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

Aims

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

Methods and results

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

Conclusion

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

Characterization of myocardial mechanics and its prognostic significance in patients with severe aortic stenosis undergoing aortic valve replacement

AIMS

Aortic stenosis (AS) induces characteristic changes in left ventricular (LV) mechanics that can be reversed after aortic valve replacement (AVR). We aimed to comprehensively characterize LV mechanics before and after AVR in patients with severe AS and identify predictors of short-term functional recovery and long-term survival.

METHODS AND RESULTS

We prospectively performed comprehensive strain analysis by 2D speckle-tracking echocardiography in 88 patients with severe AS and LV ejection fraction ≥50% (mean age 71 ± 12 years, 42% female) prior to and within 7 days after AVR. Patients were followed for up to 5.2 years until death from any cause or last encounter. Within days after AVR, we observed an absolute increase in global longitudinal strain (GLS) (-16.0 ± 2.0% vs. -18.5 ± 2.1%, P<0.0001) and a decrease in apical rotation (10.5 ± 4.0° vs. 8.3 ± 2.8°, P = 0.0002) and peak systolic twist (18.2 ± 5.0° vs. 15.5 ± 3.8°, P = 0.0008). A baseline GLS is less negative than -16.2% was 90% sensitive and 67% specific in predicting a ≥ 20% relative increase in GLS. During a median follow-up of 3.8 years, a global circumferential systolic strain rate (GCSRs) less negative than -1.9% independently predicted lower survival.

CONCLUSION

In patients with severe AS, a reversal in GLS, apical rotation, and peak systolic twist abnormalities towards normal occurs within days of AVR. Baseline GLS is the strongest predictor of GLS recovery but neither was associated with long-term survival. In contrast, abnormal baseline GCSRs are associated with worse outcomes.

Mitral annular plane systolic excursion and global longitudinal strain for the prediction of cardiotoxicity or heart failure in lymphoma patients treated with anthracycline-based chemotherapy

Background

Assessing cardiac performance of patients receiving chemotherapy is a cornerstone for adequate cardiovascular care. Mitral annular plane systolic excursion (MAPSE) has been considered as a surrogate for Ejection Fraction (EF). However, little is known about its role in predicting Cardiotoxicity or Heart Failure in Lymphoma patients, as its relationship with Global Longitudinal Strain (GLS) and EF.

Purpose

Our aims were: i) to evaluate if MAPSE and GLS can predict the development of CT and/or HF in lymphoma patients treated with anthracyclines and ii) to evaluate its correlation with GLS and EF.

Methods

For this prospective observational study, 325 Hodgkin (HL) & non-Hodgkin (NHL) lymphoma patients (n=325) treated with anthracyclines were recruited from 2013 to 2021 and followed for 1 year. MAPSE by M-mode and GLS by Speckle-Tracking (ST) were measured at baseline (T0), during treatment (T1), and up to 1 year after chemotherapy completion (T2). CT was defined as a decrease in EF by &gt;10% to a value &lt;50% and HF by a cardiologist as the first occurrence after the initiation of anthracyclines. Logistic regression analyses with Receiving operator characteristics (ROC) and Area under the curve (AUC) were performed. Pearson's correlation coefficient was also calculated. A p-value &lt;0.05 was considered statistically significant.

Results

Two hundred sixty-four patients (81.2%) had NHL and 61 (18.8%) HL. Of these, fifteen (4.6%) and 21 individuals (6.4%) developed CT at T1 and T2, respectively. Nine subjects (2.8%) developed HF at T1 and 14 (4.3%) at T2. MAPSE at T0 had the highest AUC to predict both HF at T1 (AUC=0.865, cut-off 14.9, sensitivity 100%, specificity 63%, p=0.008) and at T2 (AUC=0.757, cut-off 10.9, sensitivity 67%, specificity 93%, p=0.045). This same variable at T1 predicted HF at T2 with an AUC of 0.752 (cut-off 11.4, sensitivity 67%, specificity 94%, p=0.004). For CT prediction at T2, MAPSE at T1 had an AUC of 0.738 (cut-off 12.5, sensitivity 56%, specificity 85%, p&lt;0.0001). GLS at T0 predicted CT at T1 (AUC=0.657, cut-off −19, sensitivity 67%, specificity 63%, p=0.012) and when obtained at T1, it predicted CT at T2 (AUC=0.776, cut-off −17, sensitivity 74%, specificity 75%, p-value &lt;0.0001) (Table 1). Pearson's correlation between MAPSE and GLS at T0 (coefficient −0.25, p=0.023) at T1 (coefficient −0.38, p&lt;0.0001) at T2 (coefficient −0.037, p&lt;0.0001) and MAPSE with EF at T0 (coefficient 0.33, p=0.0002) at T1 (coefficient 0.28, p&lt;0.0001) and T2 (coefficient 0.29, p&lt;0.001).

