Sodium-Glucose Co-Transporter-2 Inhibitors and Cardiac Outcomes Among Patients Treated With Anthracyclines

Cardiovascular therapeutic targets of sodium-glucose co-transporter 2 (SGLT2) inhibitors beyond heart failure

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are oral antidiabetic agents that have shown significant improvements in cardiovascular and renal outcomes among patients with heart failure (HF), regardless of diabetic status, establishing them as a cornerstone therapy. In addition to glycemic control and the osmotic diuretic effect, the inhibition of SGLT2 improves endothelial function and vasodilation, optimizing myocardial energy metabolism and preserving cardiac contractility. Moreover, SGLT2 inhibitors may exhibit anti-inflammatory properties and attenuate acute myocardial ischemia/reperfusion injury, thereby reducing cardiac infarct size, enhancing left ventricular function, and mitigating arrhythmias. These pleiotropic effects have demonstrated efficacy across various cardiovascular conditions, ranging from acute to chronic coronary syndromes and extending to arrhythmias, valvular heart disease, cardiomyopathies, cardio-oncology, and cerebrovascular disease. This review provides an overview of the current literature on the potential mechanisms underlying the effectiveness of SGLT2 inhibitors across a wide range of cardiovascular diseases beyond HF.

Clonal hematopoiesis, cardiovascular disease and cancer treatment-induced cardiotoxicity

Clonal hematopoiesis (CH) arises when a substantial proportion of mature blood cells is derived from a single hematopoietic stem cell lineage. It is considered to be a premalignant state that predisposes individuals to an increased risk of cancers. Recently, emerging evidence has demonstrated a strong association between CH and both the incidence and mortality of cardiovascular diseases (CVD), with the relative risks being comparable to those attributed to traditional cardiovascular risk factors. In addition, CH has been suggested to play a role in CVD and anti-cancer treatment-related cardiotoxicity amongst cancer survivors. Moreover, certain forms of chemotherapy and radiation therapy have been shown to promote the clonal expansion of specific CH-related mutations. Consequently, CH may play a substantial role in the realm of cardio-oncology. In this review, we discuss the association between CH with cancer and CVD, with a special focus on anti-cancer treatment-related cardiotoxicity, discuss possible future research avenues and propose a systematic approach for clinical practice.

The effects of sodium-glucose cotransporter-2 inhibitors in chemotherapy-induced cardiotoxicity and mortality in patients with cancer: a systematic review and meta-analysis

BACKGROUND

The effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors on reducing cardiovascular events in different subgroups of diabetic patients are under investigation. The current systematic review and meta-analysis investigated the effects of SGLT2 inhibitors on preventing cardiovascular events and mortality and their adverse events in patients with active cancer and diabetes undergoing cardiotoxic cancer treatment.

METHODS

We searched PubMed, Embase, Web of Science, and Scopus to find studies investigating the effects of SGLT2 inhibitors on patients with diabetes and confirmed cancer until 19 August 2024. Meta-analyses were conducted using the random-effects model to compare all-cause mortality, cancer-associated mortality, heart failure (HF) hospitalization, arrhythmia, and adverse event rates such as ketoacidosis, hypoglycemia, urinary tract infection, and sepsis between patients with or without SGLT2 inhibitors use. Risk ratios (RRs) with 95% confidence intervals (CI) were used to compare outcomes between SGLT2 inhibitors and non-SGLT2 inhibitors groups.

RESULTS

Eleven studies were included with 88,096 patients with confirmed cancer (49% male). Among the total population, 20,538 received SGLT2 inhibitors (age 61.68 ± 10.71), while 67,558 did not receive SGLT2 inhibitors (age 68.24 ± 9.48). The meta-analysis found that the patients who received SGLT2 inhibitors had a significantly lower mortality rate than those who did not receive SGLT2 inhibitors (RR 0.46, 95% CI 0.34 to 0.63, p-value < 0.0001). Similarly, the cancer-associated mortality rate was also lower (RR 0.29, 95% CI 0.27 to 0.30, p-value < 0.0001). Further analysis found that the SGLT2 inhibitor group had a lower rate of HF hospitalization, compared to controls (RR 0.44, 95% CI 0.27 to 0.70, p-value = 0.0007). Moreover, patients receiving SGLT2 inhibitors had a statistically lower rate of arrhythmia (RR 0.38, 95% CI 0.26 to 0.56, p-value < 0.0001). Finally, patients in the SGLT2 inhibitors group had a lower rate of adverse events (RR 0.51, 95% CI 0.42 to 0.62, p-value < 0.0001).

CONCLUSIONS

SGLT2 inhibitors are effective in reducing mortality (all-cause and cancer-associated), HF hospitalization, arrhythmia, and drug adverse events in patients with cancer. If confirmed in future studies, these agents could be a potentially ideal candidate to prevent cardiotoxicity of cancer therapies.

Interaction of Body Mass Index and Glycemic Status on Cardiovascular Outcomes in Patients With Cancer Treated With Anthracyclines

BACKGROUND

Anthracycline-based chemotherapy is a vital treatment for various cancers but carries notable risks of cardiotoxicity. This study aimed to assess how different body mass index values and glycemic status influence the risk of major adverse cardiovascular events (MACE) in chemotherapy-naïve adult patients with cancer treated with anthracyclines.

METHODS

This retrospective cohort included 11 393 chemotherapy-naïve patients who initiated anthracycline-based chemotherapy between 2000 and 2019. Follow-up began from the first anthracycline dose. Body mass index was categorized as underweight/normal weight (<25 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2). Glycemic status was classified as normoglycemic or diabetes/prediabetes (diabetes: hemoglobin A1c ≥6.5% or fasting glucose ≥126 mg/dL; prediabetes: hemoglobin A1c 5.7%-6.4% or fasting glucose 100-125 mg/dL).

RESULTS

Over a median follow-up of 8.7 years, 985 (8.64%) patients experienced MACE. Obesity was significantly associated with an increased risk of MACE (hazard ratio [HR], 1.38 [95% CI, 1.10-1.73], reference: underweight/normal weight) and heart failure hospitalization, and diabetes/prediabetes also significantly predicted MACE (HR, 1.28 [95% CI, 1.10-1.50], reference: normoglycemic). Notably, overweight (HR, 0.85 [95% CI, 0.80-0.91]) and obesity (HR, 0.85 [95% CI, 0.74-0.96]) were associated with lower risk of all-cause mortality. Joint analysis revealed that patients with both obesity and diabetes/prediabetes had the highest risk of MACE (HR, 1.74 [95% CI, 1.28-2.37]) and heart failure hospitalization (HR, 1.99 [95% CI, 1.41-2.81]).

CONCLUSIONS

In patients with cancer undergoing anthracycline-based chemotherapy, both body mass index and glycemic status significantly affect cardiovascular risks, with the highest risk observed in those with concurrent obesity and diabetes/prediabetes, emphasizing the need for tailored risk assessment and management.

SGLT2 Inhibitors in Cancer Patients: A Comprehensive Review of Clinical, Biochemical, and Therapeutic Implications in Cardio-Oncology

Patients with active cancer and cancer survivors are at a markedly increased risk for developing cardiovascular comorbidities, including heart failure, coronary artery disease, and renal dysfunction, which are often compounded by the cardiotoxic effects of cancer therapies. This heightened cardiovascular vulnerability underscores the urgent need for effective, safe, and evidence-based cardioprotective strategies to reduce both cardiovascular morbidity and mortality. Sodium-glucose cotransporter 2 inhibitors (SGLT2is), a class of drugs originally developed for the treatment of type 2 diabetes, have demonstrated significant cardiovascular and renal benefits in high-risk populations, independent of glycemic control. Among the currently available SGLT2i, such as empagliflozin, canagliflozin, dapagliflozin, and sotagliflozin, there is growing evidence supporting their role in reducing major adverse cardiovascular events (MACEs), hospitalization for heart failure, and the progression of chronic kidney disease. Recent preclinical and clinical data suggest that SGLT2is exert cardioprotective effects through multiple mechanisms, including the modulation of inflammasome activity, specifically by reducing NLRP3 inflammasome activation and MyD88-dependent signaling, which are critical drivers of cardiac inflammation and fibrosis. Moreover, SGLT2is have been shown to enhance mitochondrial viability in cardiac cells, promoting improved cellular energy metabolism and function, thus mitigating cardiotoxicity. This narrative review critically evaluates the emerging evidence on the cardiorenal protective mechanisms of SGLT2is, with a particular focus on their potential role in cardio-oncology. We explore the common pathophysiological pathways between cardiovascular dysfunction and cancer, the molecular rationale for the use of SGLT2is in cancer patients, and the potential benefits in both primary and secondary prevention of cardiovascular toxicity related to oncological treatments. The aim is to propose a therapeutic paradigm utilizing SGLT2is to reduce cardiovascular mortality, MACE, and the burden of cardiotoxicity in high-risk oncology patients, fostering an integrated approach to cardio-oncology care.

