Prevention of Chemotherapy Induced Cardiomyopathy

Chemotherapy-Induced Cardiomyopathy: A Focus on the Utility of Statins

Chemotherapy-induced cardiomyopathy (CICM) is a critical adverse consequence associated with chemotherapeutic treatments such as anthracyclines, taxanes, and alkylating agents. Cardiac dysfunction, characterized by left ventricular systolic dysfunction, is the primary effect found in these patients. This may result in heart failure, with heart failure related to chemotherapy resulting in a 3.5-fold increased risk of mortality compared with idiopathic cardiomyopathy alone. Multiple factors, including oxidative stress, inflammation, and disruption of key cellular pathways, are involved in cardiomyocyte damage and influence CICM pathophysiology. So far, dexrazoxane is the sole FDA-approved preventive therapy, but alternative interventions, such as beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and statins, have been studied for their cardioprotective potential. Statins, beyond their cholesterol-lowering capabilities, stand out for their pleiotropic effects, including antioxidant, anti-inflammatory, and endothelial-protective actions, which counteract inflammatory effects. Multiple studies and meta-analyses suggest that statin therapy may decrease both the incidence and severity of chemotherapy-related cardiotoxicity (CTX), as evidenced by smaller declines in left ventricular ejection fraction and lower rates of heart failure in statin-treated patients. However, not all investigations confirm these protective benefits; for instance, some trials, including SPARE-HF, reported no significant differences in cardiac outcomes. While these conflicting findings underscore the need for larger randomized trials, they also reflect the heterogeneity of cancer types, chemotherapy regimens, and patient profiles. Statins show promise as a cardioprotective strategy for individuals at risk of CICM. Enhancing patient selection and specifying the timing and duration of statin therapy are essential steps for incorporating these agents into standard care. Optimizing these parameters may reduce chemotherapy-related cardiac damage, improve long-term cardiac function, and enhance overall survival in cancer survivors.

Sacubitril-valsartan in Cancer therapy-induced heart failure: A systematic review and meta-analysis of functional and hemodynamic parameters

BACKGROUND

Cancer therapy-induced cardiotoxicity (CTRCD), in the form of heart failure with reduced ejection fraction (HFrEF), is being increasingly recognized. However, the potential benefits of sacubitril/valsartan (S/V) in managing HFrEF secondary to CTRCD remain unclear.

OBJECTIVE

We performed a systematic review and meta-analysis to assess the effectiveness of S/V in preventing cardiotoxicity.

METHODS

We searched PubMed, Embase, and Cochrane databases for studies evaluating S/V in patients with HFrEF due to CTRCD and reporting the following outcomes: (1) NYHA class; (2) NT-ProBNP and (3) echocardiographic measurements, specifically left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and E/e' ratio. Statistical analyses were performed using RStudio software. Heterogeneity was assessed using I² statistics.

RESULTS

We included 257 patients from six studies. All patients received S/V. The mean patient age was 63 ± 8 years, and 85 % of patients had breast cancer. The mean LVEF was 34±7 % at baseline. S/V significantly improved NYHA class compared to baseline (MD -0.7; 95 % CI -1.2 to -0.3; p < 0.01), NT-proBNP (MD -985.1 pg/mL; 95 % CI -1231.3 to -739.1; p < 0.01), GLS (MD -2.5 %; 95 % CI -3.6 to -1.4; p < 0.01;), and E/e' (MD -1.99; 95 % CI 3.7 to -0.1; p = 0.03). LVEF (MD 7.3 %; 95 % CI 5.4 to 9.2; p < 0.01) with S/V treatment relative to baseline.

CONCLUSION

In patients with HFrEF due to CTRCD, S/V significantly improved the clinical and echocardiographic parameters of left ventricular systolic and diastolic functions.

Anthracycline-Induced Cardiomyopathy: Prevalence and Risk Factors Among Pediatric Cancer Patients in a Tertiary Care Center in Jeddah, Saudi Arabia

Chemotherapy-induced cardiomyopathy (CCMP) is one of the well-defined toxicities associated with chemotherapy use that can lead to serious side effects. An example of a chemotherapeutic drug class that has been well documented over the years to cause CCMP is anthracyclines. To date, few studies have been carried out in Saudi Arabia on the prevalence of CCMP and the associated risk factors. Therefore, the objective of our research is to measure the prevalence and determine the risk factors of such phenomena. This is a comparative cross-sectional study. Data from 114 patients was retrieved from the medical records of the cardiac department at Princess Noorah Oncology Center, King Abdulaziz Medical City. The research included pediatric oncology patients aged 14 or under who were treated with anthracyclines from June 2016 to May 2024. We excluded patients who did not undergo ECHO. A consecutive sampling technique was used to collect the patients. Over the eight-year study period, we found that 7.34% (8/109) of the cohort developed CCMP, with a mean age at diagnosis of 6.39 ± 3.81 years. The mean dose of anthracycline received until the diagnosis of CCMP was 194.77±145.92 mg, with a median interval between anthracycline initiation and CCMP diagnosis of 13.65 (3-89) weeks. A significant association was found between thromboembolism, PDA, type of cancer, and the development of CCMP. We found that traditional predictors such as gender, age at diagnosis, and cumulative anthracycline dose were not predictors of CCMP.

