New Insights in the Era of Clinical Biomarkers as Potential Predictors of Systemic Therapy-Induced Cardiotoxicity in Women with Breast Cancer: A Systematic Review

Cardiotoxicity induced by breast cancer therapies is a potentially serious complication associated with the use of various breast cancer therapies. Prediction and better management of cardiotoxicity in patients receiving chemotherapy is of critical importance. However, the management of cancer therapy-related cardiac dysfunction (CTRCD) lacks clinical evidence and is based on limited clinical studies.

AIM

To provide an overview of existing and potentially novel biomarkers that possess a promising predictive value for the early and late onset of CTRCD in the clinical setting.

METHODS

A systematic review of published studies searching for promising biomarkers for the prediction of CTRCD in patients with breast cancer was undertaken according to PRISMA guidelines. A search strategy was performed using PubMed, Google Scholar, and Scopus for the period 2013-2023. All subjects were >18 years old, diagnosed with breast cancer, and received breast cancer therapies.

RESULTS

The most promising biomarkers that can be used for the development of an alternative risk cardiac stratification plan for the prediction and/or early detection of CTRCD in patients with breast cancer were identified.

CONCLUSIONS

We highlighted the new insights associated with the use of currently available biomarkers as a standard of care for the management of CTRCD and identified potentially novel clinical biomarkers that could be further investigated as promising predictors of CTRCD.

Does group-based high-intensity aerobic interval training improve the inflammatory status in patients with chronic heart failure?

BACKGROUND

Chronic heart failure (CHF) is a multifaceted syndrome associated with endothelial dysfunction and increased inflammation. Despite the existing controversies regarding the appropriate training modality, it is widely accepted that supervised cardiac rehabilitation (CR) interventions lead to proinflammatory biomarkers reduction and cellular adhesion molecules in patients with CHF.

AIM

The aim of the study was to quantify the effects of 12-week group-based high-intensity aerobic interval training (HIAIT)/modified group-based HIAIT intervention (m-Ullevaal) vs. moderate continuous training (MICT) on serum levels of proinflammatory biomarkers.

DESIGN

Single-blind, two-arm, prospective randomized controlled trial conducted on CHF outpatients performing group-based CR interventions throughout a 12-week period.

SETTING

The setting of the study was the Medical Center of Outpatient Rehabilitation and Sports Medicine, Plovdiv, Bulgaria.

POPULATION

The population included a total of 120 outpatients of both genders, mean age of 63.73±6.68 years, with stable CHF (NYHA classes II to IIIB, were randomly assigned to HIAIT/ m-Ullevaal (N.=60) or to MICT (N.=60) group.

METHODS

Functional exercise capacity (FEC) of the eligible subjects was evaluated through 6-minute walk test (6MWT) and peak oxygen uptake. Blood samples were drawn at baseline, after 12 weeks follow-up for analyses of C-reactive protein (CRP), tumor necrosis factor-α (TNFα) and cellular adhesion molecules (CAM).

RESULTS

Significant decreases in the serum levels of CRP (P=0.029), TNF-α (P=0.036), and vascular cell adhesion molecule-1 (VCAM-1) (P=0.040), were observed after 48 training sessions in the group-based HIAIT/m-Ullevaal intervention, except for intercellular adhesion molecule-1 (ICAM-1), which was higher in the MICT (P=0.034). FEC was significantly inversely related to CRP (r=-0.72, P<0.05), and the levels of VCAM-1 (r=-0.68, P<0.05).

CONCLUSIONS

Both group-based CR interventions (HIAIT/m-Ullevaal and MICT) significantly reduced the serum levels of CRP, TNF- α, ICAM-1 and VCAM in patients with CHF. However, selected proinflammatory biomarkers changes and CAMs favorably decreased in the group-based HIAIT/m-Ullevaal intervention. The responses on serum levels of proinflammatory biomarkers and CAMs are dependent upon the type, intensity, and CR intervention duration.