Effect of chemotherapy and different chemotherapeutic regimens on electrocardiographic parameters in breast cancer women: a retrospective and within-subject longitudinal study

BACKGROUND

Descriptions of the effect of chemotherapy on all the electrocardiographic parameters in breast cancer women during chemotherapy are limited.

METHODS

A retrospective and within-subject longitudinal study of the effect of chemotherapeutics and different chemotherapeutic regimens on electrocardiographic parameters was conducted in 948 breast cancer women who had completed chemotherapy with ECG recording at initial diagnosis and before each cycle of chemotherpy. Heart rate (HR), QRS interval, P-R interval, QRS axis, QT interval, QTc interval, and the incidence of QTc interval prolongation were analyzed. Age, body mass index (BMI), history of hypertension, diabetes, and coronary heart disease were also collected for further stratified study.

RESULTS

Compared to initial diagnosis, changes in HR [74 (67, 82) bpm vs. 79 (73, 87)bpm], P-R interval [148 (136, 160) ms vs. 150 (138, 162) ms], QRS axis [41° (19.25°°, 60°) vs. 33° (15°, 53.75°)], QT interval [376 (358, 394) ms vs. 372 (354, 386) ms], QTc interval [417 (404, 431) ms vs. 426 (414, 436) ms], and incidence of QTc interval prolongation (9.6% vs. 15.8%) were all significant after chemotherapy, P < 0.001. There were statistically differences in HR, QRS axis, QTc interval, and the incidence of QTc interval prolongation between initial diagnosis and prechemotherapy of the last cycle under different age strata (≤ 45 years, 45 ~ 55 years, ≥ 55 years), different BMI range groups (18.5-22.9 kg/m2, 23-24.9 kg/m2, and 25-29.9 kg/m2), and even in patients without history of hypertension, diabetes, or coronary heart disease, respectively, P < 0.05. Resting HR, QRS axis, and QTc interval between each cycle of TEC regimen were different, P < 0.001. Resting HR and QTc interval between different cycles of EC-T(H) regimen were different, P < 0.05. Compared to initial diagnosis, a longer QTc interval occurred from the third to the last cycle of TEC regimen, P < 0.05. Only QTc interval before the fifth cycle of EC-T(H) regimen was statistically different from that at initial diagnosis, P = 0.012.

CONCLUSION

Chemotherapy affects the ECG parameters of HR, P-R interval, QRS axis, QT interval, QTc interval, and QTc interval prolongation in early-stage breast cancer women during chemotherapy. Electrocardiographic parameters may be affected significantly by TEC regimen than by EC-T(H) or TC regimen. Trial registration Retrospectively registered.

Doxorubicin-Induced Cardiotoxicity and the Emerging Role of SGLT2 Inhibitors: From Glycemic Control to Cardio-Oncology

Cancer remains the second leading cause of death worldwide. Doxorubicin (DOX) is a cornerstone of hematologic malignancy treatment, but it is limited by its dose-dependent cardiotoxicity, leading to systolic and diastolic cardiac dysfunction and, ultimately, dilated hypokinetic cardiomyopathy. Cardio-oncology has emerged as a subspecialty addressing cardiovascular complications in cancer patients, highlighting preventive and therapeutic strategies to reduce cancer therapy-related cardiac dysfunction (CTRCD). Current approaches, including beta-blockers, renin-angiotensin system (RAS) inhibitors, and statins, offer partial cardioprotection. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, initially developed for type 2 diabetes mellitus (T2DM), demonstrate pleiotropic cardioprotective effects beyond glycemic control, including reduced oxidative stress, inflammation, and myocardial remodeling. This review explores the interplay between anthracycline therapy, particularly DOX, and cardiotoxicity while evaluating SGLT2 inhibitors as novel agents in cardio-oncology. Preclinical studies suggest SGLT2 inhibitors attenuate CTRCD by preserving mitochondrial function and inhibiting apoptosis, while clinical trials highlight their efficacy in reducing heart failure (HF) hospitalizations and cardiovascular (CV) mortality. Integrating SGLT2 inhibitors into cardio-oncology protocols could revolutionize the management of CTRCD, enhancing patient outcomes in oncology and cardiovascular care. Considering the emerging evidence, SGLT2 inhibitors may provide significant benefits to patients undergoing anthracycline therapy, particularly those with elevated cardiovascular risk profiles. We recommend that future prospective, large-scale clinical trials further evaluate the efficacy and safety of these agents as cardioprotective therapy to optimize individualized treatment strategies.

Cancer therapy-related cardiotoxicity is associated with distinct alterations of the myocardial lipidome

AIMS

Anthracyclines are key components of various chemotherapy regimens, but their clinical utility is limited by severe cardiotoxic side effects. Previous studies have suggested that anthracycline-induced cardiotoxicity (AIC) may be driven by alterations in myocardial lipid metabolism. This study aimed to systematically explore the cardiac lipidomic landscape of AIC with regard to potential pathomechanisms and novel therapeutic targets.

METHODS AND RESULTS

Mass spectrometry-based untargeted lipidomics were performed on myocardial biopsies from 13 patients with AIC (age 53 ± 31 years, 54% female, left ventricular ejection fraction 19 ± 4%) and 15 age- and sex-matched controls. Lipidomic profiles were also compared with 15 patients with other heart failure aetiologies (matched for sex and age). A total of 627 individual lipid species from 22 different lipid classes were analysed. AIC was associated with a lower proportion of polyunsaturated fatty acids towards more monounsaturated and saturated sidechains as well as significant alterations in the proportion of odd-chain fatty acids. Pathway analyses indicated a higher precursor conversion into lysolipids in AIC. This accumulation of lysolipid species was not observed in other heart failure aetiologies and may represent a specific finding in AIC.

CONCLUSION

Anthracycline-induced cardiotoxicity leads to distinct alterations of the myocardial lipidome. Increased levels of myocardial lysolipids were identified as a novel lipidomic trait in AIC, which appears to be distinct from other causes of heart failure. Further research studying pharmacological interventions in lysolipid metabolism for prevention and therapy of AIC is warranted.

Cardiorenal protection with dapagliflozin in patients with type 2 diabetes mellitus and chronic coronary syndrome undergoing percutaneous coronary intervention: a registry cross-sectional study

IMPORTANCE

Although sodium‒glucose cotransporter-2 (SGLT2) inhibitors have cardiorenal benefits, their efficacy in patients with type 2 diabetes mellitus (T2DM) and chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI) remains underexplored.

OBJECTIVE

To evaluate the cardiorenal protective effects of the SGLT2 inhibitor dapagliflozin in patients with T2DM and CCS receiving PCI.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional analysis of 1,430 patients from a tertiary hospital database who underwent PCI (January 1, 2018, to March 31, 2022).

MAIN OUTCOMES AND MEASURES

Cardiac outcomes (PMI/4aMI) and renal outcomes (eGFR and CI-AKI).

RESULTS

After 1:1 propensity score matching (PSM) (176 dapagliflozin vs. 176 control), the dapagliflozin group showed significantly lower PMI/4aMI rates pre-PSM (39.78% vs. 66.99%; OR 0.862, 95% CI 0.823-0.904; p < 0.001) and post-PSM (39.77% vs. 60.23%; OR 0.660, 95% CI 0.531-0.821; p < 0.001), with sustained significance after adjustment (adjusted OR 0.436, 95% CI 0.285-0.668; p < 0.001). Subgroup analyses highlighted increased protection in patients aged ≥ 65 years, those with multivessel disease, and those with higher contrast volumes. Renal outcomes (CI-AKIESUR and CI-AKIKDIGOs) were not significantly different before or after PSM or after adjustment (all p > 0.05).

CONCLUSIONS AND RELEVANCE

Dapagliflozin exerted robust cardioprotective effects against PMI/4aMI in patients with T2DM and CCS undergoing PCI, particularly among patients in high-risk subgroups, but it did not significantly reduce the risk of CI-AKI. These findings support the peri-PCI use of dapagliflozin to mitigate cardiac risk while highlighting the need for further research to elucidate its renal effects in this population.

