Cardiotoxicity due to Chemotherapy: the Role of Biomarkers

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

BACKGROUND

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

HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Value of Troponin as a Biomarker of Chemotherapy-Induced Cardiotoxicity

In cancer survivors, cardiac dysfunction is the main cause of mortality. Cardiotoxicity represents a decline in cardiac function associated with cancer therapy, and the risk factors include smoking, dyslipidemia, an age of over 60 years, obesity, and a history of coronary artery disease, diabetes, atrial fibrillation, or heart failure. Troponin is a biomarker that is widely used in the detection of acute coronary syndromes. It has a high specificity, although it is not exclusively associated with myocardial ischemia. The aim of this paper is to summarize published studies and to establish the role of troponin assays in the diagnosis of cardiotoxicity associated with various chemotherapeutic agents. Troponin has been shown to be a significant biomarker in the diagnosis of the cardiac dysfunction associated with several types of chemotherapeutic drugs: anthracyclines, anti-human epidermal growth factor receptor 2 treatment, and anti-vascular endothelial growth factor therapy. Based on the data available at this moment, troponin is useful for baseline risk assessment, the diagnosis of cardiotoxicity, and as a guide for the initiation of cardioprotective treatment. There are currently clear regulations regarding the timing of troponin surveillance depending on the patient’s risk of cardiotoxicity and the type of medication administered, but data on the cut-off values of this biomarker are still under investigation.

Risk Factors for Anthracycline-Induced Cardiotoxicity in Breast Cancer Treatment: A Meta-Analysis

Background

Anthracyclines play an important role in the treatment of breast cancer (BC) and other malignant tumors. However, accompanied side-effects are non-ignorable. The purpose of this meta-analysis is to determine the risk factors for anthracycline-induced cardiotoxicity (ACT), so as to identify high-risk patients.

Methods

The search for literature was conducted in PubMed, The Cochrane Library, Embase and Web of science. Records were selected with inclusion criteria and exclusion criteria. The newcastle-ottawa scale (NOS) was used to assess the quality of literature, and Review Manager 5.3 software was used for meta-analysis.

Results

Thirteen studies met the inclusion criteria. Meta-analysis indicated that risk factors for ACT were use of trastuzumab (odds ratio [OR]: 2.84, 95% confidence interval [CI]: 2.49-3.22, p < 0.00001), cumulative dose of anthracyclines (OR: 1.45, 95%CI: 1.28-1.65, p < 0.00001), hypertension (OR: 2.95, 95%CI: 1.75-4.97, p < 0.0001), diabetes mellitus (DM) (OR: 1.39, 95%CI: 1.20-1.61, p < 0.0001), tumor metastasis (OR: 1.91, 95%CI: 1.17-3.11, p = 0.009) and coronary heart disease (CAD) (OR: 2.17, 95%CI: 1.50-3.15, p < 0.0001). In addition, our analysis revealed that body mass index (BMI) had no effect on ACT (OR: 1.18, 95%CI: 0.98-1.43, p = 0.08).

Conclusions

Patients with high risk for ACT can be identified by these factors. For such patients, a higher level of monitoring and protection for the cardiac function should be performed by clinicians.

Systematic Review Registration

INPLASY, identifier INPLASY202250140.

Heart Failure in Breast Cancer Survivors: Focus on Early Detection and Novel Biomarkers

PURPOSE OF REVIEW

Breast cancer survival rate has greatly improved in the last two decades due to the emergence of next-generation anti-cancer agents. However, cardiotoxicity remains a significant adverse effect arising from traditional and emerging chemotherapies as well as targeted therapies for breast cancer patients. In this review, we will discuss cardiotoxicities of both traditional and emerging therapies for breast cancer. We will discuss current practices to detect cardiotoxicity of these therapies with the focus on new and emerging biomarkers. We will then focus on 'omics approaches, especially the use of epigenetics to discover novel biomarkers and therapeutics to mitigate cardiotoxicity.