Computer-Assisted Algorithm for Quantification of Fibrosis by Native Cardiac CT: A Pilot Study

Background/Objectives: Recent advances in artificial intelligence, particularly in cardiac imaging, can potentially enhance patients' diagnosis and prognosis and identify novel imaging markers. We propose an automated, computer-aided algorithm utilizing native cardiac computed tomography (CT) imaging to identify myocardial fibrosis. This study aims to evaluate its performance compared to CMR markers of fibrosis in a cohort of patients diagnosed with breast cancer. Methods: The study included patients diagnosed with early HER2+ breast cancer, who presented LV dysfunction (LVEF < 50%) and myocardial fibrosis detected on CMR at the time of diagnosis. The patients were also evaluated by cardiac CT, and the extracted images were processed for the implementation of the automatic, computer-assisted algorithm, which marked as fibrosis every pixel that fell within the range of 60-90 HU. The percentage of pixels with fibrosis was subsequently compared with CMR parameters. Results: A total of eight patients (n = 8) were included in the study. High positive correlations between the algorithm's result and the ECV fraction (r = 0.59, p = 0.126) and native T1 (r = 0.6, p = 0.112) were observed, and a very high positive correlation with LGE of the LV(g) and the LV-LGE/LV mass percentage (r = 0.77, p = 0.025; r = 0.81, p = 0.015). A very high negative correlation was found with GLS (r = -0.77, p = 0.026). The algorithm presented an intraclass correlation coefficient of 1 (95% CI 0.99-1), p < 0.001. Conclusions: The present pilot study proposes a novel promising imaging marker for myocardial fibrosis, generated by an automatic algorithm based on native cardiac CT images.

Smoking, Diabetes Mellitus, and Previous Cardiovascular Disease as Predictors of Anticancer Treatment-Induced Cardiotoxicity in Non-Small-Cell Lung Cancer: A Real-World Study

PURPOSE

Cardiotoxicity is a common and under-reported side effect of tyrosine-kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI). Baseline risk factors may help in risk-stratifying patients at increased risk of cardiotoxicity. This real-world study investigated the effects of baseline risk factors in cardiotoxicity on patients with non-small-cell lung cancer (NSCLC) treated with TKIs and ICIs.

METHODS

This is a retrospective study carried out at The Royal Marsden Hospital, UK. Newly diagnosed patients with localized or metastatic NSCLC who received anticancer therapy with TKIs and/or ICIs were eligible. Patients who received only chemotherapy were excluded. Patients were followed up from the time of diagnosis until death or discharge. The relationship between cardiotoxicity and risk factors were tested by logistic regression.

RESULTS

Of 88/451 (19.5%) patients developed cardiotoxicity. Risk factors hypothesized to have a causal relationship with anticancer treatment-induced cardiotoxicity were analyzed. Cardiotoxicity risk was increased with prior diabetes mellitus (OR = 1.93, 95% CI, 1.04-3.61, P = .038), history of smoking (OR = 1.91, 95% CI, 1.13-3.22, P = .016) and presence of baseline cardiovascular disease (OR = 2.03, 95% CI, 1.13-3.64, P = .018). The risk of developing cardiotoxicity increased in patients for smokers with diabetes mellitus (OR = 3.03, 95% CI, 1.40-6.55, P < .01) and for smokers with previous cardiovascular disease (OR = 1.99, 95% CI, 1.03-3.84, P = .041).

CONCLUSION

Diabetes mellitus, smoking and baseline cardiovascular disease may synergistically contribute to cardiotoxicity when a patient is exposed to potentially cardiotoxic anticancer agents. Risk stratification at baseline may improve cardio-oncology care.

Exploring the potential molecular mechanism of trastuzumab-induced cardiotoxicity based on RNA sequencing and bioinformatics analysis

The cardiotoxicity of trastuzumab (TRZ) seriously affects the prognosis of breast cancer patients, but the underlying mechanisms remains to be elucidated. This study aimed to investigate the potential molecular mechanisms of TRZ-induced cardiotoxicity based on RNA sequencing (RNA-Seq) and bioinformatics analysis. Kunming mice were exposed to 10 mg/kg TRZ for 6 and 10 days, followed by echocardiography, histopathology and serum biochemical analysis to evaluate the cardiotoxicity model. The results showed no significant changes after 6 days administration of TRZ. After 10 days administration of TRZ, the mice showed cardiac dysfunction, myocardial injury and fibrosis, and the serum levels of LDH, CK, CK-MB and cTnI were increased compared to the control [CON (Day 10)] group, indicating the cardiotoxicity model was successfully established. We compared gene expression levels in mice cardiac tissues by RNA-Seq and screened out 593 differentially expressed genes (DEGs). Results based on Gene Ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, protein-protein interaction (PPI) network analysis and RT-PCR revealed that the CD74/STAT1 signaling pathway might play an important role in TRZ-induced cardiotoxicity. In the TRZ group, the protein expressions of CD74, p-STAT1 (Tyr) and p-STAT1 (Ser) were increased. The TUNEL staining showed increased apoptosis of cardiomyocytes. In addition, an increased expressions of Bax, Caspase-3, IFN-γ and TNF-α and a decreased expression of Bcl-2 were observed in Western blot results, indicating the apoptosis and inflammation levels were increased. These findings suggested that TRZ may induce cardiotoxicity in mice by activating the CD74/STAT1 signaling pathway, which might be related to the induction of apoptosis and inflammation.

Effects of Traditional Chinese Medicine Injections for Anthracyclines-induced Cardiotoxicity: An Overview of Systematic Reviews and Meta-Analyses

INTRODUCTION

Traditional Chinese medicine (TCM) injections, as a relatively safe and low-cost treatment, have been widely used in the prevention and treatment of anthracyclines-induced cardiotoxicity in China. However, the quality of the relevant systematic reviews and meta-analyses published in recent years is uneven, so that the effectiveness and safety of TCM injections in preventing and treating anthracyclines-induced cardiotoxicity remain to be discussed. A systematic overview is therefore needed to provide a more advanced evidentiary reference for clinical practice.

METHODS

Eight Chinese and English databases were searched by computer to screen the meta-analyses/systematic reviews on the efficacy of traditional Chinese medicine injections for the prevention and treatment of anthracyclines-induced cardiotoxicity from the database establishment to October 2022. The methodological quality and evidence quality of outcome indicators included in the study were evaluated by AMSTAR 2 tool, PRISMA statement and GRADE classification.