Effects of SGLT2 Inhibitors in Patients with Cancer and Diabetes Mellitus: A Systematic Review and Meta-analysis

AIMS

Cardiovascular disease (CVD) and cancer represent significant global health challenges. An overlap between oncology and cardiology is compounded by cancer therapies, which are known to have cardiotoxic effects. Sodium-glucose cotransporter 2 inhibitors (SGLT2i), initially developed for treating diabetes, have shown promising cardiovascular benefits in non-cancer populations, particularly in preventing heart failure (HF) and reducing HF-related hospitalization and mortality in large randomized controlled trials (RCTs) across the spectrum of left ventricular ejection fraction (LVEF). However, their potential cardioprotective role in cancer patients remains unclear.This systematic review and meta-analysis evaluated cardiovascular outcomes in cancer patients with type 2 diabetes undergoing chemotherapy with concomitant use of SGLT2i compared to those not using SGLT2i. Subgroup analyses were performed to explore patients without baseline HF and patients treated exclusively with anthracyclines.

METHODS AND RESULTS

A systematic review identified eleven observational retrospective studies (n=104,327 patients). Based on the National Institutes of Health Quality Assessment Tool (NIH-QAT) checklist, 2 studies were at moderate risk of bias, while all other included studies had a low risk of bias. Meta-analysis indicated that the use of SGLT2i was associated with a significant reduction in all-cause mortality (0.47, 95% CI 0.33-0.67, P<0.0001) and risk of HF hospitalization (0.44, 95% CI 0.27-0.72, P=0.001).

CONCLUSION

SGLT2i use may be associated with a significant reduction in all-cause mortality and risk of HF hospitalization in actively treated cancer patients with type 2 diabetes. Our study highlights the need for further investigation through prospective RCTs to confirm the efficacy and safety of SGLT2i in attenuating cardiotoxicity and supporting cardiovascular health in oncology settings.

In the Era of Cardiovascular-Kidney-Metabolic Syndrome in Cardio-Oncology: From Pathogenesis to Prevention and Therapy

Cardiovascular-kidney-metabolic (CKM) syndrome represents a complex interplay between cardiovascular disease (CVD), chronic kidney disease (CKD), and metabolic disorders, significantly impacting cancer patients. The presence of CKM syndrome in cancer patients not only worsens their prognosis but also increases the risk of major adverse cardiovascular events (MACE), reduces quality of life (QoL), and affects overall survival (OS). Furthermore, several anticancer therapies, including anthracyclines, tyrosine kinase inhibitors, immune checkpoint inhibitors, and hormonal treatments, can exacerbate CKM syndrome by inducing cardiotoxicity, nephrotoxicity, and metabolic dysregulation. This review explores the pathophysiology of CKM syndrome in cancer patients and highlights emerging therapeutic strategies to mitigate its impact. We discuss the role of novel pharmacological interventions, including sodium-glucose cotransporter-2 inhibitors (SGLT2i), proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), and soluble guanylate cyclase (sGC) activators, as well as dietary and lifestyle interventions. Optimizing the management of CKM syndrome in cancer patients is crucial to improving OS, enhancing QoL, and reducing MACE. By integrating cardiometabolic therapies into oncologic care, we can create a more comprehensive treatment approach that reduces the burden of cardiovascular and renal complications in this vulnerable population. Further research is needed to establish personalized strategies for CKM syndrome prevention and treatment in cancer patients.

Impact of SGLT2 inhibitors on survival in gastrointestinal cancer patients undergoing chemotherapy and/or radiotherapy: a real-world data retrospective cohort study

BACKGROUND

The role of sodium-glucose co-transporter 2 inhibitor (SGLT2i) drugs in the management of diabetes and cardiovascular disease is well-established, but emerging evidence suggests potential effects on cancer outcomes, including gastrointestinal (GI) cancers. We conducted an extensive, sex-oriented, real-world data analysis to investigate whether SGLT2i can enhance GI cancer outcomes when used alongside standard therapies such as chemotherapy and radiotherapy.

METHODS

The study applied a retrospective cohort design with data from the TriNetX research database ( https://trinetx.com ), examining GI cancer patients treated with chemotherapy and/or radiotherapy between 2013 and 2023. The intervention cohort consisted of Gl cancer patients who received SGLT2i, while the control cohort did not. A 5-year follow-up period was used, and baseline characteristics were balanced using a 1:1 propensity score matching technique. Cox proportional-hazards and logistic regression models assessed mortality and morbidity risks between the cohorts.

RESULTS

The study included 6,389 male and 3,457 female patients with GI cancer (ICD-10: C15-C25). The use of SGLT2i was significantly associated with improved survival for both male (HR 0.568; 95% CI 0.534-0.605) and female (HR 0.561; 95% CI 0.513-0.614) patients undergoing chemotherapy and/or radiotherapy. SGLT2i use also correlated significantly with lower hospitalisation rates both in male (OR 0.684; 95% CI 0.637-0.734) and female (OR, 0.590; 95% CI 0.536-0.650) patients. The analysis of GI cancer subtypes also demonstrated similar benefits, without significant adverse effects.

CONCLUSIONS

Repurposing SGLT2 inhibitors for cancer treatment could potentially improve outcomes for GI cancer patients without causing significant side effects. Further clinical trials are needed to confirm these findings and establish the optimal condition for its application in GI cancer treatment.

Cancer-Therapy-Related Cardiac Dysfunction: Latest Advances in Prevention and Treatment

The increasing efficacy of cancer therapies has significantly improved survival rates, but it has also highlighted the prevalence of cancer-therapy-related cardiac dysfunction (CTRCD). This review provides a comprehensive overview of the identification, monitoring, and management of CTRCD, a condition resulting from several treatments, such as anthracyclines, HER2-targeted therapies, target therapies, and radiotherapy. The paper includes a discussion of the mechanisms of CTRCD associated with various cancer treatments. Early detection through serum biomarkers and advanced imaging techniques is crucial for effective monitoring and risk stratification. Preventive strategies include pharmacological interventions such as ACE inhibitors/angiotensin receptor blockers, beta-blockers, and statins. Additionally, novel agents like sacubitril/valsartan, sodium-glucose co-transporter type 2 inhibitors, and vericiguat show promise in managing left ventricular dysfunction. Lifestyle modifications, including structured exercise programs and optimized nutritional strategies, further contribute to cardioprotection. The latest treatments for both asymptomatic and symptomatic CTRCD across its various stages are also discussed. Emerging technologies, including genomics, artificial intelligence, novel biomarkers, and gene therapy, are paving the way for personalized approaches to CTRCD prevention and treatment. These advancements hold great promise for improving long-term outcomes in cancer patients by minimizing cardiovascular complications.

Streptozotocin-induced hyperglycemia unmasks cardiotoxicity induced by doxorubicin

Late-onset cardiotoxicity induced by anthracyclines occurs years to decades after completion of anti-cancer therapy and is associated with increased morbi-mortality of cancer survivors. Chemotherapy at the time of treatment probably causes cardiac damages for which the juvenile heart compensate. Co-morbidities happening in the adulthood such as type 1 diabetes (DT1), affect the heart and thus can unmask chemotherapy induced cardiotoxicity. To prove our hypothesis, we induced hyperglycemia [Streptozotocin treatment (STZ), 50 mg/kg/day for 5 days] in 11 weeks old mice who previously received doxorubicin treatment (Dox, 3 mg/kg) when they were six-weeks old. Interestingly, streptozotocin-induced hyperglycemia in Dox-pretreated mice (Dox-STZ) induced a higher mortality (p < 0.05) and more severe cardiac dysfunction (p < 0.0001) when compared with mice receiving Dox or STZ alone. Apoptosis evaluated by caspase 3 protein expression and Bax/Bcl2 genes expression was higher in Dox-STZ mice compared to STZ or Dox alone. While Dox and STZ independently induced capillary rarefaction, cardiomyocytes atrophy was only induced by STZ. Furthermore, Sirius-red staining of cardiac sections showed higher fibrosis levels (p < 0.0001) in Dox-STZ compared to Dox or STZ alone. All together, these results demonstrate that STZ precipitates and unmask cardiac dysfunction in previously treated Dox animals.

Impact of sodium-glucose cotransporter-2 inhibitors on heart failure outcomes in cancer patients and survivors: a systematic review and meta-analysis

AIMS

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recognized for their cardiovascular benefits. This systematic review and meta-analysis evaluated the impact of SGLT2i on heart failure (HF) outcomes in cancer patients and survivors, focusing on HF hospitalization and new HF diagnoses.