RECENT FINDINGS

Significant cardiotoxicities of conventional chemotherapies remain and new and unpredictable new forms of cardiac and/or vascular toxicity emerge with the surge in novel and targeted therapies. Yet, there is no clear guidance on detection of cardiotoxicity, except for significant left ventricular systolic dysfunction, and even then, there is no uniform definition of what constitutes cardiotoxicity. The gold standard for detection of cardiotoxicity involves a serial echocardiography in conjunction with blood-based biomarkers to detect early subclinical cardiac dysfunction. However, the ability of these tests to detect early disease remains limited and not all forms of toxicity are detectable with these modalities. There is an unprecedented need to discover novel biomarkers that are sensitive and specific for early detection of subclinical cardiotoxicity. In that space, novel echocardiographic techniques, such as strain, are becoming more common-place and new biomarkers, discovered by epigenetic approaches, seem to become promising alternatives or adjuncts to conventional non-specific cardiac biomarkers.

Immediate evaluation of global longitudinal strain at initiation of trastuzumab treatment in breast cancer patients

BACKGROUND

Global longitudinal strain (GLS) is recommended to detect subclinical changes preceding reduced left ventricular ejection fraction (LVEF) in trastuzumab related cardiotoxicity. Since the possibility to detect signs of acute myocardial deterioration at treatment initiation is not clarified, the objective of this study was to assess changes in GLS and biomarkers within the first 2 weeks of trastuzumab treatment.

METHODS

In a prospective cohort study, 45 patients with non-metastatic breast cancer (age 54, LVEF 62.8%, GLS -19.9%, 40% hypertension) scheduled for trastuzumab treatment were included. Echocardiography and measurement of troponin and NT-proBrain-Natriuretic-Peptide were conducted before initiation of trastuzumab, at days 3, 7, and 14 and after 3, 6, and 9 months.

RESULTS

A significant deterioration in LVEF from 62.8% (SD±3.6) to 58.4% (SD±4.1) (p < 0.0001), GLS from -19.9 (SD±2.1) to -18.1 (SD±2.5) (p = 0.004), s' (p < 0.0001), e' septal (p = 0.008), and s' RV (p < 0.0001) occurred at 9 months and was preceded by significant changes in these parameters within the first 14 days. After 14 days, 12 patients (27%) had a ≥10% deterioration in GLS, which was associated with significantly lower LVEF at 55.2% (SD±4.1) at 9 months compared to patients with < 10% early deterioration in GLS (LVEF = 59.5% (SD±3.5) (p = 0.001)). No difference in plasma concentrations of biomarkers was observed between the two groups.

CONCLUSION

In this study deteriorations in key echocardiographic parameters within normal limits were detected during the first 2 weeks of trastuzumab treatment, and an early ≥10% deterioration in GLS was associated with a lower LVEF at 9 months.

Mechanisms and Potential Treatment Options of Heart Failure in Patients With Multiple Myeloma

Multiple myeloma is a pathology of plasma cells, with one of the most common side effects of its treatment is heart failure. In addition, cardiac amyloidosis could cause heart failure by itself. Even though mechanisms of cardiac amyloidosis are known, and they involve lysosomal dysfunction, reactive oxygen species (ROS) accumulation, and infiltrative effect by fibrils, there is no specific agent that could protect from these effects. While the molecular mechanism of doxorubicin cardiotoxicity via topoisomerase II β is established, the only FDA-approved agent for treatment is dexrazoxane. Liposomal doxorubicin can potentially improve response and decrease the development of heart failure due to microscopic liposomes that can accumulate and penetrate only tumor vasculature. Supplements that enhance mitochondrial biogenesis are also shown to improve doxorubicin-induced cardiotoxicity. Other agents, such as JR-311, ICRF-193, and ursolic acid, could potentially become new treatment options. Proteasome inhibitors, novel agents, have significantly improved survival rates among multiple myeloma patients. They act on a proteasome system that is highly active in cardiomyocytes and activates various molecular cascades in malignant cells, as well as in the heart, through nuclear factor kappa B (NF-kB), endoplasmic reticulum (ER), calcineurin-nuclear factor of activated T-cells (NFAT), and adenosine monophosphate-activated protein kinase (AMPKa)/autophagy pathways. Metformin, apremilast, and rutin have shown positive results in animal studies and may become a promising therapy as cardioprotective agents. This article aims to highlight the main molecular mechanisms of heart failure among patients with multiple myeloma and potential treatment options to facilitate the development and research of new preventive strategies. Hence, this will have a positive impact on life expectancy in patients with multiple myeloma.

An Overview of Pharmacological and Non-Pharmacological Treatment as a Useful Tool for the Protection from Cardiotoxicity of Antineoplastic Drugs

Unfortunately, in patients with cancer disease, clinical application of antineoplastic drug results in severe side effects of cardiotoxicity.