Conclusions

To our best knowledge, this is the first time that MAPSE and GLS were compared to predict CT and HF in lymphoma patients receiving anthracycline-based chemotherapy; we have demonstrated that MAPSE measured at T0 was a very good predictor of HF at T1. Either MAPSE or GLS assessment at T0 and T1 were able to predict CT or HF. Future studies could explore the combination of these two variables to predict either CT or HF.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Department of Cardiovascular Medicine. Mayo Clinic, Rochester-MN

Basic or comprehensive strain analyses, which variable is better to predict hard endpoints as clinical heart failure in lymphoma patients receiving anthracyclines

Background

Speckle tracking echocardiography (STE) has shown to be a good tool to foresee early myocardial dysfunction in lymphoma patients who receive anthracycline based chemotherapy. Conventional STE such as global longitudinal strain (GLS) is a good predictor of cardiotoxicity in these patients, however, a more in-depth characterization of conventional and comprehensive STE parameters to predict a hard end-point as chemotherapeutic related heart failure (HF) has not been evaluated.

Purpose

The aim of this prospective study was to evaluate predictability of cancer therapeutic-related clinical HF by conventional and comprehensive STE.

Methods

We enrolled 269 Hodgkin & non-Hodgkin lymphoma patients who underwent chemotherapy at Mayo Clinic from 2013 through 2021. All patients had an echocardiogram performed at baseline (T0), during chemotherapy (T1) and after (T2). HF was diagnosed by a cardiologist and defined as the first occurrence after the initiation of chemotherapy. Conventional (GLS) and comprehensive strain analyses that included: global circumferential strain (GCS), global radial strain (GRS), global longitudinal early diastolic strain rate (GLSRe), global longitudinal systolic strain rate (GLSRs), global circumferential early diastolic strain rate (GCSRe), global circumferential systolic strain rate (GCSRs), global radial early diastolic strain rate (GRSRe), and global radial systolic strain rate (GRSRs), were performed offline. Logistic regression analyses were used to evaluate the association of 2D and 3D STE measurements with the development of clinical HF.

Results

Overall, 215 (79.9%) patients had non-Hodgkin lymphoma while 54 (20.1%) had Hodgkin lymphoma. Mean age was 58.4±16.1 years and 64.7% of the patients were males. The most prevalent comorbidities were hypertension (101/37.5%), dyslipidemia (87/32.3%) and diabetes (28/10.4%). HF occurred in 21 (7.8%) patients, including 9 (3.3%) during chemotherapy and 12 (4.5%) after chemotherapy. The best predictors of HF were: i) GLSRe and GCSRs performed at baseline (T0) to predict HF at T1 with an AUC of 0.85 each and p values of 0.0006 and 0.0005 respectively (Table 1); ii) GCSRs and GCS at baseline (T0) to predict HF at T1 or T2 with AUCs of 0.82 (p, &lt;0.0001) and 0.81 (p, 0.0004), respectively. Basic strain (GLS) was able to predict HF when measured at T0 but not when measured at T1. All the AUCs for GLS were below 0.75 (Figure 1).

Conclusions

To our knowledge this is the first study to evaluate the use of conventional and comprehensive STE to predict a hard end-point as heart failure in patients with lymphoma who received anthracyclines. Comprehensive STE measurements as GLSRs, GLSRe, GCS, GCSRs and GCSRe are better than GLS to predict HF in patients with lymphoma who received anthracycline based chemotherapy. These findings can be crucial for the management of these patients by guiding when to start cardioprotection and/or avoid interruptions of cancer treatment.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Department of cardiovascular diseases, Mayo Clinic, Rochester, MN

Dissecting myocardial mechanics in patients with severe aortic stenosis: 2-dimensional vs 3-dimensional-speckle tracking echocardiography

Background

Aortic stenosis (AS) causes left ventricular (LV) pressure overload, leading to adverse LV remodeling and dysfunction. Identifying early subclinical markers of LV dysfunction in patients with significant AS is critical as this could provide support for earlier intervention, which may result in improved long-term outcomes. We therefore examined the impact of severe AS and its consequent increase in LV afterload on myocardial deformation and rotational mechanics by 2-dimensional (2D) and 3-dimensional (3D) speckle-tracking echocardiography.