RESULTS

A total of 7 articles were included in the study. The quality evaluation of AMSTAR 2 showed that 7 studies were extremely low-level; PRISMA stated that the evaluation results showed that the reports of 7 studies were of intermediate quality; The GRADE rating indicated that most of the evidence was of low quality.

CONCLUSION

The methodological quality and evidence quality of meta-analysis/system evaluation concerning the prevention and treatment of anthracyclines-induced cardiotoxicity by Chinese medicine are currently low, and the effectiveness of Chinese medicine in the treatment of anthracyclines-induced cardiotoxicity needs more high-quality evidence-based evidence.

Clinical characterization and natural history of chemotherapy-induced dilated cardiomyopathy

AIMS

Chemotherapy-induced dilated cardiomyopathy (CI-DCM) is a well-recognized phenotype of non-ischemic dilated cardiomyopathy (DCM), characterized by poor outcomes. However, a detailed comparison between idiopathic DCM (iDCM) and CI-DCM is still lacking.

METHODS AND RESULTS

All consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry were analysed. CI-DCM and iDCM were defined according to current recommendations. The primary study outcome measure was all-mortality death and secondary outcomes were a) a composite of cardiovascular death/heart-transplantation/ventricular-assist-device implantation, and b) major ventricular arrhythmias. The study included 551 patients (499 iDCM and 52 CI-DCM). At enrolment, compared with iDCM, CI-DCM patients were older (51 ± 14 years vs. 58 ± 3 years, respectively, P < 0.001) and had a higher left ventricular ejection fraction (32% ± 9 vs. 35% ± 10, respectively, P = 0.03). Over a median follow-up of 90 months (IQR 54-140 months), CI-DCM patients had a higher incidence of all-cause mortality compared with iDCM (36.5% vs. 8.4% in CI-DCM and iDCM respectively, P < 0.001), while the incidence of major ventricular arrhythmias was higher in the iDCM group compared with CI-DCM (4% vs. 0%, in CI-DCM and iDCM respectively, P = 0.03). The risk of the composite outcome was comparable between the two groups (P = 0.91). At Cox multivariable analysis, the diagnosis of CI-DCM emerged as independently associated to primary outcome (HR 6.42, 95% C.I. 2.52-16.31, P < 0.001).

CONCLUSIONS

In a well-selected DCM cohort, patients with a chemotherapy-induced aetiology had a higher incidence of all-cause mortality compared with iDCM. Conversely, the incidence of life-threatening ventricular arrhythmic events was higher among patients with iDCM.

Rational, Design and Preliminary Results of a Cohort Study on Breast and Colorectal Cancer to Develop a Risk Assessment Model to Predict Future Cardiovascular Events. "Cardio Vascular Events in Breast and Colorectal Cancers (CIBC) Study"

Breast cancer (BC) and colorectal cancer (CRC) are among the most common cancers in Iran. We aimed to develop a risk assessment model to predict the development of cardiovascular events in these patients by performing a 5 year prospective cohort study on a newly diagnosed patients with BC or CRC before they receive any treatment. A multi-center prospective cohort study of 2700 newly diagnosed BC and CRC patients has been started in Iran since 2019 and will be continued until 2024. Demographics, socioeconomic status, life style behaviors, psychological characteristics and type of cancer treatments will be collected by standard questionnaires and blood pressure, obesity indices will be measured. Blood sampling, ECG, and echocardiography will be done in all patients at base line, 6 and 12 months, then at annual basis for five years. Incidence of heart failure, acute coronary syndrome, stroke and CVD related death are the primary outcome of this study. In this preliminary analysis, 70 patients with BC and 30 patients with CRC were enrolled in this study from April 2019 to November 2019. Mean age of BC and CRC patients was 48 ± 10.5 and 61 ± 13.2 respectively. 98.6% of patients in BC group and 60% of CRC groups were female. This study will be a platform for other cancers to develop CVD risk assessment charts that can cover other cancers. Patients who lie in the high risk category according to the newly developed risk assessment chart, should receive special management and preventive interventions.

Synthesis, Molecular Docking, and Preclinical Evaluation of a New Succinimide Derivative for Cardioprotective, Hepatoprotective and Lipid-Lowering Effects

Cardiac and hepatotoxicities are major concerns in the development of new drugs. Better alternatives to other treatments are being sought to protect these vital organs from the toxicities of these pharmaceuticals. In this regard, a preclinical study is designed to investigate the histopathological effects of a new succinimide derivative (Comp-1) on myocardial and liver tissues, and the biochemical effects on selected cardiac biomarkers, hepatic enzymes, and lipid profiles. For this, an initially lethal/toxic dose was determined, followed by a grouping of selected albino rats into five groups (each group had n = 6). The control group received daily oral saline for 8 days. The 5-FU (5-Fluorouracil) group received oral saline daily for 8 days, added with the administration of a single dose of 5-FU (150 mg/kg I.P.) on day 5 of the study. The atenolol group received oral atenolol (20 mg/kg) for 8 days and 5-FU (150 mg/kg I.P.) on day 5 of the protocol. Similarly, two groups of rats treated with test compound (Comp-1) were administered with 5 mg/kg I.P. and 10 mg/kg I.P. for 8 days, followed by 5-FU (150 mg/kg I.P.) on day 5. Toxicity induced by 5-FU was manifested by increases in the serum creatinine kinase myocardial band (CK-MB), troponin I (cTnI) and lactate dehydrogenase (LDH), lipid profile, and selected liver enzymes, including ALP (alkaline phosphatase), ALT (alanine transaminase), AST (aspartate aminotransferase), BT (bilirubin total), and BD (direct bilirubin). These biomarkers were highly significantly decreased after the administration of the mentioned doses of the test compound (5 mg/kg and 10 mg/kg). Similarly, histological examination revealed cardiac and hepatic tissue toxicity by 5-FU. However, those toxic effects were also significantly recovered/improved after the administration of Comp-1 at the said doses. This derivative showed dose-dependent effects and was most effective at a dose of 10 mg/kg body weight. Binding energy data computed via docking simulations revealed that our compound interacts toward the human beta2-adrenergic G protein-coupled receptor (S = −7.89 kcal/mol) with a slight stronger affinity than the calcium channel T-type (S = −7.07 kcal/mol). In conclusion, the histological and biochemical results showed that the test compound (Comp-1) had prominent cardioprotective, hepatoprotective, and lipolytic effects against 5-FU-induced toxicity in the subjected animal model.

