifer K Lang
- Department of Medicine, Division of Cardiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
- Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Badri Karthikeyan
- Department of Medicine, Division of Cardiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
| | - Adolfo Quiñones-Lombraña
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, 14214, USA
| | - Rachael Hageman Blair
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, 14214, USA
| | - Amy P Early
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Ellis G Levine
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Umesh C Sharma
- Department of Medicine, Division of Cardiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14203, USA
| | - Javier G Blanco
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, 14214, USA.
| | - Tracey O'Connor
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA.
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9
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Varghese SS, Eekhoudt CR, Jassal DS. Mechanisms of anthracycline-mediated cardiotoxicity and preventative strategies in women with breast cancer. Mol Cell Biochem 2021; 476:3099-3109. [PMID: 33835331 DOI: 10.1007/s11010-021-04152-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/01/2021] [Indexed: 12/17/2022]
Abstract
While anthracyclines (ACs) are a class of chemotherapeutic agents that have improved the prognosis of many women with breast cancer, it is one of the most cardiotoxic agents used to treat cancer. Despite their reported dose-dependent cardiotoxicity, AC-based chemotherapy has become the mainstay of breast cancer therapy due to its efficacy. Elucidating the mechanisms of anthracycline-mediated cardiotoxicity and associated therapeutic interventions continue to be the main focus in the field of cardio-oncology. Herein, we summarized the current literature surrounding the mechanisms of anthracycline-induced cardiotoxicity, including the role of topoisomerase II inhibition, generation of reactive oxygen species, and elevations in free radicals. Furthermore, this review highlights the molecular mechanisms of potential cardioprotective interventions in this setting. The benefits of pharmaceuticals, including dexrazoxane, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, statins, and antioxidants in this setting, are reviewed. Finally, the mechanisms of emerging preventative interventions within this patient population including nutraceuticals and aerobic exercise are explored.
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Affiliation(s)
- Sonu S Varghese
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Cameron R Eekhoudt
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Davinder S Jassal
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Department of Physiology and Pathophysiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada. .,Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada. .,Department of Radiology, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
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10
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Cadeddu Dessalvi C, Deidda M, Noto A, Madeddu C, Cugusi L, Santoro C, López-Fernández T, Galderisi M, Mercuro G. Antioxidant Approach as a Cardioprotective Strategy in Chemotherapy-Induced Cardiotoxicity. Antioxid Redox Signal 2021; 34:572-588. [PMID: 32151144 DOI: 10.1089/ars.2020.8055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Significance: Chemotherapy-induced cardiotoxicity (CTX) has been associated with redox signaling imbalance. In fact, redox reactions are crucial for normal heart physiology, whereas excessive oxidative stress can cause cardiomyocyte structural damage. Recent Advances: An antioxidant approach as a cardioprotective strategy in this setting has shown encouraging results in preventing anticancer drug-induced CTX. Critical Issues: In fact, traditional heart failure drugs as well as many other compounds and nonpharmacological strategies, with a partial effect in reducing oxidative stress, have been shown to counterbalance chemotherapy-induced CTX in this setting to some extent. Future Directions: Given the various pathways of toxicity involved in different chemotherapeutic schemes, interactions with redox balance need to be fine-tuned and a personalized cardioprotective approach seems to be required.
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Affiliation(s)
| | - Martino Deidda
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonio Noto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Lucia Cugusi
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Teresa López-Fernández
- Cardiology Service, Cardio-Oncology Unit, La Paz University Hospital, IdiPAz Research Institute, Ciber CV, Madrid, Spain
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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11
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Caspani F, Tralongo AC, Campiotti L, Asteggiano R, Guasti L, Squizzato A. Prevention of anthracycline-induced cardiotoxicity: a systematic review and meta-analysis. Intern Emerg Med 2021; 16:477-486. [PMID: 33011930 DOI: 10.1007/s11739-020-02508-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/12/2020] [Indexed: 12/23/2022]
Abstract
Anthracyclines are extensively used in oncologic patients, in particular for breast cancer and hematological malignancies. Cardiac injury is a potentially dangerous side effect of these drugs. In this systematic review, we analyzed published randomized controlled trials (RCTs) to assess if potential cardioprotective drugs (i.e., renin-angiotensin-aldosterone system [RAAS] blockers and β-blockers) may prevent heart damage by anthracyclines. Studies were identified by electronic search of MEDLINE and EMBASE database until August 2020. The impact of cardioprotective drugs to prevent anthracyclines-induced cardiac injury was expressed as mean difference (MD) or odds ratio (OR) and 95% confidence intervals (95% CI). Statistical heterogeneity was assessed with the I2 statistic. Twelve RCTs for a total of 1.035 cancer patients treated with anthracyclines were included. RAAS blockers, β-blockers, and aldosterone antagonists showed a statistically significant benefit in preventing left ventricular ejection fraction (LVEF) reduction (MD 3.57, 95% CI 1.04, 6.09) in 11 studies. A non-statistically significant difference was observed in preventing E/A velocity decrease (MD 0.09, 95% CI 0.00, 0.17; 9 studies), left ventricular end-systolic diameter (LVESD) increase (MD - 0.88, 95% CI, - 2.75,0.99; 6 studies), left ventricular end-diastolic diameter (LVEDD) increase (MD -0.95, 95% CI - 2.67,0.76; 6 studies), and mitral A velocity decrease (MD - 1.42, 95% CI - 3.01,0.17; 4 studies). Heart failure was non-significantly reduced in the cardioprotective arm (OR 0.31, 95% CI 0.06, 1.59; 5 studies). Hypotension was non-significantly increased in the cardioprotective arm (OR 3.91, 95% CI 0.42, 36.46, 3 studies). Cardioprotective drugs reduce anthracycline-induced cardiac damage as assessed by echocardiographic parameters. The clinical relevance of this positive effect is still to be defined.
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Affiliation(s)
| | | | - Leonardo Campiotti
- Department of Medicine and Surgery, University of Insubria, Varese, Como, Italy
| | | | - Luigina Guasti
- Department of Medicine and Surgery, University of Insubria, Varese, Como, Italy
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12
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Elghazawy H, Venkatesulu BP, Verma V, Pushparaji B, Monlezun DJ, Marmagkiolis K, Iliescu CA. The role of cardio-protective agents in cardio-preservation in breast cancer patients receiving Anthracyclines ± Trastuzumab: a Meta-analysis of clinical studies. Crit Rev Oncol Hematol 2020; 153:103006. [DOI: 10.1016/j.critrevonc.2020.103006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 05/10/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023] Open
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13
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Bracun V, Aboumsallem JP, van der Meer P, de Boer RA. Cardiac Biomarkers in Patients with Cancer: Considerations, Clinical Implications, and Future Avenues. Curr Oncol Rep 2020; 22:67. [PMID: 32514994 PMCID: PMC7280346 DOI: 10.1007/s11912-020-00930-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF THE REVIEW As the number of cancer survivors increases due to early screening and modern (antineoplastic) treatments, cancer treatment associated cardiotoxicity (CTAC) is becoming an increasing health burden that affects survival and quality of life among cancer survivors. Thus, clinicians need to identify adverse events early, in an effort to take suitable measures before the occurrence of permanent or irreversible cardiac dysfunction. RECENT FINDINGS Cardiac troponin (cTn) and B-type natriuretic peptide (BNP) have been proven to detect subclinical cardiotoxicity during antineoplastic treatment. As such, these cardio-specific biomarkers could predict which patients are at risk of developing CTAC even before the start of therapy. Nevertheless, there are inconsistent data from published studies, and the recommendations regarding the use of these biomarkers and their validity are mostly based on expert consensus opinion. In this review, we summarize available literature that evaluates biomarkers of CTAC, and we encourage strategies that integrate circulating biomarkers and cardiac imaging in identifying cancer patients that are at high risk.