We aim to review the research focused on elimination or reduction of antineoplastic drug-induced cardiotoxicity without affecting its anticancer efficacy by different agens.

This study is based on pertinent papers that were retrieved by a selective search using relevant keywords in PubMed and ScienceDirect. Based on mentioned purpose, various strategies were investigated and proposed, and thousands of compounds were screened. The literature mainly focusing on drugs, natural products and herb extracts with therapeutic efficacies as well as non-pharmacological treatment against differently induced cardiotoxicity during treatment in patients with cancers.

Larger future studies are necessary to reach a point of secure cytostatic therapy, improved patient survival and quality of life. Until that moment, baseline and serial cardiac evaluation is recommended to facilitate early identification and treatment of cardiotoxicity.

Incidence and Associated Risk Factors of Chemotherapy-Induced Cardiomyopathy in the African American and Afro-Caribbean Populations

BACKGROUND

Chemotherapy-induced cardiomyopathy (CICM) and heart failure are major complications of cancer therapeutics and can result in significant morbidity and mortality. There is limited data on the incidence and risk factors of CICM in African American and Afro-Caribbean patients.

METHODS

We performed a retrospective chart review to evaluate the baseline characteristics that may predispose to CICM. Patients were African American and Afro-Caribbean ethnicity. Data was collected between 2014 to 2018. Patients had transthoracic echocardiogram (TTE) or multigated acquisition scan (MUGA) prior to cancer therapy and every 3 months thereafter, until the end of the regimen. CICM was defined as a ≥16% reduction in LVEF or ≥10% reduction in LVEF to a value <50%.

RESULTS

A total of 230 patients were studied, with a mean age of 54±12 years with 91% were females, BMI 30±4, 81% were taking anthracyclines, 87% were on Trastuzumab while 5% were receiving both medications. The prevalence of comorbidities was as follows: hypertension 8%, diabetes mellitus 8%, ESRD 8%, dyslipidemia 8%, CAD 7%. The incidence of CICM was 7% overall, while it was 6% and 8% for patients taking Anthracyclines and Trastuzumab, respectively. CICM was associated with dyslipidemia (r= .22, p= .001), hypertension (r= .12, p= .05), baseline ejection fraction (r= -.21, p= .001) and concomitant use of radiation therapy (r= .147, p= .02), but not with age, gender, beta blocker use, angiotensin converting enzyme inhibitor use, number of chemotherapy cycles or stage of the malignancy. On multivariate analysis CICM was independently associated with baseline ejection fraction (β= -.193, P= .003) and dyslipidemia (β= -.20, P= .003).

CONCLUSION

The incidence of CICM in African Americans and Afro-Caribbean is higher than reported in the general population. Dyslipidemia and baseline ejection fraction were seen as the major risk factors associated with the higher incidence of CICM.

The prognostic value of the NT-proBNP biomarkers and Fas ligand in assessing the risk of cardiotoxicity of anthracycline chemotherapy

Aim. To study the mechanisms, features of clinical manifestations and predicting of cardiotoxicity resulting from anthracycline chemotherapy.

Material and methods. We examined 176 women with breast cancer who received anthracycline antibiotics as part of polychemotherapeutic (PCT) treatment. Patients were divided into 2 groups: with the development of cardiotoxic remodeling — group 1 (n=52) and with preserved heart function — group 2 (n=124). We conducted echocardiographic (EchoCG) tests before the start, during and after anthracycline chemotherapy. In the serum after the termination of PCT treatment, the concentrations of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and soluble Fas ligand (sFas-L) were determined.

Results. Analysis of EchoCG parameters in patients after 12 months of PCT finish, showed a significant difference in the final systolic and end diastolic sizes, as well as a significant decrease in the left ventricular ejection fraction in group 1 compared with those before the start of treatment. A direct correlation was found between the end-systolic and end-diastolic volumes and inverse correlation between left ventricular ejection fraction and the resulting summary dose of doxorubicin. EchoCG changes in women of group 1 after the first course of PCT treatment were recorded in 49% of cases and 11% of cases — in group 2. The concentrations of sFas-L and NT-proBNP after PCT therapy finish in group 1 were significantly higher compared with group 2. Patients with significantly elevated NT-proBNP levels were had a high risk of heart disease developing during 12 months follow-up. A high concentration of NT-proBNP is a predictor of cardiovascular complications, which is more sensitive than EchoCG.