Methods

We prospectively measured various strain parameters in 168 patients (42% female, mean age 72 ± 12 years) with severe AS and LV ejection fraction (EF) ≥50%, and compared them to normal values found in literature. 2D and 3D images were analyzed for global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), basal rotation, apical rotation, and peak systolic twist. We further assessed the degree of concordance between 2D and 3D strain, and examined their association with measures of LV preload and afterload.

Results

Patients with severe AS exhibited significantly lower GLS and GRS but higher GCS, apical rotation, and twist by 2D and 3D echocardiography compared with published normal values (P = 0.003 for 3D twist, P < 0.001 for all others). Agreement between 2D- and 3D-GLS by concordance correlation coefficient was 0.49 (95% confidence interval: 0.39–0.57). GLS was correlated with valvulo-arterial impedance, a measure of LV afterload (r = 0.34, p < 0.001 and r = 0.23, p = 0.003, respectively).

Conclusion

Patients with severe AS demonstrated lower-than-normal GLS and GRS but appear to compensate with higher-than-normal GCS, apical rotation, and twist in order to maintain a preserved LVEF. GLS showed a modest correlation with valvulo-arterial impedance.

Peripheral endothelial function changes during HER2-directed therapy differ based on whether or not a patient receives anthracycline

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Background: Trastuzumab is well-demonstrated to be associated with cardiotoxicity (typically reduced ejection fraction), most commonly in patients who also receive anthracycline. The vascular effects of trastuzumab and anthracycline are understudied; we aimed to compare change in endothelial function during and after trastuzumab and to assess how anthracycline receipt affects this. Methods: This is an observational prospective study of women with newly diagnosed HER2-positive breast cancer. All participants underwent baseline evaluation of endothelial function testing by use of the EndoPAT2000 device approximately every three months over the subsequent 18 months after the initiation of HER2-directed therapy +/- anthracycline. The primary endpoint was change in endothelial function over time using the reactive hyperemia index (RHI). Framingham Risk Score (FRS) and lower RHI are both known to be independent predictors of future cardiovascular events in the general population. RHI deterioration was defined as a 20% reduction from baseline RHI to any available follow-up RHI assessment. Univariate analyses assessed if age, FRS, baseline RHI, and RHI deterioration differed between recipients and non-recipients of anthracycline using the Wilcoxon test. A multivariate logistic model evaluated FRS, age, and anthracycline receipt as possible independent predictors of RHI deterioration. Results: Among 38 eligible patients who consented and completed baseline assessments in addition to at least one follow-up assessment, 17 (45%) subsequently received anthracycline. 145 total follow-up RHI assessments were available overall (5 per patient on average). There were no differences between recipients and non-recipients of anthracyclines with regard to age [mean 49 years (SD 12) vs 53 years (SD 11); p=0.25], baseline FRS [mean 1.0 (SD 1.0) vs 1.5 (SD 1.4); p= 0.28] or baseline RHI [mean 2.4 (SD 0.6) vs 2.1 (SD 0.7); p=0.09]. RHI deterioration was more common for anthracycline recipients (mean 43% vs 21%; p=0.004), and in the multivariate model, anthracycline use was the only independent predictor of RHI deterioration (odds ratio: 2.8; 95% confidence interval: 1.35-6.07; p=0.006). Conclusions: This study suggests that endothelial dysfunction is more common after combined anthracycline and HER2-directed therapy than after HER2-directed therapy alone. RHI should be further studied as a possible early biomarker of cardiovascular toxicity in patients receiving treatment for breast cancer.

P674Behavior of 2D and 3D derived ejection fraction and strain in patients with Hodgkin and non-Hodgkin lymphoma undergoing anthracycline-based chemotherapy, a prospective study

Background

Anthracyclines are one of the most effective chemotherapeutic agents but can lead to a decline in cardiac function. Two-dimensional (2D) speckle tracking echocardiography derived strain can predict cancer therapeutics-related cardiac dysfunction (CTRCD). However, little is known about the role of three-dimensional (3D) strain imaging in this setting.

Purpose

To evaluate different methods of Left Ventricular Ejection Fraction (LVEF) and strain, and to identify the best strain parameter for the prediction of CTRCD in this group of patients during treatment with anthracycline based chemotherapy.