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Affiliation(s)
- Valentina Bracun
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Joseph Pierre Aboumsallem
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, PO Box 30.001, 9700 RB Groningen, the Netherlands
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14
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Sobczuk P, Czerwińska M, Kleibert M, Cudnoch-Jędrzejewska A. Anthracycline-induced cardiotoxicity and renin-angiotensin-aldosterone system-from molecular mechanisms to therapeutic applications. Heart Fail Rev 2020; 27:295-319. [PMID: 32472524 PMCID: PMC8739307 DOI: 10.1007/s10741-020-09977-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Few millions of new cancer cases are diagnosed worldwide every year. Due to significant progress in understanding cancer biology and developing new therapies, the mortality rates are decreasing with many of patients that can be completely cured. However, vast majority of them require chemotherapy which comes with high medical costs in terms of adverse events, of which cardiotoxicity is one of the most serious and challenging. Anthracyclines (doxorubicin, epirubicin) are a class of cytotoxic agents used in treatment of breast cancer, sarcomas, or hematological malignancies that are associated with high risk of cardiotoxicity that is observed in even up to 30% of patients and can be diagnosed years after the therapy. The mechanism, in which anthracyclines cause cardiotoxicity are not well known, but it is proposed that dysregulation of renin-angiotensin-aldosterone system (RAAS), one of main humoral regulators of cardiovascular system, may play a significant role. There is increasing evidence that drugs targeting this system can be effective in the prevention and treatment of anthracycline-induced cardiotoxicity what has recently found reflection in the recommendation of some scientific societies. In this review, we comprehensively describe possible mechanisms how anthracyclines affect RAAS and lead to cardiotoxicity. Moreover, we critically review available preclinical and clinical data on use of RAAS inhibitors in the primary and secondary prevention and treatment of cardiac adverse events associated with anthracycline-based chemotherapy.
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Affiliation(s)
- Paweł Sobczuk
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland.,Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Magdalena Czerwińska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Kleibert
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland.
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15
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Li X, Li Y, Zhang T, Xiong X, Liu N, Pang B, Ruan Y, Gao Y, Shang H, Xing Y. Role of cardioprotective agents on chemotherapy-induced heart failure: A systematic review and network meta-analysis of randomized controlled trials. Pharmacol Res 2019; 151:104577. [PMID: 31790821 DOI: 10.1016/j.phrs.2019.104577] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/07/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although previous clinical randomized controlled trials (RCTs) have tested the effect of a variety of cardioprotective agents on cancer therapy-induced cardiotoxicity, the number of included patients was limited, and the results remained controversial. In this study, we aimed to evaluate the preventive or therapeutic effects of cardioprotective agents on heart failure (HF) caused by cardiotoxicity induced by cancer therapy. METHODS We included trials of the following cardioprotective drugs: Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, aldosterone antagonists and stains. We extracted the relevant information with predefined data extraction forms, and assessed the risk of bias in randomized controlled trials with the Cochrane risk of bias tool. The primary outcome was the left ventricular ejection fraction of patients after chemotherapy. We used the random-effects model to carry out pair-wise meta-analysis, and then carry out the random-effects network meta-analysis within the Bayesian framework. RESULTS Twenty-two relevant RCTs, including 1 916 patients (79.6 % women) with a mean age of 48.4 years, were included. Based on the evaluation of all drug species from 20 studies (26 comparisons), the analysis found that 4 therapies, aldosterone antagonists (MD, 12.78 [95 % CI, 2.87-22.69] and MD, 13.75 [95 % CI, 2.21-25.30]), ACEIs (MD, 6.79 [95 % CI, 2.11-11.48] and MD, 7.76 [95 % CI, 2.64-12.88]), statin (MD, 8.35 [95 % CI, 1.11-15.59]), and beta-blockers (MD, 4.00 [95 % CI, 0.87-7.14]), had a higher efficacy than placebo and/or control, suggesting an LVEF protective effect of cardioprotective therapy. In the analysis classified by single drug or drug combination, based on 22 studies (31 comparisons), spironolactone (MD, 12.77 [95 % CI, 1.76-23.79] and MD, 14.62 [95 % CI, 1.70-27.55]), a combination of candesartan and carvedilol (MD, 12.40 [95 % CI, 0.99-23.81]), enalapril (MD, 7.35 [95 % CI, 1.16-13.54] and MD, 9.20 [95 % CI, 2.61-15.79]), and statin (MD, 8.36 [95 % CI, 0.36-16.36]) showed significant benefits in protecting left ventricular (LV) systolic function compared with the placebo and/or control. CONCLUSION When classified according to drug type, aldosterone antagonists, ACEIs, statins, and beta-blockers could substantially improve the LV systolic function. In the analysis classified by single drug or drug combination, spironolactone, enalapril, and statin have a significant cardioprotective effect. However, ARBs have no cardioprotective effect and fail to improve the LVEF.
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Affiliation(s)
- Xinye Li
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Yanda Li
- Institute of Basic Research In Clinical Medicine, China Academy Of Chinese Medical Sciences, Beijing, China
| | - Tiansong Zhang
- Jing'an District Center Hospital, Fudan Univetsity, Shanghai, China
| | - Xingjiang Xiong
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Nian Liu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bing Pang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanfei Ruan
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yonghong Gao
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China.
| | - Yanwei Xing
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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16
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Korzeniowska K, Jankowski J, Cieślewicz A, Jabłecka A. Is it possible to prevent chemotherapy-induced heart failure with cardiovascular drugs - the review of the current clinical evidence. Ther Clin Risk Manag 2019; 15:1095-1110. [PMID: 31564887 PMCID: PMC6743633 DOI: 10.2147/tcrm.s215857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/25/2019] [Indexed: 01/26/2023] Open
Abstract
Cardiovascular diseases and cancer are the most common death causes in the USA and Europe. Moreover, many patients suffer from both of these conditions - a situation which may result from cardiotoxicity of anticancer treatment. In order to reduce the severity of this adverse effect, various methods have been proposed, including the usage of new drug forms and less toxic analogs, omitting the combinations of potentially cardiotoxic drugs and introducing potential cardioprotective agents to the therapy. However, prevention of cardiotoxicity still seems to be insufficient. The article reviews the results of current studies on the use of cardiovascular drugs in the prevention of cardiotoxicity. Based on this knowledge, the most promising cardioprotective drugs seem to be carvedilol, nebivolol, enalapril, and candesartan, as they prevent heart remodeling and correct elevated resting heart rate, which directly affects mortality. Alternatively, in case of adverse reactions, statins might be considered.