METHODS AND RESULTS

A comprehensive search of PubMed, MEDLINE, and Embase via Ovid, and the Cochrane Library was conducted up to 5 June 2024, focusing on studies involving cancer patients and survivors treated with SGLT2i. The search criterion used was [(SGLT2) OR (Sodium glucose cotransporter 2 inhibitors) OR (canagliflozin) OR (dapagliflozin) OR (empagliflozin) OR (ertugliflozin) AND (cancer)]. The primary outcomes assessed were HF hospitalization and new HF diagnoses. The search yielded 1880 studies, from which 13 studies encompassing 88 273 patients were included. SGLT2i use reduced HF hospitalizations by 51% (RR 0.49, 95% CI 0.36-0.66, I² = 28%, P < 0.01) and new HF diagnoses by 71% (RR 0.29, 95% CI 0.10-0.87, I² = 71%). Multi-variate meta-regression analysis suggested that among breast cancer populations, studies with ≥50% of patients on anthracyclines exhibited a 99% reduction in HF hospitalization risk compared with similar studies that included <50% of patients on anthracyclines (RR 0.0085, 95% CI: 0.0001-0.2645, P = 0.0081).

CONCLUSION

SGLT2i significantly lower the risk of HF hospitalization and new HF diagnoses among cancer patients and survivors, with particularly pronounced benefits in breast cancer patients receiving anthracycline-based chemotherapy. These findings support the need for prospective trials to further investigate the integration of SGLT2i into cancer patient management to enhance cardiovascular outcomes.

Prevention of cancer-therapy related cardiac dysfunction

PURPOSE OF REVIEW

Introduction of modern cancer therapies has led to increased survival of affected patients. With this advantage, the incidence of cancer therapy-related cardiac dysfunction (CTRCD) has increased and reasonable prevention strategies become necessary. This review outlines the major approaches to limit development and progression of CTRCD.

RECENT FINDINGS

A broad range of cancer therapies can provoke CTRCD ranging from mild asymptomatic forms to severe heart failure. Profound cardiological assessment of cardiovascular comorbidities before initiation of cancer therapy allows identification of cancer patients at higher risk developing CTRCD which may also require closer surveillance. Cardioprotective adjustment of cancer therapy and initiation of cardioprotective medication and lifestyle optimization prior to anti-cancer treatment additionally limit the risk of CTRCD. During therapy, regular examination of cancer patients using high-sensitive cardiological diagnostic tools as three-dimensional (3D) echocardiography and global longitudinal strain (GLS) enables early detection of mild forms of CTRCD. This allows appropriate adjustment of cancer therapy and initiation of CTRCD treatment to prevent further progression to severe forms. Cardiological risk stratification before treatment initiation, cardioprotective interventions before and during cancer therapy, along with regular monitoring of treated cancer patients, can help prevent the development of CTRCD. This maintains the antitumor effects of cancer therapy while limiting cardiotoxic side effects resulting in improved quality of life and mortality of affected cancer patients.

Life's Essential 8 and Cardiovascular Disease in Breast Cancer Survivors

PURPOSE OF REVIEW

To explore the role of optimal cardiovascular health as defined by the Life's Essential 8 in breast cancer survivors.

RECENT FINDINGS

Optimal cardiovascular health may be associated with decreased cancer mortality. Breast cancer survivors may derive additional benefit from obtaining ideal cardiovascular health as defined by the Life's Essential 8. Certain components of the Life's Essential 8 may impact cardiovascular risk but also cancer mortality, and risk for cancer therapy related cardiac dysfunction. Continued physical activity, avoidance of smoking, and control of lipids and blood pressure are beneficial in breast cancer survivors. More study is needed to define the role of anti-hyperglycemic agents, BMI, and sleep on CVD risk in breast cancer survivors. The Life's Essential 8 can be a tool to inform clinicians regarding a breast cancer survivor's disease risk and to identify potential areas of improvement.

Effect on cardiovascular outcome of sodium-glucose co-transporter-2 (SGLT2) inhibitors among cancer patients treated with anthracycline: a systematic review and meta-analysis

Background/objectives

Sodium-glucose-co-transporter-2 (SGLT2) inhibitors have shown benefit in reducing cardiovascular disease outcomes in diabetes patients. Anthracycline therapy is associated with a risk of cardiomyopathy. However, the impact of SGLT2 inhibitors in the prevention of cardiomyopathy and heart failure in cancer patients undergoing anthracycline treatment remains unclear. Thus, we conducted a systematic review and meta-analysis to explore the effect of the prevention of cardiovascular outcomes in patients with cancer and diabetes who had received anthracycline therapy.

Methods

We systematically reviewed Medline and EMBASE databases from inception to January 2024 for studies focusing on cancer patients with a history of anthracycline therapy. Eligible studies had to report relative risk (RR) with 95% confidence intervals (CIs) for the clinical endpoints of mortality outcomes and the risk of heart failure exacerbation, comparing cohorts with and without SGLT2 inhibitor use.

Results

Our study included four retrospective cohort studies in the meta-analysis (n = 6,708, 24% received SGLT2). There was significantly lower all-cause mortality in the SGLT2 inhibitors group (pooled RR of 0.52, 95% CI 0.35-0.77, I 2 64%). However, there were no differences in the risk of heart failure exacerbation (pooled RR of 0.67, 95% CI 0.39-1.14, I 2 17%).

Conclusion

Our study found that anthracycline-treated cancer patients using SGLT2 inhibitors experienced lower all-cause mortality compared to the control group. A randomised clinical trial is necessary to further elucidate these findings.

SGLT2 inhibitors for prevention and management of cancer treatment-related cardiovascular toxicity: a review of potential mechanisms and clinical insights

More evidence-based strategies are needed for preventing and managing cancer treatment-related cardiovascular toxicity (CTR-CVT). Owing to the growing body of evidence supporting their cardioprotective role in several cardiac injury scenarios, sodium-glucose cotransporter 2 inhibitors (SGLT2i) may be beneficial for preventing and treating CTR-CVT. In October 2024, a search was conducted of the PubMed database to review full studies investigating the cardioprotective role of SGLT2i against CTR-CVT. We identified 44 full published/pre-print studies and 3 ongoing randomised controlled trial across eight types of cancer treatment (anthracyclines, platinum-containing therapy, immune checkpoint inhibitors, HER2-targeted therapies, kinase inhibitors, androgen deprivation therapies, multiple myeloma therapies and 5-fluorouracil). Most studies used animal models and focussed on primary prevention. 43 of the 44 studies found some cardioprotective effect of SGLT2i against CTR-CVT, which in some cases included preventing ejection fraction decline and aberrations in cardiac electrophysiological parameters. Some studies also observed beneficial effects on mortality. A central triad of anti-inflammatory, anti-oxidative and anti-apoptotic mechanisms likely underlie SGLT2i-mediated cardioprotection against CTR-CVT. Overall, this growing body of research suggests that SGLT2i may be a promising candidate for preventing CTR-CVT either as monotherapy or in combination with other cardioprotective drugs. However, the literature is limited in that no prospective randomised controlled trials investigating SGLT2i for the prevention and management of CTR-CVT exist and most existing human retrospective data is based on diabetic populations. Future work must focus on addressing these limitations of the current literature.

Advances in sodium-glucose transporter protein 2 inhibitors and tumors

Tumor is a major challenge to global health and has received extensive attention worldwide due to its high degree of malignancy and poor prognosis. Although the clinical application of targeted therapy and immunotherapy has improved the status quo of tumor treatment, the development of new therapeutic tools for tumors is still necessary. Sodium-glucose transporter protein 2 (SGLT2) inhibitors are a new type of glycemic control drugs, which are widely used in clinical practice because of their effects on weight reduction and protection of cardiac and renal functions. SGLT2 has been found to be overexpressed in many tumors and involved in tumorigenesis, progression and metastasis, suggesting that SGLT2i has a wide range of applications in tumor therapy. The aim of this article is to provide a comprehensive understanding of the research progress of SGLT2i in different tumors by integrating the latest studies and to encourage further exploration of SGLT2i therapies in clinical trials. This could pave the way for more effective management strategies and improved outcomes for tumor patients.

Glucagon-like Peptide-1 Agonists Reduce Cardiovascular Events in Cancer Patients on Immune Checkpoint Inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICIs) are associated with an increased risk of major adverse cardiovascular events (MACE). Glucagon-like peptide-1 agonists (GLP1a), initially developed for type 2 diabetes mellitus (T2DM), have shown promising results in reducing cardiovascular events. We aimed to investigate the effect of GLP1a on cardiovascular events in patients receiving ICIs.