Methods

Patients with Hodgkin's or non-Hodgkin's lymphoma receiving anthracycline based chemotherapy were enrolled. 2D-and 3D echocardiography was performed at 3 time points: baseline, at the completion of chemotherapy and at 1 year. 2D- and 3D LVEF (2D Modified Quinones, M-mode, 2D Biplane, 3D Philips, 3D GE and 3D TomTec), peak systolic left and right ventricular longitudinal, radial and circumferential strain and strain rate were measured. CTRCD was defined as a decrease in LVEF >10% to an absolute value of <53%. Lin's Concordance Correlation Coefficient (CCC) was calculated to compare LVEF methods. ANOVA, uni and multivariate analysis was performed.

Results

A total of 130 patients (79 males, mean age 57±16 years) were enrolled; 104 non-Hodgkin.3D Philips and GE (CCC 0.88 [0.84, 0.92]), 3D Philips and biplane (CCC 0.84 [0.79, 0.89]), 3D Philips and Modified Quinones (CCC 0.86 [0.82, 091]) as well as 3D Philips and M-mode (CCC 0.77 [0.70, 0.85]) showed strong correlation for LVEF. 15 patients (12%) developed CTRCD. Mean cumulative anthracycline dose was 263±65 mg/m2. 2D and 3D global longitudinal and circumferential peak systolic strain, 2D global longitudinal systolic and early diastolic strain rate, 2D global early diastolic strain rate, 2D right ventricular longitudinal peak systolic strain and systolic strain rate, 2D global radial peak systolic strain and systolic strain rate measured at the completion of chemotherapy were independent predictors of the development of CTRCD at 1 year post-chemotherapy. The strongest predictors of CTRCD were 3D global longitudinal and circumferential strain either individually (area under the curve, 0.90 and 0.95 respectively) or combined (area under the curve, 0.95) at the completion of chemotherapy; a cutoff value of <-18% in 3D global longitudinal strain had a sensitivity of 82% and specificity of 99%, while for 3D global circumferential peak systolic strain of <-24% had a sensitivity of 82% and specificity of 95%.

Conclusions

To our knowledge this is the first prospective trial that shows that 3D EF correlates well with other EF methods and 3D strain predicts cardiac toxicity in this group of patients with a very good sensitivity and specificity.

Acknowledgement/Funding

Department of Cardiovascular Medicine-Mayo Clinic Rochester MN

Echocardiographic Assessment for the Detection of Cardiotoxicity Due to Vascular Endothelial Growth Factor Inhibitor Therapy in Metastatic Renal Cell and Colorectal Cancers

BACKGROUND

Cardio-oncology is a recently established discipline that focuses on the management of patients with cancer who are at risk for developing cardiovascular complications as a result of their underlying oncologic treatment. In metastatic colorectal cancer (mCRC) and metastatic renal cell carcinoma (mRCC), vascular endothelial growth factor inhibitor (VEGF-i) therapy is commonly used to improve overall survival. Although these novel anticancer drugs may lead to the development of cardiotoxicity, whether early detection of cardiac dysfunction using serial echocardiography could potentially prevent the development of heart failure in this patient population requires further study. The aim of this study was to investigate the role of two-dimensional speckle-tracking echocardiography in the detection of cardiotoxicity due to VEGF-i therapy in patients with mCRC or mRCC.

METHODS

Patients with mRCC or mCRC were evaluated using serial echocardiography at baseline and 1, 3, and 6 months following VEGF-i treatment.

RESULTS

A total of 40 patients (34 men; mean age, 63 ± 9 years) receiving VEGF-i therapy were prospectively recruited at two academic centers: 26 (65%) were receiving sunitinib, eight (20%) pazopanib, and six (15%) bevacizumab. The following observations were made: (1) 8% of patients developed clinically asymptomatic cancer therapeutics-related cardiac dysfunction; (2) 30% of patients developed clinically significant decreases in global longitudinal strain, a marker for early subclinical cardiac dysfunction; (3) baseline abnormalities in global longitudinal strain may identify a subset of patients at higher risk for developing cancer therapeutics-related cardiac dysfunction; and (4) new or worsening hypertension was the most common adverse cardiovascular event, afflicting nearly one third of the study population.

CONCLUSIONS

Cardiac dysfunction defined by serial changes in myocardial strain assessed using two-dimensional speckle-tracking echocardiography occurs in patients undergoing treatment with VEGF-i for mCRC or mRCC, which may provide an opportunity for preventive interventions.