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Affiliation(s)
- Katarzyna Korzeniowska
- Department of Clinical Pharmacology, Poznan University of Medical Sciences, Poznan61-848, Poland
| | - Jerzy Jankowski
- Department of Clinical Pharmacology, Poznan University of Medical Sciences, Poznan61-848, Poland
| | - Artur Cieślewicz
- Department of Clinical Pharmacology, Poznan University of Medical Sciences, Poznan61-848, Poland
| | - Anna Jabłecka
- Department of Clinical Pharmacology, Poznan University of Medical Sciences, Poznan61-848, Poland
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17
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Ameliorative effect of Magnesium Isoglycyrrhizinate on hepatic encephalopathy by Epirubicin. Int Immunopharmacol 2019; 75:105774. [PMID: 31351363 DOI: 10.1016/j.intimp.2019.105774] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 06/27/2019] [Accepted: 07/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of the present study was to evaluate the protective effect of Magnesium Isoglycyrrhizinate (MI) on Epirubicin (EPI)-induced hepatic encephalopathy (HE) and explore its underlying mechanism. METHODS Mice were divided randomly into groups for treatments as follows: control group, EPI group (Model group), EPI + MI (25, 50 mg/kg) group. Morris water maze test were conducted to evaluate the spatial learning and memory ability. The serum and hippocampus levels of oxidative stress or inflammation were uncovered with the detection of superoxide dismutase (SOD), malondialdehyde (MDA), and pro-inflammatory cytokines (IL-1β, IL-6, TNF-α). RESULTS As a result, treatment with MI effectively ameliorated the EPI-induced decline in the ability of spatial learning and memory. MI also significantly relieved the severity of oxidative stress or inflammation in serum and hippocampus, which was accompanied with regulating liver functional parameters. Western blot data demonstrated that administration of MI could regulate the redox-related expressions of Txnip, Trx, Nrf2, HO-1, p-IκB-α, p-NF-κB, Caspase-3, Caspase-9, Bax and Bcl-2 in EPI-stimulated hepatic encephalopathy (HE). And the potency of MI treatments on Nrf2, NF-κB expression was also confirmed with immunohistochemical analysis. CONCLUSIONS Taken together, the protective effect of Magnesium Isoglycyrrhizinate on EPI-induced hepatic encephalopathy might be mediated via the Txnip/Nrf2/NF-κB signaling pathway.
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18
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Totzeck M, Mincu RI, Heusch G, Rassaf T. Heart failure from cancer therapy: can we prevent it? ESC Heart Fail 2019; 6:856-862. [PMID: 31297946 PMCID: PMC6676296 DOI: 10.1002/ehf2.12493] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 05/18/2019] [Accepted: 06/11/2019] [Indexed: 01/05/2023] Open
Abstract
Aims Conventional cytotoxic chemotherapy is still among the most effective treatment options for many types of cancer. However, cardiotoxicity, notably the decrease in left ventricular function under these regimens, can impair prognosis. Thus, prevention and treatment of cardiotoxicity are crucial. The present meta‐analysis aims to assess the efficacy of beta‐blockers or angiotensin‐converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) for prevention of cardiotoxicity. Methods and results We systematically searched Pubmed, Cochrane, EMBASE, and Web of Science databases for randomized controlled trials published until February 2019. The analysis included randomized studies that reported on left ventricular ejection fraction (LVEF) after 6 months of chemotherapy in cancer patients who received beta‐blockers or ACE inhibitors/ARBs for prevention of cardiotoxicity compared with controls. Studies on combination cardioprotective therapies were excluded from the analysis. The primary endpoint was prevention of a decrease in LVEF as defined by the individual study and as assessed by either transthoracic echocardiography or magnetic resonance imaging. We here show that patients under anthracycline‐based chemotherapy have a moderate yet significant benefit in LVEF from beta‐blockers or ACEs/ARBs. The beta‐blocker analysis included 769 cancer patients, and the ACE inhibitors/ARBs analysis included a total of 581 cancer patients. The mean LVEF difference between the beta‐blocker group and the control group was 2.57% (95% confidence interval 0.63–4.51, P = 0.009). The mean difference for ACE inhibitors/ARBs was 4.71% (95% confidence interval 0.38–9.03, P = 0.03). However, the beneficial effects throughout the studies were variable as documented by significant heterogeneity between the studies. Conclusions Systematic evidence is needed to solidly found recommendations for cardioprotective prevention during chemotherapy. Likewise, trials on other neurohumoral drugs (spironolactone) and lipid‐lowering approaches are required to improve protection for cardio‐oncology patients.
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Affiliation(s)
- Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Raluca I Mincu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
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19
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Tocchetti CG, Cadeddu C, Di Lisi D, Femminò S, Madonna R, Mele D, Monte I, Novo G, Penna C, Pepe A, Spallarossa P, Varricchi G, Zito C, Pagliaro P, Mercuro G. From Molecular Mechanisms to Clinical Management of Antineoplastic Drug-Induced Cardiovascular Toxicity: A Translational Overview. Antioxid Redox Signal 2019; 30:2110-2153. [PMID: 28398124 PMCID: PMC6529857 DOI: 10.1089/ars.2016.6930] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Significance: Antineoplastic therapies have significantly improved the prognosis of oncology patients. However, these treatments can bring to a higher incidence of side-effects, including the worrying cardiovascular toxicity (CTX). Recent Advances: Substantial evidence indicates multiple mechanisms of CTX, with redox mechanisms playing a key role. Recent data singled out mitochondria as key targets for antineoplastic drug-induced CTX; understanding the underlying mechanisms is, therefore, crucial for effective cardioprotection, without compromising the efficacy of anti-cancer treatments. Critical Issues: CTX can occur within a few days or many years after treatment. Type I CTX is associated with irreversible cardiac cell injury, and it is typically caused by anthracyclines and traditional chemotherapeutics. Type II CTX is generally caused by novel biologics and more targeted drugs, and it is associated with reversible myocardial dysfunction. Therefore, patients undergoing anti-cancer treatments should be closely monitored, and patients at risk of CTX should be identified before beginning treatment to reduce CTX-related morbidity. Future Directions: Genetic profiling of clinical risk factors and an integrated approach using molecular, imaging, and clinical data may allow the recognition of patients who are at a high risk of developing chemotherapy-related CTX, and it may suggest methodologies to limit damage in a wider range of patients. The involvement of redox mechanisms in cancer biology and anticancer treatments is a very active field of research. Further investigations will be necessary to uncover the hallmarks of cancer from a redox perspective and to develop more efficacious antineoplastic therapies that also spare the cardiovascular system.