Conclusion. Fas-associated apoptosis plays an important role in the pathogenesis of anthracycline cardiotoxicity. NT-proBNP may be an important biomarker for cardiotoxicity development, which already effective when EchoCG or clinical signs is absent.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current views on anthracycline cardiotoxicity

Anthracyclines are well established and effective anticancer agents used to treat a variety of adult and pediatric cancers. Unfortunately, these drugs are also among the commonest chemotherapeutic agents that have been recognized to cause cardiotoxicity. In the last years, several experimental and clinical investigations provided new information and perspectives on anthracycline-related cardiotoxicity. In particular, molecular mechanisms of cardiotoxicity have been better elucidated, early diagnosis has improved through the use of advanced noninvasive cardiac imaging techniques, and emerging data indicate a genetic predisposition to develop anthracycline-related cardiotoxicity. In this article, we review established and new knowledge about anthracycline cardiotoxicity, with special focus on recent advances in cardiotoxicity diagnosis and genetic profiling.

Cardiovascular complications of multiple myeloma in the elderly

INTRODUCTION

Multiple myeloma is a malignant neoplasm characterized by plasma cell proliferation in blood and bone marrow. Approximately two-thirds of the patients with multiple myeloma are >65 years at the time of diagnosis. Patients in this age group often have co-existing cardiovascular diseases. Areas covered: The presence of multiple myeloma adds to the malady by direct deposition of amyloid protein in the heart or via toxicity of chemotherapeutic agents. Cardiac contractile dysfunction, arrhythmias and thromboembolic disorders are the main issues in the management of elderly patients with multiple myeloma. Expert commentary: Assessment of cardiac risk and functional status requires careful evaluation by history, physical examination and imaging studies such as echocardiography and magnetic resonance imaging. The management of cardiovascular disorders in the presence of multiple myeloma is difficult and poses a challenge for the internist, the oncologist, and the cardiologist alike. This review is an overview of the problem of cardiovascular risk in and management of elderly patients with multiple myeloma.

Creating a Biomarker Panel for Early Detection of Chemotherapy Related Cardiac Dysfunction in Breast Cancer Patients

Cardiotoxicity is an important issue for breast cancer patients receiving anthracycline-trastuzumab therapy in the adjuvant setting. Studies show that 3-36% of patients receiving anthracyclines and/or trastuzumab experience chemotherapy related cardiac dysfunction (CRCD) and approximately 17% of patients must stop chemotherapy due to the consequences of CRCD. There is currently no standardized, clinically verified way to detect CRCD early, but common practices include serial echocardiography and troponin measurements, which can be timely, costly, and not always available in areas where health care resources are scarce. Furthermore, detection of CRCD, before there is any echocardiographic evidence of dysfunction or clinical symptoms present, would allow maximal benefit of chemotherapy and minimize cardiac complications. Creating a panel of serum biomarkers would allow for more specificity and sensitivity in the early detection of CRCD, which would be easy to implement and cost effective in places with limited health care. Based on a review of the literature, we propose creating a biomarker panel consisting of topoisomerase 2β, serum troponin T/I, myeloperoxidase, NT-proBNP, miR-208b, miR-34a, and miR-150 in breast cancer patients receiving anthracyclines and/or trastuzumab to detect CRCD before any signs of overt cardiotoxicity are apparent.

Cardiotoxicity of anticancer treatments: Epidemiology, detection, and management

Answer questions and earn CME/CNE Cancer and heart disease are the leading causes of morbidity and mortality in the industrialized world. Modern treatment strategies have led to an improvement in the chances of surviving a diagnosis of cancer; however, these gains can come at a cost. Patients may experience adverse cardiovascular events related to their cancer treatment or as a result of an exacerbation of underlying cardiovascular disease. With longer periods of survival, late effects of cancer treatment may become clinically evident years or decades after completion of therapy. Current cancer therapy incorporates multiple agents whose deleterious cardiac effects may be additive or synergistic. Cardiac dysfunction may result from agents that can result in myocyte destruction, such as with anthracycline use, or from agents that appear to transiently affect left ventricular contractility. In addition, cancer treatment may be associated with other cardiac events, such as severe treatment-induced hypertension and vasospastic and thromboembolic ischemia, as well as rhythm disturbances, including QTc prolongation, that may be rarely life-threatening. Early and late effects of chest radiation can lead to radiation-induced heart disease, including pericardial disease, myocardial fibrosis, cardiomyopathy, coronary artery disease, valvular disease, and arrhythmias, in the setting of myocardial fibrosis. The discipline of cardio-oncology has developed in response to the combined decision making necessary to optimize the care of cancer patients, whether they are receiving active treatment or are long-term survivors. Strategies to prevent or mitigate cardiovascular damage from cancer treatment are needed to provide the best cancer care. This review will focus on the common cardiovascular issues that may arise during or after cancer therapy, the detection and monitoring of cardiovascular injury, and the best management principles to protect against or minimize cardiotoxicity during the spectrum of cancer treatment strategies. CA Cancer J Clin 2016;66:309-325. © 2016 American Cancer Society.

