Fluoropyrimidine Cardiotoxicity: Incidence, Outcomes, and Safety of Rechallenge

Primary prevention of cardiotoxicity in cancer patients treated with fluoropyrimidines: a randomized controlled trial

BACKGROUND

Fluoropyrimidines (FP) are the third most used chemotherapeutic drugs administered in solid tumors but have cardiotoxic side effects. We aimed to determine whether pre-chemotherapeutic cardiological assessment and management of cardiovascular risk factors could prevent FP-induced cardiotoxicity and if the coronary artery calcium (CAC) score was predictive of chest pain.

METHODS

This was a randomized, controlled, single center trial of patients with various cancer types who were treated with FP and had no known ischemic heart disease. All patients had CAC score obtained by cardiac CT scan. Patients were randomized to pre-chemotherapeutic cardiological management or standard care. Cardiological management included risk reduction based on electro- and echocardiographic evaluation and blood samples. Primary composite endpoint included hospital admission for chest pain, acute coronary syndrome, coronary angiography intervention, or all-cause mortality. Secondary outcome was chest pain. Follow-up was 6 months. Data were analyzed using Kaplan-Meier survival function with log-rank test and ROC-analyses.

RESULTS

Of the 192 patients included, the primary endpoint occurred in 9/95 (9.5%) patients in the intervention group and 15/97 (15.5%) patients in the control group (log-rank p = 0.19) with an incidence rate ratio (IRR) of 0.57 (95% CI [0.22 - 1.39]). Chest pain occurred in 6/95 (6.3%) patients in the intervention group and 13/97 (13.4%) in the control group, yielding an IRR of 0.44 (95% CI [0.14 - 1.23]). CAC score did not predict chest pain occurrence.

CONCLUSIONS

Cardiological management of cardiovascular risk factors prior to treatment with fluoropyrimidines resulted in half as many cardiotoxic events but the study did not reach statistical significance. Further studies are needed to investigate the optimal strategies to prevent fluoropyrimidine-induced cardiotoxicity in cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifyer NCT03486340.

Risk factors for fluorouracil-induced cardiotoxicity in patients with gastrointestinal tumor

Objective

To explore the risk factors for cardiotoxicity in patients with gastrointestinal (GI) tumors treated with fluorouracil drugs.

Methods

This study included patients with GI tumors who received fluorouracil at our hospital between January 2018 and April 2022. The demographic and clinical characteristics were collected. The risk factors associated with the cardiotoxicity of fluorouracil were explored using multivariable logistic regression.

Results

A total of 300 patients were finally included and divided into the cardiotoxicity (n = 81) and non-cardiotoxicity groups (n = 219). The occurrence of fluorouracil-induced cardiotoxicity was higher in patients with hypertension, hyperlipidemia, diabetes mellitus, older age, those treated with capecitabine, and combined radiotherapy. The multivariable logistic regression showed that treatment with capecitabine, history of hyperlipidemia, history of diabetes, older age, and combined radiotherapy were independent risk factors for the cardiotoxicity of fluorouracil.

Conclusion

Hyperlipidemia, diabetes, older age, treatment with capecitabine, and adjuvant radiotherapy might be independent risk factors for the cardiotoxicity of fluorouracil in patients with GI tumors.

Cancer and Cardiovascular Disease: The Conjoined Twins

Cancer and cardiovascular disease are the two most common causes of death worldwide. As the fields of cardiovascular medicine and oncology continue to expand, the area of overlap is becoming more prominent demanding dedicated attention and individualized patient care. We have come to realize that both fields are inextricably intertwined in several aspects, so much so that the mere presence of one, with its resultant downstream implications, has an impact on the other. Nonetheless, cardiovascular disease and cancer are generally approached independently. The focus that is granted to the predominant pathological entity (either cardiovascular disease or cancer), does not allow for optimal medical care for the other. As a result, ample opportunities for improvement in overall health care are being overlooked. Herein, we hope to shed light on the interconnected relationship between cardiovascular disease and cancer and uncover some of the unintentionally neglected intricacies of common cardiovascular therapeutics from an oncologic standpoint.

Management of Fluoropyrimidine-Induced Cardiac Adverse Outcomes Following Cancer Treatment

Advancements in cancer treatments have improved survival rates but have also led to increased cardiotoxicities, which can cause adverse cardiovascular events or worsen pre-existing conditions. Herein, cardiotoxicity is a severe adverse effect of 5-fluorouracil (5-FU) therapy in cancer patients, with reported incidence rates ranging from 1 to 20%. Some studies have also suggested subclinical effects and there are reports which have documented instances of cardiac arrest or sudden death during 5-FU treatment, highlighting the importance of timely management of cardiovascular symptoms. However, despite being treated with conventional medical approaches for this cardiotoxicity, a subset of patients has demonstrated suboptimal or insufficient responses. The frequent use of 5-FU in chemotherapy and its association with significant morbidity and mortality indicates the need for a greater understanding of 5-FU-associated cardiotoxicity. It is essential to reduce the adverse effects of anti-tumor medications while preserving their efficacy, which can be achieved through drugs that mitigate toxicity associated with these drugs. Underpinning cardiotoxicity associated with 5-FU therapy also has the potential to offer valuable guidance in pinpointing pharmacological approaches that can be employed to prevent or ameliorate these effects. The present study provides an overview of management strategies for cardiac events induced by fluoropyrimidine-based cancer treatments. The review encompasses the underlying molecular and cellular mechanisms of cardiotoxicity, associated risk factors, and diagnostic methods. Additionally, we provide information on several available treatments and drug choices for angina resulting from 5-FU exposure, including nicorandil, ranolazine, trimetazidine, ivabradine, and sacubitril-valsartan, which have demonstrated potential in mitigating or protecting against chemotherapy-induced adverse cardiac effects.

Cardioprotective effects of Ferulic acid against various drugs and toxic agents

Background

Homeostatic regulation of cardiomyocytes is indispensable in maintaining the normal physiological activity of cardiac tissue. Cardiotoxicity induced by drugs may lead to cardiac abnormalities such as arrhythmia, myocardial infarction and myocardial hypertrophy. Moreover, drug-induced cardiotoxicity confines the additional use of the implicated drugs. Several studies have reported that consumption of phytochemicals on regular intervals shall protect humans against numerous diseases such as diabetes, cardiovascular disease, inflammatory diseases and cancer.

Main body

Ferulic acid (FA) is a plant derived polyphenol abundantly found in vegetables, fruits and grains. FA is widely known for its antioxidant, anti-inflammatory, anticancer, nephroprotective and hepatoprotective effects. FA has been well documented for its cardioprotective activity against various drugs and toxic agents as well. However, the cardioprotective action of FA have remained a challenge with regard to understanding its mechanism in health and diseases.

Conclusion

The main purpose of this review is to explore the cardioprotective mechanisms of FA against several drugs and chemicals to recommend further studies to investigate the potential protective effect of FA.