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Affiliation(s)
| | - Christian Cadeddu
- 2 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Daniela Di Lisi
- 3 Biomedical Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Saveria Femminò
- 4 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Rosalinda Madonna
- 5 Center of Aging Sciences and Translational Medicine - CESI-MeT, "G. d'Annunzio" University, Chieti, Italy.,6 Department of Internal Medicine, The Texas Heart Institute and Center for Cardiovascular Biology and Atherosclerosis Research, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Donato Mele
- 7 Cardiology Unit, Emergency Department, University Hospital of Ferrara, Ferrara, Italy
| | - Ines Monte
- 8 Department of General Surgery and Medical-Surgery Specialities, University of Catania, Catania, Italy
| | - Giuseppina Novo
- 3 Biomedical Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Claudia Penna
- 4 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Alessia Pepe
- 9 U.O.C. Magnetic Resonance Imaging, Fondazione Toscana G. Monasterio C.N.R., Pisa, Italy
| | - Paolo Spallarossa
- 10 Clinic of Cardiovascular Diseases, IRCCS San Martino IST, Genova, Italy
| | - Gilda Varricchi
- 1 Department of Translational Medical Sciences, Federico II University, Naples, Italy.,11 Center for Basic and Clinical Immunology Research (CISI) - Federico II University, Naples, Italy
| | - Concetta Zito
- 12 Division of Cardiology, Clinical and Experimental Department of Medicine and Pharmacology, Policlinico "G. Martino" University of Messina, Messina, Italy
| | - Pasquale Pagliaro
- 4 Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giuseppe Mercuro
- 2 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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20
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Risk of Cardiomyopathy in Breast Cancer: How Can We Attenuate the Risk of Heart Failure from Anthracyclines and Anti-HER2 Therapies? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:30. [DOI: 10.1007/s11936-019-0736-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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21
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Two-Dimensional Speckle Tracking Echocardiography-Derived Strain Measurements in Survivors of Childhood Cancer on Angiotensin Converting Enzyme Inhibition or Receptor Blockade. Pediatr Cardiol 2018; 39:1404-1412. [PMID: 29789916 DOI: 10.1007/s00246-018-1910-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/10/2018] [Indexed: 02/01/2023]
Abstract
Speckle tracking echocardiography (STE)-derived strain indices are believed to detect early cardiac dysfunction in survivors of childhood cancer and have potential to identify patients who may benefit from early heart failure treatment. However, effects of heart failure treatment on STE-derived strain measurements in this population are unknown. The aim of this study was to assess STE-derived strain measurements in survivors of childhood cancer treated with angiotensin converting enzyme inhibition or receptor blockade (ACEi/ARB). Two-dimensional speckle tracking analysis was retrospectively performed on echocardiograms from childhood cancer survivors before and during therapy with ACEi/ARB. Global left ventricular longitudinal and circumferential strain (GLS and GCS) and strain rates (LSR and CSR) were assessed and correlated with conventional echocardiographic measures of function. In 22 childhood cancer survivors (median age: 14.8, range 6.4-21.6 years), mean GLS (- 13.83 ± 0.74% to - 15.94 ± 0.74%, p = 0.002), GCS (- 18.79 ± 1.21% to - 20.74 ± 0.84%, p = 0.027), LSR (- 0.78 ± 0.04 to - 0.88 ± 0.04 s-1, p = 0.022), and CSR (- 1.08 ± 0.07 to - 1.21 ± 0.06 s-1, p = 0.027) improved on therapy. Improvement in GLS was maintained for greater than 1 year on ACEi/ARB (p = 0.02). Measures of strain and strain rate correlated with standard echocardiographic measures of function and were reproducible. These findings support the use of ACEi/ARB to treat post-chemotherapy-related cardiovascular changes in childhood cancer survivors, provide proof-of-concept that STE-derived strain and strain rate may be used to reliably monitor cardiac function during therapy, and support continued investigation into the clinical benefit of strain measurements in this population.
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22
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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23
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Vallakati A, Konda B, Lenihan DJ, Baliga RR. Management of Cancer Therapeutics-Related Cardiac Dysfunction. Heart Fail Clin 2018; 14:553-567. [PMID: 30266364 DOI: 10.1016/j.hfc.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Improvements in detection and treatment of cancer have resulted in a significant increase in cancer survivors. However, cancer survivorship comes with long-term risk of adverse effects of cancer therapies, including cardiomyopathy, heart failure, arrhythmias, ischemic heart disease, atherosclerosis, thrombosis, and hypertension. There is a renewed interest in understanding the pathophysiology of cancer therapeuticserelated cardiac dysfunction. In recent years, efforts have been directed to the management of cancer therapeuticserelated cardiac dysfunction. This article discusses the pathophysiology and molecular mechanisms that contribute to cancer therapeutics-related cardiac dysfunction and presents an napproach to the evaluation and treatment of these patients.
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Affiliation(s)
- Ajay Vallakati
- Division of Cardiovascular Diseases, Department of Internal Medicine, The Ohio State University, 410 West 10th, Avenue, Columbus, OH 43210, USA.
| | - Bhavana Konda
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, A440 Starling Loving Hall, 320 West 10th Avenue, Columbus, OH 43210, USA
| | - Daniel J Lenihan
- Division of Cardiovascular Diseases, Department of Internal Medicine, Washington University, St Louis, MO 63110, USA
| | - Ragavendra R Baliga
- Division of Cardiovascular Diseases, Department of Internal Medicine, The Ohio State University, 410 West 10th, Avenue, Columbus, OH 43210, USA
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24
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Cadeddu Dessalvi C, Deidda M, Mele D, Bassareo PP, Esposito R, Santoro C, Lembo M, Galderisi M, Mercuro G. Chemotherapy-induced cardiotoxicity. J Cardiovasc Med (Hagerstown) 2018; 19:315-323. [DOI: 10.2459/jcm.0000000000000667] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Tilemann LM, Heckmann MB, Katus HA, Lehmann LH, Müller OJ. Cardio-oncology: conflicting priorities of anticancer treatment and cardiovascular outcome. Clin Res Cardiol 2018; 107:271-280. [PMID: 29453595 PMCID: PMC5869944 DOI: 10.1007/s00392-018-1202-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/11/2018] [Indexed: 12/03/2022]
Abstract
BACKGROUND This article about the emerging field of cardio-oncology highlights typical side effects of oncological therapies in the cardiovascular system, cardiovascular complications of malignancies itself, and potential preventive or therapeutic modalities. METHODS We performed a selective literature search in PubMed until September 2016. RESULTS Cardiovascular events in cancer patients can be frequently attributed to oncological therapies or to the underlying malignancy itself. Furthermore, many patients with cancer have pre-existing cardiovascular diseases that can be aggravated by the malignancy or its therapy. Cardiovascular abnormalities in oncological patients comprise a broad spectrum from alterations in electrophysiological, laboratory or imaging tests to the occurrence of thromboembolic, ischemic or rhythmological events and the impairment of left ventricular function or manifest heart failure. DISCUSSION A close interdisciplinary collaboration between oncologists and cardiologists/angiologists as well as an increased awareness of potential cardiovascular complications could improve clinical care of cancer patients and provides a basis for an improved understanding of underlying mechanisms of cardiovascular morbidity.
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Affiliation(s)
- Lisa M Tilemann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Markus B Heckmann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Hugo A Katus
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Lorenz H Lehmann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany.
| | - Oliver J Müller
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany.
- Department of Internal Medicine III, University of Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
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Varricchi G, Ameri P, Cadeddu C, Ghigo A, Madonna R, Marone G, Mercurio V, Monte I, Novo G, Parrella P, Pirozzi F, Pecoraro A, Spallarossa P, Zito C, Mercuro G, Pagliaro P, Tocchetti CG. Antineoplastic Drug-Induced Cardiotoxicity: A Redox Perspective. Front Physiol 2018; 9:167. [PMID: 29563880 PMCID: PMC5846016 DOI: 10.3389/fphys.2018.00167] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/20/2018] [Indexed: 12/28/2022] Open
Abstract
Antineoplastic drugs can be associated with several side effects, including cardiovascular toxicity (CTX). Biochemical studies have identified multiple mechanisms of CTX. Chemoterapeutic agents can alter redox homeostasis by increasing the production of reactive oxygen species (ROS) and reactive nitrogen species RNS. Cellular sources of ROS/RNS are cardiomyocytes, endothelial cells, stromal and inflammatory cells in the heart. Mitochondria, peroxisomes and other subcellular components are central hubs that control redox homeostasis. Mitochondria are central targets for antineoplastic drug-induced CTX. Understanding the mechanisms of CTX is fundamental for effective cardioprotection, without compromising the efficacy of anticancer treatments. Type 1 CTX is associated with irreversible cardiac cell injury and is typically caused by anthracyclines and conventional chemotherapeutic agents. Type 2 CTX, associated with reversible myocardial dysfunction, is generally caused by biologicals and targeted drugs. Although oxidative/nitrosative reactions play a central role in CTX caused by different antineoplastic drugs, additional mechanisms involving directly and indirectly cardiomyocytes and inflammatory cells play a role in cardiovascular toxicities. Identification of cardiologic risk factors and an integrated approach using molecular, imaging, and clinical data may allow the selection of patients at risk of developing chemotherapy-related CTX. Although the last decade has witnessed intense research related to the molecular and biochemical mechanisms of CTX of antineoplastic drugs, experimental and clinical studies are urgently needed to balance safety and efficacy of novel cancer therapies.