METHODS

We conducted a retrospective, propensity score-matched cohort study using the TriNetX database. We identified adults with cancer and T2DM who received ICIs between April 2013 and May 2023. The primary efficacy outcome was incident MACE, defined as a composite of myocardial infarction, need for coronary revascularization, heart failure, ischemic stroke, and cardiac arrest. The secondary efficacy outcomes were the individual components of MACE as well as myocarditis and pericarditis. Safety outcomes included the occurrence of immune-related adverse events, serious adverse events related to GLP1a use, and all-cause mortality.

RESULTS

We identified 7651 patients eligible for inclusion, among which 479 received GLP1a and 7172 received non-GLP1a diabetes medications. After matching (469 patients each), baseline characteristics were well-balanced. Over a median 12-month follow-up, the GLP1a cohort had a significantly lower MACE incidence than the non-GLP1a cohort (9.0 vs. 17.1 events per 100 patient-years) with a 54 % lower risk of MACE (Hazard ratio (HR),0.46 [95 % CI: 0.32-0.67]). There were reductions in myocardial infarction or need for coronary revascularization, heart failure, and all-cause mortality, with no differences in other cardiovascular events. GLP1a use did not increase risk of adverse events, including pancreatitis, biliary disease, bowel obstruction, gastroparesis, and immune-related adverse events.

CONCLUSION

GLP1a use in cancer patients with T2DM receiving ICIs was associated with reduced MACE and all-cause mortality without an increased risk in serious adverse events.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Sodium-glucose cotransporter 2 inhibitors and the cancer patient: from diabetes to cardioprotection and beyond

Sodium-glucose cotransporter 2 inhibitors (SGLT2i), a new drug class initially designed and approved for treatment of diabetes mellitus, have been shown to exert pleiotropic metabolic and direct cardioprotective and nephroprotective effects that extend beyond their glucose-lowering action. These properties prompted their use in two frequently intertwined conditions, heart failure and chronic kidney disease. Their unique mechanism of action makes SGLT2i an attractive option also to lower the rate of cardiac events and improve overall survival of oncological patients with preexisting cardiovascular risk and/or candidate to receive cardiotoxic therapies. This review will cover biological foundations and clinical evidence for SGLT2i modulating myocardial function and metabolism, with a focus on their possible use as cardioprotective agents in the cardio-oncology settings. Furthermore, we will explore recently emerged SGLT2i effects on hematopoiesis and immune system, carrying the potential of attenuating tumor growth and chemotherapy-induced cytopenias.

Cardioprotection strategies for anthracycline cardiotoxicity

Thanks to the fantastic progress in cancer therapy options, there is a growing population of cancer survivors. This success has resulted in a need to focus much effort into improving the quality of life of this population. Cancer and cardiovascular disease share many common risk factors and have an interplay between them, with one condition mechanistically affecting the other and vice versa. Furthermore, widely prescribed cancer therapies have known toxic effects in the cardiovascular system. Anthracyclines are the paradigm of efficacious cancer therapy widely prescribed with a strong cardiotoxic potential. While some cancer therapies cardiovascular toxicities are transient, others are irreversible. There is a growing need to develop cardioprotective therapies that, when used in conjunction with cancer therapies, can prevent cardiovascular toxicity and thus improve long-term quality of life in survivors. The field has three main challenges: (i) identification of the ultimate mechanisms leading to cardiotoxicity to (ii) identify specific therapeutic targets, and (iii) more sensible diagnostic tools to early identify these conditions. In this review we will focus on the cardioprotective strategies tested and under investigation. We will focus this article into anthracycline cardiotoxicity since it is still the agent most widely prescribed, the one with higher toxic effects on the heart, and the most widely studied.

SGLT2i Therapy Prevents Anthracycline-Induced Cardiotoxicity in a Large Animal Model by Preserving Myocardial Energetics

BACKGROUND

Anthracycline-induced cardiotoxicity (AIC) is characterized by a disruption in myocardial metabolism.

OBJECTIVES

The authors used a large animal model to test sodium-glucose cotransporter inhibitor therapy to prevent AIC.

METHODS

Female large white pigs (n = 36) were used to identify the most translational AIC regimen: 6 triweekly intravenous doxorubicin injections (1.8 mg/kg each). Another group of 32 pigs were randomized (1:1:2) to doxorubicin plus empagliflozin 20 mg, doxorubicin plus empagliflozin 10 mg, or doxorubicin control. Pigs were serially examined using multiparametric cardiac magnetic resonance and magnetic resonance spectroscopy. At the end of the 21-week follow-up period, blood samples were obtained to measure myocardial metabolic substrate extraction, and the left ventricle was harvested and processed for analysis using metabolomics, transmission electron microscopy, mitochondrial respirometry, and histopathology.

RESULTS

Final left ventricular ejection fraction (LVEF), the prespecified primary outcome, was significantly higher in pigs receiving 20 mg empagliflozin than in the doxorubicin control group (median 57.5% [Q1-Q3: 55.5%-60.3%] vs 47.0% [Q1-Q3: 40.8%-47.8%]; P = 0.027). Final LVEF in pigs receiving 10 mg empagliflozin was 51% (Q1-Q3: 46.5%-55.5%; P = 0.020 vs 20 mg empagliflozin). The incidence of AIC events was 0%, 50%, and 72% in the empagliflozin 20 mg, empagliflozin 10 mg, and doxorubicin control groups, respectively. Empagliflozin 20 mg treatment resulted in enhanced ketone body consumption by the myocardium, preserved magnetic resonance spectroscopy-measured cardiac energetics, and improved mitochondrial structure and function on transmission electron microscopy and respirometry. These changes were more modest with the 10-mg empagliflozin dose.

CONCLUSIONS

Sodium-glucose cotransporter-2 inhibitor therapy with empagliflozin exerts a dose-dependent cardioprotective effect against AIC. The improved LVEF was accompanied by enhanced ketone body consumption, improved cardiac energetics, and preserved mitochondrial structure and function.

Anthracycline-induced cardiomyopathy: risk prediction, prevention and treatment

Anthracyclines are the cornerstone of treatment for many malignancies. However, anthracycline cardiotoxicity is a considerable concern given that it can compromise the clinical effectiveness of the treatment and patient survival despite early discontinuation of therapy or dose reduction. Patients with cancer receiving anthracycline treatment can have a reduction in their quality of life and likelihood of survival due to cardiotoxicity, irrespective of their oncological prognosis. Increasing knowledge about anthracycline cardiotoxicity has enabled the identification of patients who are candidates for anthracycline regimens and those who might develop anthracycline-induced cardiomyopathy. Anthracycline cardiotoxicity is a unique and evolving phenomenon that begins with myocardial cell damage, progresses to reduced left ventricular ejection fraction, and culminates in symptomatic heart failure if it is not promptly detected and treated. Early risk stratification can be guided by imaging or biomarkers. In this Review, we present a comprehensive and clinically useful approach to cardiomyopathy related to anthracycline therapy, encompassing its epidemiology, definition, mechanisms, novel classifications, risk factors and patient risk stratification, diagnostic approaches (including imaging and biomarkers), treatment guidelines algorithms, and the role of new cardioprotective drugs that are used for the treatment of heart failure.

Atherosclerosis and the Bidirectional Relationship Between Cancer and Cardiovascular Disease: From Bench to Bedside, Part 2 Management

The first part of this review highlighted the evolving landscape of atherosclerosis, noting emerging cardiometabolic risk factors, the growing impact of exposomes, and social determinants of health. The prominent role of atherosclerosis in the bidirectional relationship between cardiovascular disease and cancer was also discussed. In this second part, we examine the complex interplay between multimorbid cardio-oncologic patients, cardiometabolic risk factors, and the harmful environments that lend a "syndemic" nature to these chronic diseases. We summarize management strategies targeting disordered cardiometabolic factors to mitigate cardiovascular disease and explore molecular mechanisms enabling more tailored therapies. Importantly, we emphasize the early interception of atherosclerosis through multifactorial interventions that detect subclinical signs (via biomarkers and imaging) to treat modifiable risk factors and prevent clinical events. A concerted preventive effort-referred to by some as a "preventome"-is essential to reduce the burden of atherosclerosis-driven chronic diseases, shifting from mere chronic disease management to the proactive promotion of "chronic health".