Cardiac complications of cancer therapies

The quest of defeating cancer and improving prognosis in survivors has generated remarkable strides forward in research and have advanced the development of new antineoplastic therapies. These achievements, combined with rapid screening and early detection, have considerably extended the life expectancy of patients surviving multiple types of malignancies. Consequently, chemotherapy-related toxicity in several organ systems, especially the cardiovascular system, has surfaced as one of the leading causes of morbidity and mortality among cancer survivors. Recent evidence classifies chemotherapy-induced cardiotoxicity as the second-leading cause of morbidity and mortality, closely comparing with secondary cancer malignancies. While a certain degree of cardiotoxicity has been reported to accompany most chemotherapies, including anthracyclines, anti-metabolites, and alkylating agents, even the latest targeted cancer therapies such as immune checkpoint inhibitors and tyrosine kinase inhibitors have been associated with acute and chronic cardiac sequelae. In this chapter, we focus on describing the principal mechanism(s) for each class of chemotherapeutic agents that lead to cardiotoxicity and the innovative translational research approaches that are currently being explored to prevent or treat cancer therapy-induced cardiotoxicity and related cardiac complications.

Endoplasmic Reticulum Stress in Chemotherapy-Induced Peripheral Neuropathy: Emerging Role of Phytochemicals

Chemotherapy-induced peripheral neuropathy (CIPN) is a significant dose-limiting long-term sequela in cancer patients undergoing treatment, often leading to discontinuation of treatment. No established therapy exists to prevent and/or ameliorate CIPN. Reactive oxygen species (ROS) and mitochondrial dysregulation have been proposed to underlie the pathobiology of CIPN. However, interventions to prevent and treat CIPN are largely ineffective. Additional factors and mechanism-based targets need to be identified to develop novel strategies to target CIPN. The role of oxidative stress appears to be central, but the contribution of endoplasmic reticulum (ER) stress remains under-examined in the pathobiology of CIPN. This review describes the significance of ER stress and its contribution to CIPN, the protective role of herbal agents in countering ER stress in nervous system-associated disorders, and their possible repurposing for preventing CIPN.

Atrial fibrillation in older adults with cancer

Cancer and atrial fibrillation (AF) are common co-morbid conditions in older adults. Both cancer and cancer treatment increase the risk of developing new AF which increases morbidity and mortality. Heart rate and rhythm control along with anticoagulation therapy remain the mainstay of treatment of AF in older adults with both cancer and AF. Adjustments to the treatment may be necessary because of drug interactions with concurrent chemotherapy. Cancer and old age increase the risk of both, thromboembolism and bleeding. The risk of these complications is further enhanced by concomitant cancer therapy, frailty, poor nutrition status and, coexisting geriatric syndromes. Therefore, careful attention needs to be given to the risks and benefits of using anticoagulant medications. This review focuses on the management of AF in older patients with cancer, including at the end-of-life care.

Evaluating anthracycline + taxane versus taxane-based chemotherapy in older women with node-negative triple-negative breast cancer: a SEER-Medicare study

Purpose

Adjuvant chemotherapy reduces recurrence in early-stage triple-negative breast cancer (TNBC). However, data are lacking evaluating anthracycline + taxane (ATAX) versus taxane-based (TAX) chemotherapy in older women with node-negative TNBC, as they are often excluded from trials. The purpose of this study was to evaluate the effect of adjuvant ATAX versus TAX on cancer-specific (CSS) and overall survival (OS) in older patients with node-negative TNBC.

Patients and methods

Using the SEER-Medicare database, we selected patients aged ≥ 66 years diagnosed with Stage T1-4N0M0 TNBC between 2010 and 2015 (N = 3348). Kaplan–Meier survival curves and adjusted Cox proportional hazards models were used to estimate 3-year OS and CSS. Multivariant Cox regression analysis was used to identify independent factors associated with use of ATAX compared to TAX.

Results

Approximately half (N = 1679) of patients identified received chemotherapy and of these, 58.6% (N = 984) received TAX, 25.0% (N = 420) received ATAX, and 16.4% (N = 275) received another regimen. Three-year CSS and OS was improved with any adjuvant chemotherapy from 88.9 to 92.2% (p = 0.0018) for CSS and 77.2% to 88.6% for OS (p < 0.0001). In contrast, treatment with ATAX compared to TAX was associated with inferior 3-year CSS and OS. Three-year CSS was 93.7% with TAX compared to 89.8% (p = 0.048) for ATAX and OS was 91.0% for TAX and 86.4% for ATAX (p = 0.032).

Conclusion

While adjuvant chemotherapy was associated with improved clinical outcomes, the administration of ATAX compared to TAX was associated with inferior 3-year OS and CSS in older women with node-negative TNBC. The use of adjuvant ATAX should be considered carefully in this patient population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06424-z.