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Affiliation(s)
- Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
- Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research, University of Naples Federico II, Naples, Italy
| | - Pietro Ameri
- Clinic of Cardiovascular Diseases, IRCCS San Martino IST, Genova, Italy
| | - Christian Cadeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, Turin, Italy
| | - Rosalinda Madonna
- Institute of Cardiology, Center of Excellence on Aging, Università degli Studi “G. d'Annunzio” Chieti – Pescara, Chieti, Italy
- Department of Internal Medicine, Texas Heart Institute and Center for Cardiovascular Biology and Atherosclerosis Research, University of Texas Health Science Center, Houston, TX, United States
| | - Giancarlo Marone
- Section of Hygiene, Department of Public Health, University of Naples Federico II, Naples, Italy
- Monaldi Hospital Pharmacy, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Ines Monte
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, Catania, Italy
| | - Giuseppina Novo
- U.O.C. Magnetic Resonance Imaging, Fondazione Toscana G. Monasterio C.N.R., Pisa, Italy
| | - Paolo Parrella
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonio Pecoraro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Paolo Spallarossa
- Clinic of Cardiovascular Diseases, IRCCS San Martino IST, Genova, Italy
| | - Concetta Zito
- Division of Clinical and Experimental Cardiology, Department of Medicine and Pharmacology, Policlinico “G. Martino” University of Messina, Messina, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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27
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Spallarossa P, Maurea N, Cadeddu C, Madonna R, Mele D, Monte I, Novo G, Pagliaro P, Pepe A, Tocchetti CG, Zito C, Mercuro G. A recommended practical approach to the management of anthracycline-based chemotherapy cardiotoxicity: an opinion paper of the working group on drug cardiotoxicity and cardioprotection, Italian Society of Cardiology. J Cardiovasc Med (Hagerstown) 2018; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e84-e92. [PMID: 27183529 PMCID: PMC4927325 DOI: 10.2459/jcm.0000000000000381] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Anthracyclines are the mainstay of treatment of a variety of haematological malignancies and solid tumours. Unfortunately, the clinical use of these drugs is limited by cumulative, dose-related cardiotoxicity which may ultimately lead to a severe and irreversible form of cardiomyopathy. Thus, there is an increasing need for close cooperation among cardiologists, oncologists and haemato-oncologists. As anthracyclines save lives, the logical goal of this cooperation, besides preventing or mitigating cardiotoxicity, is to promote an acceptable balance between the potential cardiac side effects and the vital benefit of anticancer treatment. This manuscript, which is specifically addressed to the cardiologist who has not accumulated much experience in the field of cancer therapy, focuses on several topics, that is old and new mechanisms of cardiac toxicity, late cardiac toxicity, the importance of overall risk assessment, the key role of a cardiology consult before starting cancer therapy, and the pros and cons of primary and secondary prevention programmes.
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Affiliation(s)
- Paolo Spallarossa
- aClinic of Cardiovascular Diseases, IRCCS San Martino IST, Genoa bDivision of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale' - IRCCS, Naples cDepartment of Medical Sciences 'Mario Aresu', University of Cagliari dInstitute of Cardiology, Center of Excellence on Aging, 'G. d'Annunzio' University, Chieti eCardiology Unit, University Hospital of Ferrara, Ferrara fDepartment of General Surgery and Medical-Surgery Specialties, University of Catania, Catania gChair and Division of Cardiology, University of Palermo, Palermo hDepartment of Clinical and Biological Sciences, University of Turin, Orbassano iU.O.C. Magnetic Resonance Imaging, Fondazione G. Monasterio C.N.R., Pisa jDepartment of Translational Medical Sciences, Federico II University, Naples kU.O.C. Cardiology Intensive Unit, A.O.U. Policlinico 'G. Martino', University of Messina, Messina, Italy
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Abdel-Qadir H, Ong G, Fazelzad R, Amir E, Lee DS, Thavendiranathan P, Tomlinson G. Interventions for preventing cardiomyopathy due to anthracyclines: a Bayesian network meta-analysis. Ann Oncol 2017; 28:628-633. [PMID: 28028033 DOI: 10.1093/annonc/mdw671] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background The relative efficacy of interventions for primary prevention of anthracycline-associated cardiotoxicity is unknown. Methods We conducted a systematic review of randomized controlled trials for primary prevention of anthracycline-associated cardiotoxicity in adult cancer patients. We used hierarchal outcome definitions in the following order of priority: (1) composite of heart failure or decline in left ventricular ejection fraction, (2) decline in ejection fraction, or (3) heart failure. Data were analyzed using a Bayesian network meta-analysis with random effects. Results A total of 16 trials reported cardiotoxicity as a dichotomous outcome among 1918 patients, evaluating dexrazoxane, angiotensin antagonists, beta-blockers, combination angiotensin antagonists and beta-blockers, statins, Co-enzyme Q-10, prenylamine, and N-acetylcysteine. Compared with control, dexrazoxane reduced cardiotoxicity with a pooled odds ratio (OR) of 0.26 (95% credible interval [CrI] 0.11-0.74) and had the highest probability (33%) of being most effective. No other agent was demonstrably better than placebo. Angiotensin antagonists had an 84% probability of being most effective in a sensitivity analysis excluding one outlying study (OR 0.06 [95% CrI 0.01- 0.24]). When the outcome was restricted to heart failure, dexrazoxane was associated with an OR of 0.12 (95% CrI 0.06-0.23) relative to control and had 58% probability of being most effective, while angiotensin antagonists had an OR of 0.18 (95% CrI 0.05-0.55). Available data suggested that dexrazoxane and angiotensin antagonists did not affect malignancy response rate or risk of death. Conclusion Moderate quality data suggest that dexrazoxane, and low quality data suggest angiotensin antagonists, are likely to be effective for cardiotoxicity prevention.
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Affiliation(s)
- H Abdel-Qadir
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Department of Medicine, Women's College Hospital, Toronto, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - G Ong
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - R Fazelzad
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - E Amir
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - D S Lee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Canada
| | - P Thavendiranathan
- Department of Medicine, University of Toronto, Toronto, Canada.,Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Canada
| | - G Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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29
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Luo R, Cui H, Huang D, Li G. Early assessment of the left ventricular function by epirubicin-induced cardiotoxicity in postoperative breast cancer patients. Echocardiography 2017; 34:1601-1609. [PMID: 28895191 DOI: 10.1111/echo.13693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Epirubicin (Epi) is a potent and effective drug for many malignant cancers with serious cardiotoxicity. Therefore, layer-specific two-dimensional speckle tracking echocardiography (2D-STE) was used to evaluate the longitudinal and circumferential systolic function of the left ventricular for the early detection of cardiotoxicity in this retrospective work. METHODS Overall, 130 female patients with postoperative breast cancer who did not receive radiotherapy were classified into three groups: Group A (control group, n = 40) without any chemotherapy; Group B (n = 44) administered Epi at 180 ~ 240 mg/m2 ; and Group C (n = 46) administered Epi at ≥360 mg/m2 . Peak and global systolic longitudinal strains (GLS) in the total and endocardium, mid-myocardium, and epicardium were measured and calculated from apical four-chamber, apical two-chamber, and left ventricular long-axis views, respectively. Peak and global circumferential strains (GCS) in the total and endocardium, mid-myocardium, and epicardium were measured and calculated from mitral annulus, papillary muscle, and apical levels of the short-axis view, respectively. RESULTS The total GLS and GLS of the endocardium in every view were significantly reduced in group C compared with both groups A and B (P < .05), but there was no significant difference between groups A and B (P > .05). The GLS of the epicardium and mid-myocardium in groups B and C were not significantly reduced (P > .05). There were no significant differences in the total GCS and layer-specific GCS of endocardium, mid-myocardium, and epicardium among the three groups (P > .05). CONCLUSIONS Left ventricular longitudinal systolic dysfunction was detected. Moreover, an impaired endocardium was also detected in an early assessment by layer-specific 2DSTE.