Cancer survivors and cardiovascular diseases: from preventive strategies to treatment

During the last decades, progress in the treatment of oncological diseases has led to an increase in the survival of cancer patients: cancer survivors (CS). Thus, the incidence of CS has increased enormously, in both adult CS and childhood and adolescent CS. Unfortunately, CS treated with anthracyclines, chest radiotherapy (RT) and other potentially cardiotoxic drugs have a higher risk of cardiovascular (CV) toxicity: heart failure with reduced ejection fraction (HFrEF), valve diseases, coronary artery diseases, vascular diseases and pericardial diseases. In fact, chest irradiation can cause coronary artery diseases that can be latent until at least 10 years after exposure; also, valvular heart diseases can appear after >20 years following irradiation; heart failure may appear later, several years after anticancer drugs or RT. Therefore, it is very important to stratify the CV risk of cancer patients at the end of cardiotoxic drugs, to plan the most appropriate long-term surveillance program, in accordance with 2022 ESC Guidelines on Cardio-Oncology, to prevent late cardiovascular complications. Monitoring of cancer patients must not stop during anticancer treatment but it must continue afterwards, depending on the patient's CV risk. CV toxicity risk should be reassessed 5 years after therapy to organize long-term follow-up. Considering late cardiotoxicity in CS, our review aims to evaluate the incidence of cardiovascular diseases in CS, their mechanisms, surveillance protocols, preventive strategies, diagnosis and treatment.

New insights into mitochondrial quality control in anthracycline-induced cardiotoxicity: molecular mechanisms, therapeutic targets, and natural products

Anthracyclines (ANTs) are widely used in cancer therapy, particularly for lymphoma, sarcoma, breast cancer, and childhood leukemia, and have become the cornerstone of chemotherapy for various malignancies. However, it is associated with fatal and dose-dependent cardiovascular complications, especially cardiotoxicity. Mitochondrial quality control mechanisms, encompassing mitophagy, mitochondrial dynamics, and mitochondrial biogenesis, maintain mitochondrial homeostasis in the cardiovascular system. Recent studies have highlighted that mitochondrial quality control mechanisms play considerable roles in ANTs-induced cardiotoxicity (AIC). In addition, natural products targeting mitochondrial quality control mechanisms have emerged as potential therapeutic strategies to alleviate AIC. This review summarizes the types, incidence, prevention, treatment, and pathomechanism of AIC, delves into the molecular mechanisms of mitochondrial quality control in the pathogenesis of AIC, and explores natural products that target these mechanisms, so as to provide potential targets and therapeutic drugs for address the clinical challenges in AIC prevention and treatment, where no effective medicines are available.

Cancer Therapy-Related Cardiac Dysfunction: A Review of Current Trends in Epidemiology, Diagnosis, and Treatment

Cancer therapy-related cardiac dysfunction (CTRCD) has emerged as a significant concern with the rise of effective cancer treatments like anthracyclines and targeted therapies such as trastuzumab. While these therapies have improved cancer survival rates, their unintended cardiovascular side effects can lead to heart failure, cardiomyopathy, and arrhythmias. The pathophysiology of CTRCD involves oxidative stress, mitochondrial dysfunction, and calcium dysregulation, resulting in irreversible damage to cardiomyocytes. Inflammatory cytokines, disrupted growth factor signaling, and coronary atherosclerosis further contribute to this dysfunction. Advances in cardio-oncology have led to the early detection of CTRCD using cardiac biomarkers like troponins and imaging techniques such as echocardiography and cardiac magnetic resonance (CMR). These tools help identify asymptomatic patients at risk of cardiac events before the onset of clinical symptoms. Preventive strategies, including the use of cardioprotective agents like beta-blockers, angiotensin-converting enzyme inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors have shown promise in reducing the incidence of CTRCD. This review summarizes the mechanisms, detection methods, and emerging treatments for CTRCD, emphasizing the importance of interdisciplinary collaboration between oncologists and cardiologists to optimize care and improve both cancer and cardiovascular outcomes.

SGLT2 Inhibitor for Cardiac Protection in a Patient With Osimertinib-Responsive Advanced EGFR-Positive Lung Cancer

An 85-year-old man with recently diagnosed metastatic EGFR+ lung adenocarcinoma treated with osimertinib presented after 1 month of therapy in decompensated congestive heart failure along with atrial fibrillation, prolonged QTc and acute kidney injury. Osimertinib was held. His hemodynamic status was optimized, and he was started on cardioprotective medications (losartan and metoprolol succinate), and LVEF recovered. However, after reintroducing osimertinib, LVEF reduced, indicating possible osimertinib-induced cardiomyopathy. An SGLT2 inhibitor was added for cardioprotection before another rechallenge of osimertinib. SGLT2 inhibitors are a powerful tool for heart failure and may have a potential secondary benefit in ameliorating cardiotoxic processes. Although their use in osimertinib-induced cardiomyopathy has not been well-established, current heart failure guidelines and emerging research support its use in this setting. This case and the accompanying literature review highlight the novel use of SGLT2 inhibitors coupled with regular clinical and imaging monitoring, as a compelling intervention for osimertinib-induced cardiomyopathy.

A Systematic Review and Meta-Analysis of Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors and Their Impact on the Management of Heart Failure

Heart failure (HF) is a life-threatening condition with severe incapacitating consequences. Many body organs and systems may be affected, which may also hinder the quality of life and finances at the individual and societal levels. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have also emerged as potentially useful drugs in the HF domain and other medical fields, in addition to their glucose-lowering effect. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the authors searched Google Scholar, PubMed, and Scopus websites for SGLT2i and SGLT2i-related terms and their impact on HF events, major adverse cardiovascular events (MACEs), renal composite outcomes, and improvement in the Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, involving human adult populations. Two reviewers conducted the literature search, and disagreements were resolved through mutual consensus and input from a third reviewer. A literature search was conducted from 1st February to 20th February 2024. We included studies published after 2018 to focus only on the latest advancements. Randomized controlled trials, observational studies, or systematic reviews of these studies were included in our study. Of the 44 initial articles identified, only 14 met the inclusion and exclusion criteria. The outcomes revealed the superiority of SGLT2i therapeutics over placebo in all four domains mentioned above. A total of 234,509 patients from 11 papers with moderate heterogeneity (P = 0.07; I2 = 42%) evaluating the effect of SGLT2i in comparison to placebo on HF events were considered; of these, 128,477 patients received the intervention drug, and 106,032 individuals were assigned to the control group. The absolute numbers of HF events were 6845 and 8877, respectively. The study showed an overall benefit of SGLT2i in patients with heart failure due to their ability to major adverse cardiovascular events (MACE) in comparison to placebo (OR: 0.92; 95% CI: 0.89-0.96; P < 0.00001). This systematic review confirmed previous findings related to the use of SGLT2i as adjunctive therapy for HF and amelioration of KCCQ scores and as a protective agent against MACE and renal impairment progression.

Deciphering the cardioprotective effects of statins in anthracycline-related cardiac dysfunction: A systematic review and meta-analysis

Background

Cancer induced chronic inflammation and cancer drugs effects on the vascular system can lead to rapidly progressing atherosclerotic burden. Statins drugs are known to reduce atherosclerotic plaque burden and inflammation. We studied outcomes of statins for anthracycline-related cardiac dysfunction (ARCD).

Methods

We conducted an online systematic search on PubMed and Embase to identify studies assessing statins' role in alleviating ARCD. We selected 9 studies that had patients with ARCD and use of statins. We primarily focused on outcomes including incidence of heart failure (HF), mean changes in left ventricular ejection fraction (LVEF), end-diastolic volume (LVEDV), and end-systolic volume (LVESV) from baseline. Odds ratios (OR) were calculated using a random effect model in R-statistics.

Results

Among 9 studies with a total of 2784 patients we noticed a significant reduction in the incidence of HF among patients administered statins, with an OR of 0.52 (95 % CI 0.37-0.74, p < 0.0003), indicating a substantial protective effect. However, the mean changes in EF, LVEDV, and LVESV from baseline, represented by Hedges's g of 1.09 (95 % CI -0.40 to 2.57, p = 0.15), 0.91 (95 % CI -1.69 to 3.51, p = 0.47), and 1.32 (95 % CI -2.30 to 4.94, p = 0.49) respectively, were not statistically significant. (Figure 1).

Conclusion

Our meta-analysis confirms statins' effectiveness in reducing risk of ARCD. However, their influence on EF, LVEDV, and LVESV remains uncertain, warranting further study.