Anticancer Drug-Induced Cardiotoxicity: Insights and Pharmacogenetics

The advancement in therapy has provided a dramatic improvement in the rate of recovery among cancer patients. However, this improved survival is also associated with enhanced risks for cardiovascular manifestations, including hypertension, arrhythmias, and heart failure. The cardiotoxicity induced by chemotherapy is a life-threatening consequence that restricts the use of several chemotherapy drugs in clinical practice. This article addresses the prevalence of cardiotoxicity mediated by commonly used chemotherapeutic and immunotherapeutic agents. The role of susceptible genes and radiation therapy in the occurrence of cardiotoxicity is also reviewed. This review also emphasizes the protective role of antioxidants and future perspectives in anticancer drug-induced cardiotoxicities.

Statin Use Can Attenuate the Decline in Left Ventricular Ejection Fraction and the Incidence of Cardiomyopathy in Cardiotoxic Chemotherapy Recipients: A Systematic Review and Meta-Analysis

There is insufficient evidence about the cardioprotective effects of statins against chemotherapy-induced cardiomyopathy. The MEDLINE and EMBASE databases were searched from inception to March 2021 for studies that reported the mean left ventricular ejection fraction (LVEF) before and after chemotherapy and the incidence of chemotherapy-induced cardiotoxicity in patients who received concurrent statin therapy and those who received chemotherapy alone. A random effects meta-analysis was performed to obtain the pooled weighted mean difference (WMD) and the 95% confidence interval (CI) for the mean final LVEF and the mean LVEF change, and the pooled odds ratio (OR) and the 95% CI of the incidence of chemotherapy-induced cardiomyopathy. Seven studies with 3042 patients were included in this meta-analysis (statin group: 1382 patients received concurrent statin with chemotherapy; control group: 1660 patients received chemotherapy alone). Patients in the control group had a more significant decline in LVEF (WMD = −6.08%, 95% CI: −8.55 to −3.61, p < 0.001) compared to those in the statin group. Additionally, the statin group had a significantly lower incidence of chemotherapy-induced cardiomyopathy compared to the control group (OR = 0.41, 95% CI = 0.28–0.60, p < 0.001). Consequently, our study showed a significant reduction in the incidence of chemotherapy-induced cardiomyopathy and the degree of LVEF decline in patients in the statin group compared to those in the control group.

Life after Cell Death-Survival and Survivorship Following Chemotherapy

Simple Summary

Treatment of aggressive cancers often relies on chemotherapy. This treatment has improved survival rates, but while effective at killing cancer cells, inevitably it also kills or alters the function of others. While many of the known effects are transient and resolve after treatment, as survival rates increase, so does our understanding of the long-term health costs that accompany cancer survivors. Here we provide an overview of common long-term morbidities known to be caused by conventional chemotherapy, including the risk of relapse, but more importantly, the cost of quality of life experienced, especially by those who have cancer in early life. We aim to highlight the importance of the development of targeted therapies to replace the use of conventional chemotherapy, but also that of treating the patients along with the disease to enable not only longer but also healthier life after cancer.

Abstract

To prevent cancer cells replacing and outnumbering their functional somatic counterparts, the most effective solution is their removal. Classical treatments rely on surgical excision, chemical or physical damage to the cancer cells by conventional interventions such as chemo- and radiotherapy, to eliminate or reduce tumour burden. Cancer treatment has in the last two decades seen the advent of increasingly sophisticated therapeutic regimens aimed at selectively targeting cancer cells whilst sparing the remaining cells from severe loss of viability or function. These include small molecule inhibitors, monoclonal antibodies and a myriad of compounds that affect metabolism, angiogenesis or immunotherapy. Our increased knowledge of specific cancer types, stratified diagnoses, genetic and molecular profiling, and more refined treatment practices have improved overall survival in a significant number of patients. Increased survival, however, has also increased the incidence of associated challenges of chemotherapy-induced morbidity, with some pathologies developing several years after termination of treatment. Long-term care of cancer survivors must therefore become a focus in itself, such that along with prolonging life expectancy, treatments allow for improved quality of life.

Modeling Precision Cardio-Oncology: Using Human-Induced Pluripotent Stem Cells for Risk Stratification and Prevention

Purpose of Review

Cardiovascular toxicity is a leading cause of mortality among cancer survivors and has become increasingly prevalent due to improved cancer survival rates. In this review, we synthesize evidence illustrating how common cancer therapeutic agents, such as anthracyclines, human epidermal growth factors receptors (HER2) monoclonal antibodies, and tyrosine kinase inhibitors (TKIs), have been evaluated in cardiomyocytes (CMs) derived from human-induced pluripotent stem cells (hiPSCs) to understand the underlying mechanisms of cardiovascular toxicity. We place this in the context of precision cardio-oncology, an emerging concept for personalizing the prevention and management of cardiovascular toxicities from cancer therapies, accounting for each individual patient’s unique factors. We outline steps that will need to be addressed by multidisciplinary teams of cardiologists and oncologists in partnership with regulators to implement future applications of hiPSCs in precision cardio-oncology.

Recent Findings

Current prevention of cardiovascular toxicity involves routine screenings and management of modifiable risk factors for cancer patients, as well as the initiation of cardioprotective medications. Despite recent advancements in precision cardio-oncology, knowledge gaps remain and limit our ability to appropriately predict with precision which patients will develop cardiovascular toxicity. Investigations using patient-specific CMs facilitate pharmacological discovery, mechanistic toxicity studies, and the identification of cardioprotective pathways. Studies with hiPSCs demonstrate that patients with comorbidities have more frequent adverse responses, compared to their counterparts without cardiac disease. Further studies utilizing hiPSC modeling should be considered, to evaluate the impact and mitigation of known cardiovascular risk factors, including blood pressure, body mass index (BMI), smoking status, diabetes, and physical activity in their role in cardiovascular toxicity after cancer therapy. Future real-world applications will depend on understanding the current use of hiPSC modeling in order for oncologists and cardiologists together to inform their potential to improve our clinical collaborative practice in cardio-oncology.