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Affiliation(s)
- Runlan Luo
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hongyan Cui
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Dongmei Huang
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangsen Li
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
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30
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Levis BE, Binkley PF, Shapiro CL. Cardiotoxic effects of anthracycline-based therapy: what is the evidence and what are the potential harms? Lancet Oncol 2017; 18:e445-e456. [DOI: 10.1016/s1470-2045(17)30535-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/04/2017] [Accepted: 01/12/2017] [Indexed: 01/07/2023]
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31
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Bassareo PP, Monte I, Romano C, Deidda M, Piras A, Cugusi L, Coppola C, Galletta F, Mercuro G. Cardiotoxicity from anthracycline and cardioprotection in paediatric cancer patients. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e55-e63. [PMID: 27755243 DOI: 10.2459/jcm.0000000000000375] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Notwithstanding the steady progress in survival rates of children and adolescents suffering from cancer, the benefits associated with chemotherapy do not come without risks involving multiple organs and systems, including the cardiovascular apparatus. Anthracyclines-often administered in combination with radiation therapy and/or surgery-are the most used chemotherapeutic compounds in order to treat tumours and blood malignancies even in paediatric age. Being an important side-effect of anthracyclines, carduitoxicity may limit their efficacy during the treatment and induce long-term sequelae, observed even many years after therapy completion. The purpose of this review was to perform an overview about all the possible strategies to prevent and/or limit the anthracyclines adverse side-effects for the cardiovascular system in childhood cancer survivors.
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Affiliation(s)
- Pier P Bassareo
- aDepartment of Medical Sciences 'Mario Aresu', University of Cagliari bGeneral Surgery and Medical-Surgery Specialities Department, University of Catania cDivision of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori 'Fondazione Giovanni Pascale'-IRCCS, Naples, Italy
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32
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Cadeddu C, Mercurio V, Spallarossa P, Nodari S, Triggiani M, Monte I, Piras R, Madonna R, Pagliaro P, Tocchetti CG, Mercuro G. Preventing antiblastic drug-related cardiomyopathy: old and new therapeutic strategies. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e64-e75. [PMID: 27755244 DOI: 10.2459/jcm.0000000000000382] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Because of the recent advances in chemotherapeutic protocols, cancer survival has improved significantly, although cardiovascular disease has become a major cause of morbidity and mortality among cancer survivors: in addition to the well-known cardiotoxicity (CTX) from anthracyclines, biologic drugs that target molecules that are active in cancer biology also interfere with cardiovascular homeostasis.Pharmacological and non-pharmacological strategies to protect the cardiovascular structure and function are the best approaches to reducing the prevalence of cardiomyopathy linked to anticancer drugs. Extensive efforts have been devoted to identifying and testing strategies to achieve this end, but little consensus has been reached on a common and shared operability.Timing, dose and mode of chemotherapy administration play a crucial role in the development of acute or late myocardial dysfunction. Primary prevention initiatives cover a wide area that ranges from conventional heart failure drugs, such as β-blockers and renin-angiotensin-aldosterone system antagonists to nutritional supplementation and physical training. Additional studies on the pathophysiology and cellular mechanisms of anticancer-drug-related CTX will enable the introduction of novel therapies.We present various typologies of prevention strategies, describing the approaches that have already been used and those that could be effective on the basis of a better understanding of pharmacokinetic and pharmacodynamic CTX mechanisms.
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Affiliation(s)
- Christian Cadeddu
- aDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari bDepartment of Translational Medical Sciences, Division of Internal Medicine, Federico II University, Naples cClinic of Cardiovascular Diseases, IRCCS San Martino IST, Genoa dDepartment of Clinical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia eDepartment of General Surgery and Medical-Surgery Specialities, University of Catania, Catania fInstitute of Cardiology, Center of Excellence on Aging, 'G. d'Annunzio' University, Chieti gDepartment of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
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33
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Novo G, Cadeddu C, Sucato V, Pagliaro P, Romano S, Tocchetti CG, Zito C, Longobardo L, Nodari S, Penco M. Role of biomarkers in monitoring antiblastic cardiotoxicity. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e27-e34. [PMID: 27755240 DOI: 10.2459/jcm.0000000000000379] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Early detection of anticancer drug-induced cardiotoxicity (CTX) has been evaluated by most international scientific cardiology and oncology societies. High expectations have been placed on the use of specific biomarkers. In recent years, conventional biomarkers and molecules of more recent interest have been tested and compared in the context of anticancer drug-related CTX. Encouraging results were obtained from studies on molecules of myocardial damage, such as troponin and markers of myocardial wall stress, including circulating natriuretic peptides, as well as from the assessment of the products of inflammation or circulating levels of free radicals. However, clear guidelines on their sensitivity, specificity, and accuracy are not yet available, and many challenges, such as the optimal time of assessing, optimal schedule for evaluation, optimal cut-off point for positivity with the highest level of specificity, and optimal comparability of different assays for the measurements, remain unresolved. Given the importance of having a reliable and accurate tool for monitoring anticancer drug-induced CTX, this review will focus on the available data on the most effective and widely used biomarkers and the studies that are currently underway that aim to identify the effectiveness of new approaches in this therapeutic setting.
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Affiliation(s)
- Giuseppina Novo
- aDepartment of Internal Medicine and Specialties (DIBIMIS), Chair of Cardiology, University of Palermo, Palermo Italy bDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari Italy cDepartment of Clinical and Biological Sciences, University of Turin, Orbassano Italy dDepartment of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy eDepartment of Translational Medical Sciences, University of Napoli Federico II, Naples Italy fDepartment of Clinical and Experimental Medicine. Section of Cardiology, University of Messina, Messina Italy gDepartment of Clinical and Surgical Specialities, Radiological Sciences and Public Health University of Brescia, Brescia, Italy
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Mele D, Tocchetti CG, Pagliaro P, Madonna R, Novo G, Pepe A, Zito C, Maurea N, Spallarossa P. Pathophysiology of anthracycline cardiotoxicity. J Cardiovasc Med (Hagerstown) 2017; 17 Suppl 1 Special issue on Cardiotoxicity from Antiblastic Drugs and Cardioprotection:e3-e11. [PMID: 27755237 DOI: 10.2459/jcm.0000000000000378] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Anthracyclines (ANTs) are powerful drugs that have reduced the mortality of cancer patients. However, their use is limited by the development of cardiotoxicity (CTX), which is dose dependent and may lead to left ventricular dysfunction and heart failure. Although various strategies have been suggested to reduce the negative effects of ANTs, CTX is still an important unresolved clinical issue. This may be due at least partly to the incomplete characterization of the molecular and cellular mechanisms of ANT-induced CTX. In addition, although various forms of cardiac damage have been demonstrated with the use of these drugs in experimental studies, it is not yet clear how these translate to the clinical setting. Appropriate characterization of potential candidates for ANT-based therapies is essential to decide whether to administer these drugs. Hopefully, new information from genetic profiling will help to identify patients who are at high risk of developing CTX.