SGLT2i and Primary Prevention of Cancer Therapy-Related Cardiac Dysfunction in Patients With Diabetes

Background

Specific cancer treatments can lead to cancer therapy-related cardiac dysfunction (CTRCD). Sodium glucose cotransporter-2 inhibitors (SGLT2is) can potentially prevent these cardiotoxic effects.

Objectives

This study sought to determine whether SGLT2i use is associated with a lower incidence of CTRCD in patients with type 2 diabetes mellitus (T2DM) and cancer, exposed to potentially cardiotoxic antineoplastic agents, and without a prior documented history of cardiomyopathy or heart failure.

Methods

We conducted a retrospective analysis of patients aged ≥18 years within the TriNetX database with T2DM, cancer, exposure to cardiotoxic therapies, and no prior documented history of cardiomyopathy or heart failure. Patients were categorized by SGLT2i use. After propensity score matching, outcomes were compared over 12 months using Cox proportional HRs. Subgroup analyses focusing on different cancer therapy classes were performed.

Results

The study included 8,675 propensity-matched patients in each cohort (mean age = ∼65 years, 42% females, 71% White, ∼19% gastrointestinal malignancy, and ∼25% anthracyclines). Patients prescribed SGLT2is had a lower risk of developing CTRCD (HR: 0.76: 95% CI: 0.69-0.84). SGLT2is also reduced heart failure exacerbations (HR: 0.81; 95% CI: 0.72-0.90), all-cause mortality (HR: 0.67; 95% CI: 0.61-0.74), and all-cause hospitalizations/emergency department visits (HR: 0.93; 95% CI: 0.89-0.97). Subgroup analyses also demonstrated reduced CTRCD risk across various classes of cancer therapies in patients prescribed SGLT2is.

Conclusions

SGLT2i administration was associated with a significantly decreased risk of developing CTRCD in patients with T2DM and cancer.

Anti-Diabetic Therapies and Cancer: From Bench to Bedside

Diabetes mellitus (DM) is a significant risk factor for various cancers, with the impact of anti-diabetic therapies on cancer progression differing across malignancies. Among these therapies, metformin has gained attention for its potential anti-cancer effects, primarily through modulation of the AMP-activated protein kinase/mammalian target of rapamycin (AMPK/mTOR) pathway and the induction of autophagy. Beyond metformin, other conventional anti-diabetic treatments, such as insulin, sulfonylureas (SUs), pioglitazone, and dipeptidyl peptidase-4 (DPP-4) inhibitors, have also been examined for their roles in cancer biology, though findings are often inconclusive. More recently, novel medications, like glucagon-like peptide-1 (GLP-1) receptor agonists, dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) agonists, and sodium-glucose co-transporter-2 (SGLT-2) inhibitors, have revolutionized DM management by not only improving glycemic control but also delivering substantial cardiovascular and renal benefits. Given their diverse metabolic effects, including anti-obesogenic properties, these novel agents are now under meticulous investigation for their potential influence on tumorigenesis and cancer advancement. This review aims to offer a comprehensive exploration of the evolving landscape of glucose-lowering treatments and their implications in cancer biology. It critically evaluates experimental evidence surrounding the molecular mechanisms by which these medications may modulate oncogenic signaling pathways and reshape the tumor microenvironment (TME). Furthermore, it assesses translational research and clinical trials to gauge the practical relevance of these findings in real-world settings. Finally, it explores the potential of anti-diabetic medications as adjuncts in cancer treatment, particularly in enhancing the efficacy of chemotherapy, minimizing toxicity, and addressing resistance within the framework of immunotherapy.

Meta-analysis of the efficacy and impact on cardiac function of sodium-glucose cotransporter 2 inhibitor Empagliflozin in heart failure patients

BACKGROUND

Currently, there is no comprehensive systematic review available to comprehensively assess the efficacy and safety of Empagliflozin and other sodium-glucose cotransporter 2 inhibitors in the treatment of heart failure (HF). This study employed a meta-analysis approach to systematically evaluate the therapeutic effects of Empagliflozin in HF patients and its impact on cardiac function.

METHOD

The keywords including "heart failure," "HF," "cardiac failure," "cardiac disease," "Empagliflozin," and "sodium-glucose cotransporter 2 inhibitors" were utilized to search for relevant clinical studies on Empagliflozin in the treatment of HF in various databases, such as China National Knowledge Infrastructure, Wanfang, VIP Chinese Medical Journal Database, PubMed, MEDLINE, Embase, Cochrane Library, Springer, and Science Direct. The studies included patients with HF who received drug treatment. Data on baseline characteristics and posttreatment outcomes, including HF hospitalization (HHF), cardiovascular mortality, all-cause mortality, estimated glomerular filtration rate changes, Kansas City Cardiomyopathy Questionnaire quality of life (QoL) scores, N-terminal pro-B-type natriuretic peptide, left ventricular ejection fraction, hematocrit, and other relevant indicators were collected. Meta-analysis was conducted using RevMan5.3 to analyze the extracted data.

RESULTS

A total of 15 studies were included in the final analysis, comprising 36,917 patients with HF. Among them, 18,486 patients were in Empagliflozin group, and 18,431 patients were in control (Ctrl) group. The results of the meta-analysis demonstrated that, relative to Ctrl group, Empagliflozin group showed a substantially lower HHF rate, a substantial improvement in estimated glomerular filtration rate changes, a reduced cardiovascular mortality rate, a higher Kansas City Cardiomyopathy Questionnaire QoL score, increased hematocrit values, reduced N-terminal pro-B-type natriuretic peptide changes, and enhanced left ventricular ejection fraction changes. These findings suggest that remarkable improvements in various outcomes compared to the Ctrl group.

CONCLUSION

The sodium-glucose cotransporter 2 inhibitor Empagliflozin markedly reduces the HHF rate and cardiovascular mortality in HF patients. It also improves patients' QoL, enhances renal function, and increases cardiac function while reducing both, the preload and afterload.

Digital solutions to optimize guideline-directed medical therapy prescription rates in patients with heart failure: a clinical consensus statement from the ESC Working Group on e-Cardiology, the Heart Failure Association of the European Society of Cardiology, the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology, the ESC Digital Health Committee, the ESC Council of Cardio-Oncology, and the ESC Patient Forum

The 2021 European Society of Cardiology guideline on diagnosis and treatment of acute and chronic heart failure (HF) and the 2023 Focused Update include recommendations on the pharmacotherapy for patients with New York Heart Association (NYHA) class II-IV HF with reduced ejection fraction. However, multinational data from the EVOLUTION HF study found substantial prescribing inertia of guideline-directed medical therapy (GDMT) in clinical practice. The cause was multifactorial and included limitations in organizational resources. Digital solutions like digital consultation, digital remote monitoring, digital interrogation of cardiac implantable electronic devices, clinical decision support systems, and multifaceted interventions are increasingly available worldwide. The objectives of this Clinical Consensus Statement are to provide (i) examples of digital solutions that can aid the optimization of prescription of GDMT, (ii) evidence-based insights on the optimization of prescription of GDMT using digital solutions, (iii) current evidence gaps and implementation barriers that limit the adoption of digital solutions in clinical practice, and (iv) critically discuss strategies to achieve equality of access, with reference to patient subgroups. Embracing digital solutions through the use of digital consults and digital remote monitoring will future-proof, for example alerts to clinicians, informing them of patients on suboptimal GDMT. Researchers should consider employing multifaceted digital solutions to optimize effectiveness and use study designs that fit the unique sociotechnical aspects of digital solutions. Artificial intelligence solutions can handle larger data sets and relieve medical professionals' workloads, but as the data on the use of artificial intelligence in HF are limited, further investigation is warranted.

Sodium-Glucose Cotransporter 2 Inhibitors During Cancer Therapy: Benefits, Risks, and Ongoing Clinical Trials

PURPOSE OF REVIEW

The goal of this paper is to summarize the data pertaining to the use of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) for the prevention of cardiotoxicity in patients receiving anthracyclines for cancer treatment. We discuss the potential efficacy of this class of medications, incorporating insights from existing literature and ongoing studies.

RECENT FINDINGS

SGLT2i are a class of medications which were initially developed for treatment of Type 2 diabetes and later extended to treat heart failure with reduced and preserved ejection fraction regardless of diabetes status. There remains a need for effective and safe treatments to preventing cardiotoxicity in anthracycline-treated patients. It has been proposed that SGLT2i may provide protection against the cardiotoxic effects of anthracyclines. Some of the proposed mechanisms include beneficial metabolic, neurohormonal, and hemodynamic effects, renal protection, as well as a decrease in inflammation, oxidative stress, apoptosis, mitochondrial dysfunction and ion homeostasis. There is emerging evidence from basic science and observational studies that SGLT2i may play a role in the prevention of chemotherapy-induced cardiotoxicity. Randomized controlled trials are needed to conclusively determine the role of SGLT2 inhibitors as a cardioprotective therapy in patients receiving anthracyclines for the treatment of cancer.