CLINICAL REHABILITATION IMPACT

The group-based high-intensity aerobic interval training reduces significantly the proinflammatory biomarkers and cellular adhesion molecules in patients with chronic heart failure.

Eversion Carotid Endarterectomy: Cardiac Troponin Assessment

Myocardial infarction (MI) is an eversion carotid endarterectomy (eCEA) complication, but most events are unknown, and true incidence and correlation remain controversial. Routine cardiac troponin measurement is a commonly used method for assessing early identification and treatment of MI and stratifying high-risk patients. The aim of the present study is to evaluate the effect of troponin elevation levels following eCEA and to investigate a possible correlation between adverse cardiovascular events and the incidence of postoperative myocardial infarction following emergent vascular surgery. The study included 54 patients who underwent eCEA. High-sensitive troponin I (hsTnI) levels were routinely monitored pre- and postoperatively, with an upper reference range of 34.5 pg/mL for men and 15.6 pg/mL for women. Increases were correlated with demographic and clinical risk factors, as well as clinical or subclinical cardiovascular events. hsTnI was increased in percentage (13%) postoperatively, and non-ST segment elevation MI was diagnosed in eight patients. No patient had clinical symptoms of MI and only two of them presented with simultaneous electrocardiographic changes. Increased levels did not correlate with comorbidities or other surgical risk factors. hsTnI elevation may occur in patients after eCEA and mostly correlates with silent non-ST segment elevation MI that occurred in the early postoperative phase, indicating a possible value as a tool for cardiovascular event diagnosis during the patient's hospitalization.

Cardiovascular disease in women: Executive summary of the expert panel statement of women in cardiology of the hellenic cardiological society

The perception that women represent a low-risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality as compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated, and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are underrepresented, leading to the limited knowledge of CV and systemic impact effects of several treatment modalities on women's health. Thus, in this consensus, a group of female cardiologists from the Hellenic Society of Cardiology presents the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies that may be implemented in daily clinical practice to eliminate underestimation and undertreatment of CVD in the female population.

Development of a multivariate model of the six-minute walked distance to predict functional exercise capacity in hypertension

BACKGROUND

Hypertension is associated with deterioration of musculoskeletal function and functional capacity. Existing prediction models for assessment of the 6-min walk test (6MWT) do not capture the disease-related functional capacity. This study developed a multivariate prediction model of the measured 6-min walked distance (6MWD_M) in hypertension and proposed target-values based on optimal therapeutic aims.

METHODS

Seventy-six patients (38 men, 56.1 ± 14.3 years, systolic pressure 156.7 ± 17.5 mmHg, diastolic pressure 92.9 ± 6.9 mmHg) underwent anamnesis, physical examination, and laboratory analysis. Functional capacity was assessed using the 6MWT, being the 6MWD_M considered as the dependent variable. Independent variables included sex (S, coded 'male' = 1, 'female' = 0), age (A), body height (H), body mass, mean blood pressure (MBP), and physical activity (IPAQ, coded 1-5). Target-values were derived from theoretical scenarios of optimal blood pressure and physical activity, separately and combined.

RESULTS

Patients walked 324.5 ± 10.1 m in the average of two trials 30-min apart. Pearson's correlation coefficient showed moderate-to-weak significant associations between 6MWD_M and all independent variables. The final multivariate model was 6MWD_P = 611.347-4.446 × MBP + 267.630 × H - 1.511 × A + IPAQ_code + S_code (adjusted R² = 0.680, SE of bias = 6.3 m), suggesting that clinical, anthropometric, and hemodynamic information determines functional capacity. Predicted values yielded a group-average of 325 ± 87 m. Target-values under the optimal scenario resulted in 420 ± 60 m.

CONCLUSIONS

Sex (men), higher body height, higher physical activity, lower mean blood pressure, and lower age are independently correlated with higher 6MWD_M in patients with hypertension. Target-values can be estimated for therapeutic aims related to hemodynamics and lifestyle.