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Affiliation(s)
- Donato Mele
- aCardiology Unit, University Hospital of Ferrara bDepartment of Translational Medical Sciences, Division of Internal Medicine, Federico II University, Naples cDepartment of Clinical and Biological Sciences, University of Turin, Orbassano dCardiology, Center of Excellence on Aging, 'G. d'Annunzio' University, Chieti eChair and Division of Cardiology, University of Palermo, Palermo fU.O.C. Magnetic Resonance Imaging, Fondazione G. Monasterio C.N.R., Pisa gU.O.C. Cardiology Intensive Unit, A.O.U. Policlinico 'G. Martino', University of Messina, Messina hDivision of Cardiology, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione Giovanni Pascale" -IRCCS, Naples, Italy iClinic of Cardiovascular Diseases, IRCCS San Martino IST, Genoa, Italy
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Cardinale D, Biasillo G, Salvatici M, Sandri MT, Cipolla CM. Using biomarkers to predict and to prevent cardiotoxicity of cancer therapy. Expert Rev Mol Diagn 2017; 17:245-256. [DOI: 10.1080/14737159.2017.1283219] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | - Gina Biasillo
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | - Michela Salvatici
- Division of Laboratory Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Maria Teresa Sandri
- Division of Laboratory Medicine, European Institute of Oncology, IRCCS, Milan, Italy
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Thavendiranathan P, Amir E. Left Ventricular Dysfunction With Trastuzumab Therapy: Is Primary Prevention the Best Option? J Clin Oncol 2016; 35:820-825. [PMID: 28029315 DOI: 10.1200/jco.2016.71.0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 51-year-old women with left-sided, T2N1, grade 3, estrogen receptor- and progesterone receptor-negative, human epidermal growth factor receptor 2 (HER2)-positive breast cancer was referred to a cardio-oncology clinic for pre-cancer treatment cardiovascular risk assessment. The planned cancer treatment was 3 cycles of FEC (fluorouracil, epirubicin [100 mg/m2 per dose], and cyclophosphamide), followed by 3 cycles of concurrent docetaxel and trastuzumab, followed by maintenance trastuzumab to complete a 1-year course. Other than a prior history of hysterectomy, there was no relevant medical history. Her cardiac history was notable for the absence of prior cardiovascular disease, hypertension, diabetes, or hypercholesterolemia. She was a nonsmoker. At initial clinic visit, her blood pressure was 138/84 with an unremarkable cardiovascular examination. Her echocardiography demonstrated normal sinus rhythm at 73 beats per minute. During cancer treatment, she was observed with echocardiography (baseline left ventricular ejection fraction [LVEF], 61%; global longitudinal strain, -21.5%), cardiac magnetic resonance imaging (CMR, as part of an ongoing study), high-sensitivity troponin I, and B-type natriuretic peptide ( Table 1 ). Given that her baseline evaluations were negative at her initial visit, we discussed whether there were agents to prevent the rare, but serious, complication of congestive heart failure (HF) associated with anthracycline- and trastuzumab-based therapy.
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Affiliation(s)
- Paaladinesh Thavendiranathan
- Paaladinesh Thavendiranathan, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- Paaladinesh Thavendiranathan, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, Toronto, Ontario, Canada; and Eitan Amir, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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37
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Cadeddu C, Piras A, Dessì M, Madeddu C, Mantovani G, Scartozzi M, Hagendorff A, Colonna P, Mercuro G. Timing of the negative effects of trastuzumab on cardiac mechanics after anthracycline chemotherapy. Int J Cardiovasc Imaging 2016; 33:197-207. [PMID: 27696298 DOI: 10.1007/s10554-016-0987-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/26/2016] [Indexed: 01/09/2023]
Abstract
Trastuzumab (TZB) has been shown to be extremely effective in breast cancer patients over-expressing HER-2, but careful cardiac monitoring is required when TZB is administered with anthracyclines, since the combination can increase its toxicity. Myocardial deformation indexes associated with speckle tracking echocardiography (STE) have proven to be very sensitive in identifying early myocardial dysfunction. An observational, prospective study was designed to assess TZB-induced cardiac damage using STE in patients with HER-2 positive breast cancer who had been sequentially treated with TZB following epirubicin (EPI). Conventional echocardiographic parameters and STE deformation indexes (longitudinal, radial, and circumferential strain/strain rate and apical rotation) were analyzed at baseline, after each EPI treatment, and 1 week after every other dose of TZB administration until 1 year follow up, in order to focus on the timing and extent of myocardial impairment. In the forty-five enrolled patients, a reduction in subendocardial function after EPI treatment was observed by a significant impairment of the global longitudinal strain/strain rate (GLS/SR), while a significant increase in the activity of the subepicardial fibers was highlighted by an increase in apical rotation. After the second TZB dose, a sudden reduction of the apical rotation was seen, together with circumferential and radial strain/SR. Most importantly, the extent to which the apical rotation increased and decreased was found to strictly correlate with the GLS reduction at follow up. We found that after EPI therapy, subendocardial function was impaired, even while a compensatory increase in apical rotation occurred. Following TZB treatment, we observed impairment in apical rotation, which seems to be the first sign of global LV dysfunction predicting GLS reduction found at the end of treatment.
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Affiliation(s)
- Christian Cadeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Alessandra Piras
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Mariele Dessì
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giovanni Mantovani
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Mario Scartozzi
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Andreas Hagendorff
- Division of Cardiology and Angiology, Department of Internal Medicine, Neurology and Dermatology, University of Leipzig, Leipzig, Germany
| | - Paolo Colonna
- U.O. di Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Consorziale Policlinico, Bari, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Chang WT, Cheng JT, Chen ZC. Telmisartan improves cardiac fibrosis in diabetes through peroxisome proliferator activated receptor δ (PPARδ): from bedside to bench. Cardiovasc Diabetol 2016; 15:113. [PMID: 27519769 PMCID: PMC4983091 DOI: 10.1186/s12933-016-0430-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/29/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Despite the known risk of diabetes-induced cardiac fibrosis, less is known about whether diabetes causes an altered cardiac phenotype independent of coronary atherosclerosis. Peroxisome proliferator-activated receptor δ (PPARδ), a versatile regulator of metabolic homeostasis, may be a potential therapeutic target. Herein we investigated the effectiveness of telmisartan, a unique angiotensin receptor blocker that increases PPARδ expression, in improving left ventricular remodeling in diabetic humans and rats. METHODS In this longitudinal, prospective study, we enrolled 15 diabetic patients receiving telmisartan (20 mg/day) for 12 weeks. After treatment, strain was measured and compared with the baseline value. Using streptozotocin to induce type 1 diabetes rat model, we measured PPARδ expression and downstream targets. RESULTS After treatment with telmisartan, both longitudinal and circumferential strains improved in diabetic patients. Compared with that of controls, the diabetic rat heart developed significant fibrosis, which markedly decreased after treatment with telmisartan (30 mg/kg/day, orally) for 7 days. After incubation with 30 mM glucose, rat cardiomyocytes showed a significant down-regulation of PPARδ. Interestingly, the increased expression of fibrosis-associated proteins, including signal transducer and activator of transcription 3 (STAT3) was attenuated by the co-incubation of GW0742, a PPARδ agonist. By knockdown or inhibition of STAT3, the hyperglycemia related high expression of fibrosis associated targets was reversed. Independent from the hyperglycemic incubation, STAT3 over-expression led to similar results. Conversely, in the presence of GSK0660, a PPARδ inhibitor, the protective effects of telmisartan were diminished. CONCLUSION Telmisartan improved the hyperglycemia-induced cardiac fibrosis through the PPARδ/STAT3 pathway. Graphical abstract Summary of the mechanism of telmisartan's effect on the suppression of hyperglycemia-induced cardiac fibrosis through PPARδ instead of the AMPK pathway. PPARδ peroxisome proliferator-activated receptor δ, STAT3 signal transducer and activator of transcription 3, CTGF connective tissue growth factor, MMP9 matrix metallopeptidase 9.