Summary

When applying such in vitro characterization, it is hypothesized that a safety score can be assigned to each individual to determine who has a greater probability of developing cardiovascular toxicity. Using hiPSCs to create personalized models and ultimately evaluate the cardiovascular toxicity of individuals’ treatments may one day lead to more patient-specific treatment plans in precision cardio-oncology while reducing cardiovascular disease (CVD) morbidity and mortality.

High intensity exercise during breast cancer chemotherapy - effects on long-term myocardial damage and physical capacity - data from the OptiTrain RCT

BACKGROUND

Adjuvant systemic breast cancer treatment improves disease specific outcomes, but also presents with cardiac toxicity. In this post-hoc exploratory analysis of the OptiTrain trial, the effects of exercise on cardiotoxicity were monitored by assessing fitness and biomarkers over the intervention and into survivorship. Methods; Women starting chemotherapy were randomized to 16-weeks of resistance and high-intensity interval training (RT-HIIT), moderate-intensity aerobic and high-intensity interval training (AT-HIIT), or usual care (UC). Outcome measures included plasma troponin-T (cTnT), Nt-pro-BNP and peak oxygen uptake (VO_2peak), assessed at baseline, post-intervention, and at 1- and 2-years.

RESULTS

For this per-protocol analysis, 88 women met criteria for inclusion. Plasma cTnT increased in all groups post-intervention. At the 1-year follow-up, Nt-pro-BNP was lower in the exercise groups compared to UC. At 2-years there was a drop in VO_2peak for patients with high cTnT and Nt-pro-BNP. Fewer patients in the RT-HIIT group fulfilled biomarker risk criteria compared to UC (OR 0.200; 95% CI = 0.055-0.734).

CONCLUSIONS

In this cohort, high-intensity exercise was associated with lower levels of NT-proBNP 1-year post-baseline, but not with cTnT directly after treatment completion. This may, together with the preserved VO_2peak in patients with low levels of biomarkers, indicate a long-term cardioprotective effect of exercise.

TRIAL REGISTRATION

Clinicaltrials. govNCT02522260 , Registered 13th of august 2015 - Retrospectively Registered.

Cardiotoxicity in HER2-positive breast cancer patients

Due to the recent advances in diagnosis and management of patients with HER2-positive breast cancer, especially through novel HER2-targeted agents, cardiotoxicity becomes an emerging problem. Although chemotherapy significantly increases survival, the risk of cardiovascular disease development is high and still underestimated and could imply treatment discontinuation. Frequently, due to lack of rigorous diagnosis strategies, cardiotoxicity assessment is delayed, and, moreover, the efficacy of current therapy options in restoring heart function is questionable. For a comprehensive risk assessment, it is vital to characterize the clinical spectrum of HER2-targeted agents and anthracyclines, as well as their pathogenic pathways involved in cardiotoxicity. Advanced cardiovascular multimodal imaging and circulating biomarkers plays primary roles in early assessing cardiotoxicity and also in guiding specific preventive measures. Even though the knowledge in this field is rapidly expanding, there are still questions that arise regarding the optimal approach in terms of timing and methods. The aim of the current review aims to providean overview of currently available data.

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.

The effect of prophylactic carvedilol on subclinical left ventricular dysfunction after 1 cycle FAC chemotherapy in breast cancer patients

Background

Despite its efficacy, FAC regimen may cause fatal cardiotoxicity. Carvedilol may also exert additional antioxidant effects. This study aimed to assess the effect of carvedilol in preventing decline of left ventricular function in breast cancer patients receiving FAC regimen chemotherapy.

Methods

The study was a quasi-experimental study. The study subjects were consisted of breast cancer patients currently receiving post-first cycle FAC chemotherapy regimen in period of March – May 2019. The study subjects were divided into 2 groups: control and intervention group. In intervention groups, the patients consumed up titrated carvedilol with initial dose of 2 × 6.25 mg daily, follow-up echocardiography was performed for the patients in order to assess GLS score of left ventricle.

Result

Eighty patients were enrolled to the study, with each group consisted of 40 patients. Patient baseline characteristics were not significantly different between both groups. Left ventricular function was assessed using speckle tracking echocardiography and assessing the change of GLS score. Decrease of GLS score was higher in the intervention group compared to the control group, although the decrease was not statistically significant (0.767 ± 0.355 vs. 0.897 ± 0.526; p = 0.838). Percentage wise, similar findings were reported, albeit no significant (3.34 ± 1.65 vs. 3.46 vs. 2.58; p = 0.968).

Conclusions

Carvedilol was not able to prevent the decline of subclinical left ventricular function after such chemotherapy cycle. However, it maybe more likely that the benefits appear in patients whose given larger cumulative dose of anthracycline and have multiple risk factors.

A QSAR study that compares the ability of bisdioxopiperazine analogs of the doxorubicin cardioprotective agent dexrazoxane (ICRF-187) to protect myocytes with DNA topoisomerase II inhibition

The cardiotoxicity caused by doxorubicin and extravasation injury caused by anthracyclines is reduced by the clinically approved bisdioxopiperazine drug dexrazoxane. Dexrazoxane is a rings-closed analog of EDTA and is hydrolyzed in vivo to a form that strongly binds iron. Its protective effects were originally thought to be due to the ability of its metabolite to remove iron from the iron-doxorubicin complex, thereby preventing oxygen radical damage to cellular components. More recently it has been suggested that dexrazoxane may exert its protective effects by inhibiting topoisomerase IIβ in the heart and inducing a reduction in its protein levels through induction of proteasomal degradation. The ability of dexrazoxane, other bisdioxopiperazines, and mitindomide to protect against doxorubicin-induced damage was determined in primary neonatal rat myocytes. This QSAR study showed that the protection that a series of bisdioxopiperazine analogs of dexrazoxane and the bisimide mitindomide offered against doxorubicin-induced myocyte damage was highly correlated with the ability of these compounds to catalytically inhibit the decatenation activity of topoisomerase II. The structural features of the dexrazoxane analogs that contribute to the binding and inhibition of topoisomerase II have been identified. These results suggest that the inhibition of topoisomerase II in myocytes by dexrazoxane is central to its role in its activity as an anthracycline cardioprotective agent. Additionally, sequence identity analysis of the amino acids surrounding the dexrazoxane binding site showed extremely high identity, not only between both invertebrate topoisomerase II isoforms, but also with yeast topoisomerase II as well.