Therapeutic effects of the combination of inhaled beta2-agonists and beta-blockers in COPD patients with cardiovascular disease

Chronic obstructive pulmonary disease (COPD) is a major health problem worldwide, with co-morbidities contributing to the overall severity and mortality of the disease. The incidence and prevalence of cardiovascular disease among COPD patients are high. Both disorders often co-exist, mainly due to smoking, but they also share common underlying risk factors, such as aging and low-grade systemic inflammation. The therapeutic approach is based on agents, whose pharmacological properties are completely opposed. Beta2-agonists remain the cornerstone of COPD treatment due to their limited cardiac adverse effects. On the other hand, beta-blockers are administered in COPD patients with cardiovascular disease, but despite their proven cardiac benefits, they remain underused. There is still a trend among physicians over underprescription of these drugs in patients with heart failure and COPD due to bronchoconstriction. Therefore, cardioselective beta-blockers are preferred, and recent meta-analyses have shown reduced rates in mortality and exacerbations in COPD patients treated with beta-blockers.

Effect of alcohol on endothelial function in healthy subjects

While studies have shown that red wine improves endothelial function, the effect of pure alcohol, the common denominator of all alcoholic beverages, on endothelial function has not been defined. The effect of oral intake of alcohol (one ounce - a dose corresponding to two drink equivalents) on flow-mediated dilatation of the brachial artery was studied in 12 healthy subjects using high-resolution ultrasonography according to a randomized, sham procedure-controlled, single-blind protocol. Alcohol produced a significant vasodilatation of the brachial artery at resting conditions. Furthermore, it led to a significant increase of the brachial artery diameter at reactive hyperemia; however, the percentage flow-mediated dilatation did not change. This study shows, for the first time, that acute moderate intake of alcohol has a potent dilating effect on large arteries both at resting and at reactive hyperemic conditions, without affecting flow-mediated dilatation as a percentage. This may be useful for explaining the divergent effect of different alcoholic beverages on endothelial function and provides valuable insight into the mechanisms involved in the vascular effects of alcohol.

Bilateral symmetry of local inflammatory activation in human carotid atherosclerotic plaques

INTRODUCTION

Only a few studies have investigated the structural and functional characteristics of carotid arteries bilaterally. Furthermore, there is controversy as to whether inflammation in paired vascular beds is a local or systemic phenomenon. We aimed to examine, in patients with coronary artery disease, whether intra-subject left and right carotid arteries have similar inflammatory status, as determined non-invasively by microwave radiometry (MWR).

METHODS

Consecutive patients (n=200) with significant coronary artery disease were evaluated via an ultrasound echo-colour Doppler (US-ECD) study of both carotid arteries and temperature measurements with MWR. During thermography, thermal heterogeneity (ΔT) was defined as the maximum temperature along the carotid artery minus the minimum temperature.

RESULTS

Mean T was similar between the left and right carotid arteries (0.78 ± 0.48 vs. 0.84 ± 0.52°C, p=0.12). Mean right intima-media thickness (IMT) was greater compared to mean left IMT (2.16 ± 1.20 vs. 1.93 ± 0.94 mm, p<0.01). In all carotids, there was a correlation between left and right carotid plaque ΔT (R=0.38, p<0.001) and between left and right IMT (R=0.48, p<0.001). Independent predictors for the presence of bilateral carotid plaques were found to be the extent of coronary artery disease, high ΔT, and therapy with angiotensin II receptor blockers; predictors for the presence of high ΔT bilaterally were bilateral carotid plaques, male sex, diabetes mellitus, and hypertension.

CONCLUSIONS

There is bilateral inflammatory activation in the carotid atherosclerotic lesions of patients with coronary artery disease. At this stage of carotid disease, arterial hypertension and diabetes mellitus are more strongly correlated with bilateral functional abnormalities in carotid plaques than with structural changes.