Bortezomib-Induced Complete Heart Block and Myocardial Scar: The Potential Role of Cardiac Biomarkers in Monitoring Cardiotoxicity

Bortezomib is a proteasome inhibitor used to treat multiple myeloma and mantle cell lymphoma. Traditionally, bortezomib was thought to have little cardiovascular toxicity; however, there is increasing evidence that bortezomib can lead to cardiac complications including left ventricular dysfunction and atrioventricular block. We present the case of a 66-year-old man with multiple myeloma and persistent asymptomatic elevations of cardiac biomarkers who developed complete heart block and evidence of myocardial scar after his eighth cycle of bortezomib, requiring permanent pacemaker placement. In addition to discussing the cardiovascular complications of bortezomib therapy, we propose a potential role for biomarkers in the prediction and monitoring of bortezomib cardiotoxicity.

S100A1 as a Potential Diagnostic Biomarker for Assessing Cardiotoxicity and Implications for the Chemotherapy of Certain Cancers

This study examined the value of blood marker S100A1 in detecting cardiotoxicity induced by chemotherapy agents; trastuzumab and lapatinib, in normal rat heart. The rats were divided into three groups: control (n = 8, no treatment), T (n = 8, one time ip treatment with 10 mg/kg trastuzumab) and L (n = 8, oral treatment with 100 mg/kg/day lapatinib for 7 days). The activities of oxidative stress parameters Malondialdehyde (MDA), Superoxide dismutase (SOD), Catalase (CAT) and Glutathione (GSH) were measured from the extracted cardiac tissues. The levels of troponinI and S100A1 expressions were measured from blood samples. All biomarkers responded to the treatments as they exhibited alterations from their normative values, validating the chemically induced cardiotoxicity. S100A1 expression attenuated significantly (75%), which made the sensitive detection of cardiotoxicity feasible. Assessment of cardiotoxicity with S100A1 may be a valuable alternative in clinical oncology of cancers in some organs such as breast and prostate, as they do not overexpress it to compete against.

Serum biomarkers evaluation to predict chemotherapy-induced cardiotoxicity in breast cancer patients

Anti-neoplastic chemotherapy can determine various side effects, including cardiotoxicity, and no real guidelines for its early detection and management have been developed. The aim of this study is to find some plasmatic markers able to identify breast cancer patients that are at greater risk of developing cardiovascular complications during chemotherapy, in particular heart failure. A prospective study on 100 breast cancer patients with mean age of 66 years in adjuvant treatment with anthracyclines, taxanes, and trastuzumab was performed. Patients underwent cardiological examination before starting treatment (T0) and at 3 months (T1), 6 months (T2), and 1 year (T3) after treatment. Evaluation of serum cardiac markers and N-terminal pro-brain natriuretic peptide (NT-proBNP) was performed at T0, T1, T2, and T3, simultaneously to electrocardiogram and echocardiogram, showing a significant increase in NT-proBNP concentration (p > 0.0001) at T1, T2, and T3, before left ventricular ejection fraction decrease became evident. Human epidermal growth factor receptor 2 (HER2)-negative patients were more susceptible to mild hematological cardiotoxicity, while HER2-positive patients were more susceptible to severe cardiotoxicity. A significant correlation between NT-proBNP increased values after chemotherapy and prediction of mortality at 1 year was evidenced. From our experience, serum biomarker detection was able to support an early diagnosis of cardiac damage, also in the absence of left ventricular ejection fraction decrease. Therefore, the evaluation of specific plasmatic markers for cardiac damage is more sensitive than echocardiography in the early diagnosis of chemotherapy-related cardiotoxicity; furthermore, it can also add a prognostic value on outcome.