Fatal heart disease among cancer patients

As the overlap between heart disease and cancer patients increases as cancer-specific mortality is decreasing and the surviving population is aging, it is necessary to identify cancer patients who are at an increased risk of death from heart disease. The purpose of this study is to identify cancer patients at highest risk of fatal heart disease compared to the general population and other cancer patients at risk of death during the study time period. Here we report that 394,849 of the 7,529,481 cancer patients studied died of heart disease. The heart disease-specific mortality rate is 10.61/10,000-person years, and the standardized mortality ratio (SMR) of fatal heart disease is 2.24 (95% CI: 2.23-2.25). Compared to other cancer patients, patients who are older, male, African American, and unmarried are at a greatest risk of fatal heart disease. For almost all cancer survivors, the risk of fatal heart disease increases with time.

[Curing cancer and protecting the heart : Challenges in cardio-oncology in the era of modern tumor treatment]

Recent advances in the medical oncological treatment options for cancer have led to a clear improvement in the survival rate worldwide; however, many of the recently developed new drugs are directly or indirectly associated with cardiovascular side effects. Cardiovascular diseases are already the most frequent non-cancerous cause of death in tumor patients. Prevention, early detection of these complications, correct management and timely initiation of specific cardiac medical treatment are the key for an improvement of the cardiovascular prognosis. This article provides an overview and comprehensive summary of the possible cardiotoxic side effects of important oncological therapies and offers possible practical strategies with respect to risk stratification, cardiological follow-up care and management approaches for chemotherapy-induced left ventricular dysfunction.

Efficacy of Dexrazoxane in Preventing Anthracycline Cardiotoxicity in Breast Cancer

Objectives

The authors performed a systematic review and meta-analysis of randomized and nonrandomized trials on the efficacy of dexrazoxane in patients with breast cancer who were treated with anthracyclines with or without trastuzumab.

Background

Breast cancer treatment with anthracyclines and trastuzumab is associated with an increased risk of cardiotoxicity. Among the various strategies to reduce the risk of cardiotoxicity, dexrazoxane is an option for primary prevention, but it is seldom used in clinical practice.

Methods

Online databases were searched from January 1990 up to March 1, 2019, for clinical trials on the use of dexrazoxane for the prevention of cardiotoxicity in patients with breast cancer receiving anthracyclines with or without trastuzumab. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model meta-analysis.

Results

Seven randomized trials and 2 retrospective trials with a total of 2,177 patients were included. Dexrazoxane reduced the risk of clinical heart failure (RR: 0.19; 95% CI: 0.09 to 0.40; p < 0.001) and cardiac events (RR: 0.36; 95% CI: 0.27 to 0.49; p < 0.001) irrespective of previous exposure to anthracyclines. The rate of a partial or complete oncological response, overall survival, and progression-free survival were not affected by dexrazoxane.

Conclusions

Dexrazoxane reduced the risk of clinical heart failure and cardiac events in patients with breast cancer undergoing anthracycline chemotherapy with or without trastuzumab and did not significantly impact cancer outcomes. However, the quality of available evidence is low, and further randomized trials are warranted before the systematic implementation of this therapy in clinical practice.

Efficacy of Neurohormonal Therapies in Preventing Cardiotoxicity in Patients with Cancer Undergoing Chemotherapy

BACKGROUND

Various cardioprotective approaches have been evaluated to prevent chemotherapy-related cardiotoxicity; however, their overall utility remains uncertain.

OBJECTIVES

To assess the effects of neurohormonal therapies in preventing cardiotoxicity in patients receiving chemotherapy.

METHODS

This meta-analysis included randomized clinical trials of adult patients that underwent chemotherapy and neurohormonal therapies (beta-blockers, mineralocorticoid receptor antagonists, or ACE inhibitors/ARBs) vs. placebo with follow-up ≥4 weeks. The primary outcome was change in left ventricular ejection fraction (LVEF) from baseline to the end of trial. Other outcomes of interest were measures of LV size, strain, and diastolic function. Pooled estimates for each outcome were reported as standardized mean difference (SMD) and weighted mean difference (WMD) between the neurohormonal therapy and placebo groups using random effects models.

RESULTS

We included 17 trials, collectively enrolling 1,984 participants. In pooled analysis, neurohormonal therapy (vs. placebo) was associated with significantly higher LVEF on follow-up [SMD(95% CI): +1.04(0.57 to 1.50)] but with significant heterogeneity in the pooled estimate (I² = 96%). Compared with placebo-treated patients, those randomized to neurohormonal therapies experienced a 3.96% (95%CI: 2.9% to 5.0%) less decline in LVEF estimated by WMD, but with significant heterogeneity (I² = 98%). There was a trend towards lower adverse clinical events with neurohormonal therapy (vs. placebo) without statistical significance [risk ratio(95%CI): 0.80(0.53-1.20) I² = 71%].

CONCLUSIONS

Neurohormonal therapies are associated with higher LVEF in follow-up among cancer patients receiving chemotherapy, although absolute changes in LVEF are small and may be within inter-test variability. Furthermore, significant heterogeneity is observed in the treatment effects across studies highlighting the need for larger trials of cardioprotective strategies.