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Affiliation(s)
- Wei-Ting Chang
- Department of Cardiology, Chi Mei Medical Center, 901, Zhonghua Road, Yongkang District, Tainan, Taiwan, ROC
| | - Juei-Tang Cheng
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Department of Cardiology, Chi Mei Medical Center, 901, Zhonghua Road, Yongkang District, Tainan, Taiwan, ROC. .,Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
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Ahmed SH, Moussa Sherif DE, Fouad Y, Kelany M, Abdel-Rahman O. Principles of a risk evaluation and mitigation strategy (REMS) for breast cancer patients receiving potentially cardiotoxic adjuvant treatments. Expert Opin Drug Saf 2016; 15:911-23. [DOI: 10.1517/14740338.2016.1170115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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40
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Di Lisi D, Leggio G, Vitale G, Arrotti S, Iacona R, Inciardi RM, Nobile D, Bonura F, Novo G, Russo A, Novo S. Chemotherapy cardiotoxicity. J Cardiovasc Med (Hagerstown) 2016; 17:270-5. [DOI: 10.2459/jcm.0000000000000232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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41
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Yun S, Vincelette ND, Abraham I. Cardioprotective role of β-blockers and angiotensin antagonists in early-onset anthracyclines-induced cardiotoxicity in adult patients: a systematic review and meta-analysis. Postgrad Med J 2015; 91:627-33. [DOI: 10.1136/postgradmedj-2015-133535] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/01/2015] [Indexed: 01/13/2023]
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An update on the risk prediction and prevention of anticancer therapy-induced cardiotoxicity. Curr Opin Oncol 2015; 26:590-9. [PMID: 25233068 DOI: 10.1097/cco.0000000000000132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Cardiotoxicity is a well established complication of anticancer therapy. As cancer survivorship and life expectancy for cancer patients improves, the morbidity and mortality of anticancer therapy-related cardiotoxicity has become more problematic. It is of utmost importance to identify patients at the highest risk for the development of cardiotoxicity and to determine strategies for prevention, early detection and treatment. RECENT FINDINGS Clinical risk factors, biomarkers, advanced cardiac imaging and pharmacogenomics may be used to classify patients at risk for therapy-induced cardiotoxicity. A much broader armamentarium of imaging modalities for risk prediction, in addition to simple two-dimensional echocardiogram and radionucleotide angiography, has also shown clinical utility in identifying early-onset cardiotoxicity and areas of reversible myocardial injury. Exciting new research aimed at predicting cardiotoxicity and developing cardioprotective strategies may lead to changes in the administration of cardiotoxic chemotherapies. SUMMARY Personalized assessments of the risks and benefits of therapy should be used as opposed to standardized dosing and schedules. Patients at higher risk for cardiotoxicity should receive closer monitoring, cardioprotective agents, dose adjustment or alternative regimens in an effort to reduce cardiovascular morbidity and mortality. Future research will hopefully define specific risk prediction tools and clinical protocols to prevent irreversible cardiotoxicity.
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Valachis A, Nilsson C. Cardiac risk in the treatment of breast cancer: assessment and management. BREAST CANCER-TARGETS AND THERAPY 2015; 7:21-35. [PMID: 25653554 PMCID: PMC4303336 DOI: 10.2147/bctt.s47227] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
As the number of long-term breast cancer survivors has increased, the side effects of adjuvant cancer therapy, such as cardiac toxicity, remain clinically important. Although the cardiac toxicity due to anthracyclines, radiotherapy, or trastuzumab is well-documented, several issues need to be clarified and are the subjects of extensive ongoing clinical research. This review summarizes the incidence of cardiac toxicity due to breast cancer adjuvant therapy and highlights the current trends in early detection and management of cardiac toxicities.
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Affiliation(s)
- Antonis Valachis
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Cecilia Nilsson
- Center for Clinical Research, Västmanlands County Hospital, Västerås, Sweden
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Lipshultz SE, Diamond MB, Franco VI, Aggarwal S, Leger K, Santos MV, Sallan SE, Chow EJ. Managing chemotherapy-related cardiotoxicity in survivors of childhood cancers. Paediatr Drugs 2014; 16:373-89. [PMID: 25134924 PMCID: PMC4417358 DOI: 10.1007/s40272-014-0085-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the US, children diagnosed with cancer are living longer, but not without consequences from the same drugs that cured their cancer. In these patients, cardiovascular disease is the leading cause of non-cancer-related morbidity and mortality. Although this review focuses on anthracycline-related cardiomyopathy in childhood cancer survivors, the global lifetime risk of other cardiovascular diseases such as atherosclerosis, arrhythmias and intracardiac conduction abnormalities, hypertension, and stroke also are increased. Besides anthracyclines, newer molecularly targeted agents, such as vascular endothelial growth factor receptor and tyrosine kinase inhibitors, also have been associated with acute hypertension, cardiomyopathy, and increased risk of ischemic cardiac events and arrhythmias, and are summarized here. This review also covers other risk factors for chemotherapy-related cardiotoxicity (including both modifiable and non-modifiable factors), monitoring strategies (including both blood and imaging-based biomarkers) during and following cancer treatment, and discusses the management of cardiotoxicity (including prevention strategies such as cardioprotection by use of dexrazoxane).
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Affiliation(s)
- Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine and the Children's Research Center of Michigan at the Children's Hospital of Michigan, 3901 Beaubien Boulevard, Suite 1K40, Detroit, MI, 48201, USA,
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Chemotherapy-Induced Cardiotoxicity: Detection, Prevention, and Management. Can J Cardiol 2014; 30:869-78. [DOI: 10.1016/j.cjca.2014.04.029] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 01/05/2023] Open
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Colombo A, Sandri MT, Salvatici M, Cipolla CM, Cardinale D. Cardiac complications of chemotherapy: role of biomarkers. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:313. [PMID: 24771223 DOI: 10.1007/s11936-014-0313-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Both conventional and novel antineoplastic drugs may cause damage to the heart, ultimately affecting patients' survival and quality of life. In fact, the most frequent and typical clinical manifestation of cardiotoxicity, asymptomatic or symptomatic left ventricular dysfunction, may be induced not only by conventional cancer therapy, like anthracyclines, but also by new antitumoral targeted therapy such as trastuzumab. At present, left ventricular ejection fraction assessment represents the main standard practice for cardiac monitoring during cancer therapy, but it detects myocardial damage only when a functional impairment has already occurred, not allowing for early preventive strategies. In the last decade, a newer approach based on the measurement of cardiospecific biomarkers has been proposed, proving to have higher prognostic value than imaging modalities. In particular, cardiac troponin elevation during chemotherapy allows us to identify patients who are more prone to develop myocardial dysfunction and cardiac events during follow up. In these patients, the use of an angiotensin-converting enzyme inhibitor, such as enalapril, has shown to be effective in improving clinical outcome, giving the chance for a cardioprotective strategy in a selected population.
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Affiliation(s)
- Alessandro Colombo
- Cardiology Division, European Institute of Oncology, I.R.C.C.S., Via Ripamonti 435, 20141, Milan, Italy,
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Florescu M, Magda LS, Enescu OA, Jinga D, Vinereanu D. Early Detection of Epirubicin-Induced Cardiotoxicity in Patients with Breast Cancer. J Am Soc Echocardiogr 2014; 27:83-92. [DOI: 10.1016/j.echo.2013.10.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Indexed: 11/28/2022]
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