Testosterone deficiency: a determinant of aortic stiffness in men

OBJECTIVE

Low testosterone levels and increased aortic stiffness are predictors of cardiovascular events. The influence of androgen level on the age- and blood pressure-related increase in aortic stiffness is unknown.

METHODS

From January 2007 to June 2011 we enrolled 455 consecutive men with no evidence of cardiovascular disease from a large cohort followed in our Department for arterial function studies. Their total testosterone (TT) levels were measured and carotid-femoral pulse wave velocity (PWVc-f) was measured as an index of aortic stiffness.

RESULTS

In multivariable analysis, PWVc-f values were inversely correlated to TT after adjustment for confounders (β = -0.365, P < 0.001). In younger age categories (<50 yrs and 50-59 yrs), patients with testosterone deficiency (TD) had higher blood pressure-adjusted PWVc-f (P < 0.001 and P = 0.005, respectively) compared to subjects with normal TT, indicating an "aging effect" of 10 years, whereas in older age categories such a difference was not observed. Furthermore, in men with a higher mean pressure (102-108 mmHg and >108 mmHg), patients with TD had higher age-adjusted PWVc-f (P < 0.001) compared to subjects with normal TT, indicating a synergistic unfavorable effect of testosterone deficiency and blood pressure on aortic stiffness.

CONCLUSIONS

TT levels are independently associated with aortic stiffening. The effect of low testosterone concentration on aortic stiffness is more prominent in young men and in subjects with higher blood pressure levels. These findings identify testosterone as a marker of arterial damage with special emphasis on young and hypertensive individuals and support its role as predictor of events.

Type 5 phosphodiesterase inhibition by sildenafil abrogates acute smoking-induced endothelial dysfunction

BACKGROUND

Endothelial dysfunction is a key early event in the process of atherosclerosis and a risk factor for cardiovascular events. Sildenafil, an effective oral treatment for patients with erectile dysfunction, inhibits cGMP degradation by specific type 5 phosphodiesterase (PDE) inhibition. Sildenafil has been shown to improve vascular function, however, the effect of type 5 PDE inhibition on acute smoking-induced endothelial dysfunction is unknown.

METHODS

We studied the effect of 50 mg of sildenafil on acute smoking-induced endothelial dysfunction in 14 male smokers according to a randomized, placebo-controlled, cross-over design. Endothelial function was evaluated with flow-mediated dilatation (FMD) of the brachial artery using high-resolution ultrasonography.

RESULTS

Sildenafil abolishes the decrease in FMD of the brachial artery that is induced acutely by smoking (placebo/smoking session: from 4.56% +/- 0.60% to 2.80% +/- 0.43%, sildenafil/smoking session: from 3.83% +/- 0.64% to 4.33% +/- 0.47%, ie, improvement of 51%, P < .05). This was associated with no reversal effect of sildenafil on smoking-induced decrease in resting brachial artery diameter and with a partial reversal of the smoking-induced decrease in hyperemic brachial artery diameter (placebo/smoking session: from 4.68 +/- 0.13 mm to 4.53 +/- 0.15 mm, sildenafil/smoking session: from 4.72 +/- 0.12 mm to 4.64 +/- 0.13 mm, ie, improvement of 1.5%, P < .005).

CONCLUSIONS

The present study shows, for the first time, that type 5 PDE inhibition with sildenafil abrogates the smoking-induced acute decrease in FMD of the brachial artery. These findings may have clinical implications given the detrimental consequences of smoking and the strategic role of normal endothelial function.

Stents covered by an autologous arterial graft in porcine coronary arteries: feasibility, vascular injury and effect on neointimal hyperplasia

OBJECTIVE

The use of stents has improved results after balloon coronary angioplasty. Several materials have been proposed for covering the metallic surface of the stent to reduce the rate of subacute thrombosis and restenosis. In our institution, an autologous arterial graft was used for covering the external surface of a conventional stent. The angiographic and histological response in a porcine coronary artery model was investigated.