Genetic Variants Associated With Cancer Therapy-Induced Cardiomyopathy

BACKGROUND

Cancer therapy-induced cardiomyopathy (CCM) is associated with cumulative drug exposures and preexisting cardiovascular disorders. These parameters incompletely account for substantial interindividual susceptibility to CCM. We hypothesized that rare variants in cardiomyopathy genes contribute to CCM.

METHODS

We studied 213 patients with CCM from 3 cohorts: retrospectively recruited adults with diverse cancers (n=99), prospectively phenotyped adults with breast cancer (n=73), and prospectively phenotyped children with acute myeloid leukemia (n=41). Cardiomyopathy genes, including 9 prespecified genes, were sequenced. The prevalence of rare variants was compared between CCM cohorts and The Cancer Genome Atlas participants (n=2053), healthy volunteers (n=445), and an ancestry-matched reference population. Clinical characteristics and outcomes were assessed and stratified by genotypes. A prevalent CCM genotype was modeled in anthracycline-treated mice.

RESULTS

CCM was diagnosed 0.4 to 9 years after chemotherapy; 90% of these patients received anthracyclines. Adult patients with CCM had cardiovascular risk factors similar to the US population. Among 9 prioritized genes, patients with CCM had more rare protein-altering variants than comparative cohorts ( P≤1.98e-04). Titin-truncating variants (TTNtvs) predominated, occurring in 7.5% of patients with CCM versus 1.1% of The Cancer Genome Atlas participants ( P=7.36e-08), 0.7% of healthy volunteers ( P=3.42e-06), and 0.6% of the reference population ( P=5.87e-14). Adult patients who had CCM with TTNtvs experienced more heart failure and atrial fibrillation ( P=0.003) and impaired myocardial recovery ( P=0.03) than those without. Consistent with human data, anthracycline-treated TTNtv mice and isolated TTNtv cardiomyocytes showed sustained contractile dysfunction unlike wild-type ( P=0.0004 and P<0.002, respectively).

CONCLUSIONS

Unrecognized rare variants in cardiomyopathy-associated genes, particularly TTNtvs, increased the risk for CCM in children and adults, and adverse cardiac events in adults. Genotype, along with cumulative chemotherapy dosage and traditional cardiovascular risk factors, improves the identification of patients who have cancer at highest risk for CCM.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01173341; AAML1031; NCT01371981.

[Mitochondrial Antioxidant Plastomitin Improves Cardiac Function in Doxorubicin-Induced Cardiomyopathy]

The aim of the study was to ascertain whether the use of plastomitin, the mitochondrial antioxidant, can affect the development of systolic dysfunction that occurs in rats after 4 weeks of doxorubicin treatment (2 mg/kg weekly). Materials and methods. Male Wistar rats weighing 320-380 g were used in this work. Echocardiographic study was carried out using Vevo 1100 with linear probe 13-24 MHz frequency. Results. Echocardiographic study of rats through 8 weeks from the beginning of doxorubicin treatment showed the presence of systolic dysfunction with decrease of ejection fraction of the left ventricle (LV) by 32%. Hearts of rats, to which plastomitin (0.32 mg/kg daily) was administered simultaneously with doxorubicin, showed significantly increased ejection fraction and shortening fraction as compared with doxorubicin group, and these values were close to the control. In experiments with simultaneous registration of LV pressure and volume, it was found that the hearts of all rats treated with doxorubicin showed reduced contractility index and stroke work, while maintaining normal cardiac output. Such compensation in experiments with treatment with doxorubicin alone was achieved through significant reduction in the peripheral resistance, slowing of myocardial relaxation, and facilitation of LV diastolic filling during prolonged diastolic pause (the heart rate was slowed by 23%). In experiments with simultaneous application of doxorubicin and plastomitin, the compensation was achieved through preservation of myocardial contractility and relaxability, the heart rate and peripheral resistance. This method of compensation is more beneficial for the body, because it does not restrict the supply of organs and tissues with oxygen, and has significant advantage over doxorubicin group at equal heart rate. Conclusion. The results allow to conclude that the use of plastomitin together with doxorubicin prevents the development of doxorubicin-induced systolic dysfunction.

Protecting the heart in cancer therapy

Recent advances in cancer prevention and management have led to an exponential increase of cancer survivors worldwide. Regrettably, cardiovascular disease has risen in the aftermath as one of the most devastating consequences of cancer therapies. In this work, we define cancer therapeutics-induced cardiotoxicity as the direct or indirect cardiovascular injury or injurious effect caused by cancer therapies. We describe four progressive stages of this condition and four corresponding levels of prevention, each having a specific goal, focus, and means of action. We subsequently unfold this didactic framework, surveying mechanisms of cardiotoxicity, risk factors, cardioprotectants, biomarkers, and diagnostic imaging modalities. Finally, we outline the most current evidence-based recommendations in this area according to multidisciplinary expert consensus guidelines.

Cardio-oncology: A Focus on Cardiotoxicity

Cardio-oncology is a recently developed field in cardiology aimed at significantly reducing cardiovascular morbidity and mortality and improving quality of life in cancer survivors. Cancer survival rates have been constantly increasing, mainly because of the advent of new, more potent and targeted therapies. However, many of the new therapies - along with some of the older chemotherapeutic regimens such as anthracyclines - are potentially cardiotoxic, which is reflected increasingly frequently in the published literature. Cardiotoxicity adversely affects prognosis in cancer patients, thus its prevention and treatment are crucial to improve quality and standards of care. This review aims to explore the existing literature relating to chemotherapy- and radiotherapy-induced cardiotoxicity. An overview of the imaging modalities for the identification of cardiotoxicity and therapies for its prevention and management is also provided.