Detection of Carotid Atherosclerotic Plaque Neovascularization Using Contrast Enhanced Ultrasound: A Systematic Review and Meta-Analysis of Diagnostic Accuracy Studies

BACKGROUND

Intraplaque neovascularization is considered an important indicator of plaque vulnerability. Contrast-enhanced ultrasound (CEUS) of carotid arteries improves imaging of carotid intima-media thickness and permits real-time visualization of neovascularization of the atherosclerotic plaque. The authors conducted a systematic review and meta-analysis to evaluate the accuracy of CEUS-detected carotid atherosclerotic plaque.

METHODS

A systematic search was performed to identify studies published in the MEDLINE, Embase, Scopus, and Web of Science databases from 2004 to June 2015. Studies evaluating the accuracy of quantitative analysis and qualitative analysis (visual interpretation) for the diagnosis of intraplaque neovascularization compared with histologic specimens and/or clinical diagnosis of symptomatic plaque were included. Parameters evaluated were plaque quantitative CEUS intensity and the visual grading of plaque CEUS. A random-effects meta-analysis was used to pool the likelihood ratios (LRs), diagnostic odds ratios, and summary receiver operating characteristic curves. Corresponding areas under the curves were calculated.

RESULTS

The literature search identified 203 studies, 20 of which were selected for systematic review; the final meta-analysis included seven studies. For qualitative CEUS, pooled sensitivity was 0.80 (95% CI, 0.72-0.87), pooled specificity was 0.83 (95% CI, 0.76-0.89), the pooled positive LR was 3.22 (95% CI, 1.67-6.18), the pooled negative LR was 0.24 (95% CI, 0.09-0.64), the pooled diagnostic odds ratio was 15.57 (95% CI, 4.94-49.03), and area under the curve was 0.894. For quantitative CEUS, pooled sensitivity was 0.77 (95% CI, 0.71-0.83), pooled specificity was 0.68 (95% CI, 0.62-0.73), the pooled positive LR was 2.34 (95% CI, 1.69-3.23), the pooled negative LR was 0.34 (95% CI, 0.25-0.47), the pooled diagnostic odds ratio was 7.06 (95% CI, 3.6-13.82), and area under the curve was 0.888.

CONCLUSIONS

CEUS is a promising noninvasive diagnostic modality for detecting intraplaque neovascularization. Standardization of quantitative analysis and visual grading classification is needed to increase reliability and reduce technical heterogeneity.

Relationship between glycosylated hemoglobin A1c and coronary flow reserve in patients with Type 2 diabetes mellitus

Type 2 diabetes mellitus patients are at increased risk for macrovascular and microvascular complications. Both in vivo and in vitro studies of small arteries and arterioles of diabetic subjects demonstrate impaired endothelial function without anatomic lesions. Coronary flow reserve (CFR) is a surrogate marker of coronary microcirculatory endothelial function in diabetic patients without significant stenosis of the associated epicardial coronary artery. Glycosylated hemoglobin A1c is related to likelihood of occurrence of microvascular events. The objective of this article is to report on recent developments in multiple noninvasive techniques to assess CFR and their use in aiding the understanding of the relationship of CFR, glycemic control and cardiovascular outcomes.

Relationship between HgbA1c and myocardial blood flow reserve in patients with type 2 diabetes mellitus: noninvasive assessment using real-time myocardial perfusion echocardiography

To study the relationship between glycosylated hemoglobin (HgbA1c) and myocardial perfusion in type 2 diabetes mellitus (T2DM) patients, we prospectively enrolled 24 patients with known or suspected coronary artery disease (CAD) who underwent adenosine stress by real-time myocardial perfusion echocardiography (RTMPE). HgbA1c was measured at time of RTMPE. Microbubble velocity (β min(-1)), myocardial blood flow (MBF, mL/min/g), and myocardial blood flow reserve (MBFR) were quantified. Quantitative MCE analysis was feasible in all patients (272/384 segments, 71%). Those with HgbA1c > 7.1% had significantly lower βreserve and MBFR than those with HgbA1c ≤ 7.1% (P < 0.05). In patients with suspected CAD, there was a significant inverse correlation between MBFR and HgbA1c (r = -0.279, P = 0.01); however, in those with known CAD, this relationship was not significant (r = -0.117, P = 0.129). Using a MBFR cutoff value > 2 as normal, HgbA1c > 7.1% significantly increased the risk for abnormal MBFR, (adjusted odds ratio: 1.92, 95% CI: 1.12-3.35, P = 0.02). Optimal glycemic control is associated with preservation of MBFR as determined by RTMPE, in T2DM patients at risk for CAD.