METHODS

An autologous arterial graft was removed from the femoral artery and carefully prepared. Subsequently, a conventional stent was covered externally by the arterial graft. Twenty-two covered stents and 22 uncovered regular stents were implanted alternatively in the coronary arteries of 22 pigs. One animal died immediately after the procedure, due to thrombus formation in the uncovered stent. Six animals were sacrificed at seven days and the remaining animals were sacrificed at two months. Before the sacrifice, coronary angiography was performed in all animals.

RESULTS

Thrombosis was detected in two control segments and in one covered stented segment. After seven days, the luminal surface of the covered stents was covered by a new endothelial layer in contrast to partial endothelial cell appearance in the control group. The angiographic parameters were similar between the two groups. Histologically, the covered stents were associated with less vascular injury compared to uncovered stents. In covered stents a trend towards reduction of maximal intimal hyperplasia was detected (covered: 116.6 +/- 47.75 vs uncovered: 150.25 +/- 46.81 microns, p = 0.08); also the thickness of the arterial media was reduced (covered: 21.34 +/- 10.28 vs uncovered: 102.63 +/- 18.71 microns, p = 0.02). The luminal and vessel areas were similar in the two groups.

CONCLUSIONS

The preparation and implantation of the autologous arterial graft-covered stent is technically safe and feasible. This type of covered stent results in accelerated endothelialization, less vascular injury, thinning of the arterial media and a trend to reduce the intimal hyperplasia in normal coronary arteries.

Unfavorable effects of passive smoking on aortic function in men

BACKGROUND

The aorta acts as both a conduit and an elastic buffering chamber that modulates left ventricular function and coronary blood flow. Previous studies have shown that active smoking has unfavorable effects on aortic elasticity.

OBJECTIVE

To study the association between passive smoking and the elastic properties of the human aorta.

DESIGN

Comparison of nonsmokers during passive smoking studies and smokers during active smoking or sham smoking studies.

SETTING

Academic medical center.

PARTICIPANTS

16 male nonsmokers were assigned to passive smoking studies, and 32 current, long-term, male smokers were randomly assigned to either active smoking (16 patients) or sham smoking (16 patients) studies.

INTERVENTION

All participants underwent diagnostic catheterization. In the passive smoking group, environmental tobacco smoke was vented into an exposure chamber for 5 minutes (mean carbon monoxide level, 30 parts per million). Each participant in the active smoking group smoked one filtered cigarette (1.0 mg of nicotine) under standardized conditions within 5 minutes; each participant in the sham smoking group performed a similar pattern of inhalation with one unlit cigarette.

MEASUREMENTS

Aortic elastic properties were studied by measuring the aortic pressure-diameter relation before and for 20 minutes after passive, active, or sham smoking. Instantaneous diameter of the thoracic aorta was measured with a high-fidelity ultrasonic dimension catheter. Instantaneous aortic pressure and diameter were measured at the same site.

RESULTS

Both passive and active smoking were associated with changes in the aortic pressure-diameter relation (change in mean distensibility in the passive smoking group, from 2.02 to 1.59 x 10(-6) cm2 x dyne(-1) [for comparisons of time course between passive and sham smoking groups, P < 0.001]; change in mean distensibility in the active smoking group, from 2.08 to 1.51 x 10(-6) cm2 x dyne(-1) [for comparisons of time course between active and sham smoking groups, P < 0.001]). These changes represent decreases of 21% and 27%, respectively. No changes in aortic elasticity were seen in the sham smoking group.

CONCLUSIONS

Both passive and active smoking are associated with an acute deterioration in the elastic properties of the aorta. This association between exposure to tobacco smoke and aortic elasticity indicates that aortic function deteriorates during passive or active smoking.