Cardiovascular Considerations Before Cancer Therapy: Gaps in Evidence and JACC: CardioOncology Expert Panel Recommendations

Baseline cardiovascular assessment before the initiation of potentially cardiotoxic cancer therapies is a key component of cardio-oncology, aiming to reduce cardiovascular complications and morbidity in patients and survivors. Recent clinical practice guidelines provide both general and cancer therapy-specific recommendations for baseline cardiovascular toxicity risk assessment and management, including the use of dedicated risk scores, cardiovascular imaging, and biomarker testing. However, the value of such interventions in altering disease trajectories has not been established, with many recommendations based on expert opinion or Level of Evidence: C, studies with a potential for high risk of bias. Advances in understanding underlying mechanisms of cardiotoxicity and the increased availability of genetic and immunologic profiling present new opportunities for personalized risk assessment. This paper evaluates the existing evidence on cardiovascular care of cancer patients before cardiotoxic cancer therapy and highlights gaps in evidence and priorities for future research.

How to utilize current guidelines to manage patients with cancer at high risk for heart failure

Heart failure (HF) in patients with cancer is associated with high morbidity and mortality. The success of cancer therapy has resulted in an exponential rise in the population of cancer survivors, however cardiovascular disease (CVD) is now a major life limiting condition more than 5 years after cancer diagnosis [Sturgeon, Deng, Bluethmann, et al 40(48):3889-3897, 2019]. Prevention and early detection of CVD, including cardiomyopathy (CM) and HF is of paramount importance. The European Society of Cardiology (ESC) published guidelines on Cardio-Oncology (CO) [Lyon, López-Fernández, Couch, et al 43(41):4229-4361, 2022] detailing cardiovascular (CV) risk stratification, prevention, monitoring, diagnosis, and treatment throughout the course and following completion of cancer therapy. Here we utilize a case to summarize aspects of the ESC guideline relevant to HF clinicians, with a focus on risk stratification, early detection, prevention of CM and HF, and the role for guideline directed medical therapy in patients with cancer.

Use of EMPAgliflozin in the prevention of CARDiotoxicity: the EMPACARD - PILOT trial

BACKGROUND

Anthracycline-based chemotherapy represents a cornerstone treatment for a number of common cancers, including breast cancer, lymphoma, and sarcoma. However, anthracycline-induced cardiotoxicity remains a significant concern, often presenting as a decline in cardiac function which can ultimately lead to heart failure (HF) or asymptomatic left ventricular dysfunction, in up to 10-15% of patients.Sodium-glucose transport protein 2 inhibitor (SGLT2i) therapies have been demonstrated to reduce the incidence of HF in high-risk non-cancer patients. Preliminary retrospective data suggest their role in mitigating the incidence of HF during or after anthracycline treatment METHODS: The EMPACARD-PILOT trial was a prospective case‒control study involving breast cancer patients scheduled to undergo anthracycline-based chemotherapy in a 4-cycle protocol of 60 mg/m2 doxorubicin. We used the HFA/ICOS risk score to identify patients at high or very high risk of cardiotoxicity. Patients with diabetes mellitus or stable heart failure with preserved ejection fraction (HFpEF) were prescribed empagliflozin (10 mg per day), starting seven days before the administration of anthracyclines and continuing for a period of six months. Those not meeting these criteria served as controls. The primary endpoint was cancer therapy-related cardiac dysfunction (CTRCD) incidence. CTRCD was defined as either a decrease in left ventricular ejection fraction (LVEF) of at least 10% to a final value below 50% or a reduction in global longitudinal strain (GLS) of at least 15% from baseline at any point during the study. The secondary endpoints included mortality and hospitalization due to cardiovascular causes or clinical heart failure. Exploratory endpoints included increases in serum troponin and NT-proBNP levels and a decrease in the glomerular filtration rate (GFR). The safety endpoints tracked includedketoacidosis, hypoglycemia, sepsis, neutropenic fever, and urinary tract infections.

RESULTS

During the enrollment period, 785 breast cancer patients were analysed. Of these, 107 met the inclusion criteria, and 76 subsequently provided informed consent. The study was conducted with comparable adherence rates of 81.5% in both the empagliflozin group (n = 38) and the control group (n = 38). The follow-up data from 62 patients revealed a significant reduction in the primary outcome within 6 months for the empagliflozin group compared with the control group (6.5% vs. 35.5%, p = 0.005), with a relative risk of 0.18 (95% CI: 0.04-0.75). Compared with the control treatment, treatment with empagliflozin also significantly preserved the ejection fraction at 6 months follow-up (56.8% ± 5.8% vs. 53.7% ± 6.7, p = 0.029). However, there were no significant differences between the groups in terms of NT-proBNP, cTnI, clinical heart failure, GFR, or mortality/hospitalization due to heart failure.

CONCLUSION

Empagliflozin is associated with reduced incidence of CTRCD in high-risk patients treated with anthracyclines. These data should serve as the foundation for a clinical trial to test whether SGLT2 inhibitors can reduce the incidence of heart failure in this patient group.

Atrial fibrillation in cancer, anticancer therapies, and underlying mechanisms

Atrial fibrillation (AF) is a common arrhythmic complication in cancer patients and can be exacerbated by traditional cytotoxic and targeted anticancer therapies. Increased incidence of AF in cancer patients is independent of confounding factors, including preexisting myocardial arrhythmogenic substrates, type of cancer, or cancer stage. Mechanistically, AF is characterized by fast unsynchronized atrial contractions with rapid ventricular response, which impairs ventricular filling and results in various symptoms such as fatigue, chest pain, and shortness of breath. Due to increased blood stasis, a consequence of both cancer and AF, concern for stroke increases in this patient population. To compound matters, cardiotoxic anticancer therapies themselves promote AF; thereby exacerbating AF morbidity and mortality in cancer patients. In this review, we examine the relationship between AF, cancer, and cardiotoxic anticancer therapies with a focus on the shared molecular and electrophysiological mechanisms linking these disease processes. We also explore the potential role of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in the management of anticancer-therapy-induced AF.

Mitigating Cardiotoxicity Associated with Anticancer Drugs: An Updated Systematic Review

INTRODUCTION

This systematic review investigated strategies to mitigate cardiotoxicity induced by anticancer medications, emphasizing exercise and pharmacological interventions.

METHODS

We systematically reviewed three randomized controlled trials, one ATOPE trial, and one retrospective cohort study.

RESULTS

Among 448 patients, exercise interventions, particularly in breast cancer patients, demonstrated significant improvements in left ventricular ejection fraction (LVEF) and cardiotoxicity prevention. Pharmacological interventions, including candesartan and carvedilol, have shown potential in reducing early DOX-induced subclinical cardiotoxicity (DISC). The protective efficacy of candesartan in alleviating DISC was greater than carvedilol and the control group. Combination therapy with lisinopril and bisoprolol effectively preserved the LVEF. A retrospective cohort study demonstrated the cardioprotective potential of sodium-glucose cotransporter-2 inhibitors in reducing cardiovascular events.

CONCLUSION

This systematic review underscores the promise of exercise and pharmacological interventions for preserving cardiac function in cancer patients receiving chemotherapy. These findings have significant implications for enhancing the quality of care for cancer patients.

Empagliflozin attenuates doxorubicin-impaired cardiac contractility by suppressing reactive oxygen species in isolated myocytes

In animal studies, sodium-glucose co-transporter-2 inhibitors-such as empagliflozin-have been shown to improve heart failure and impaired cardiac contractility induced by anthracyclines-including doxorubicin-although the therapeutic mechanism remains unclear. Moreover, abnormalities in Ca2+ handling within ventricular myocytes are the predominant feature of heart failure. Accordingly, this study aimed to investigate whether empagliflozin can alleviate Ca2+ handling disorders induced by acute doxorubicin exposure and elucidate the underlying mechanisms. To this end, ventricular myocytes were isolated from C57BL/6 mice. Contraction function, Ca2+ handling, and mitochondrial reactive oxygen species (ROS) generation were then evaluated using IonOptix or confocal microscopy. Ca2+ handling proteins were detected by western blotting. Results show that incubation with 1 μmol/L of doxorubicin for 120-min impaired cardiac contractility in isolated myocytes, which was significantly alleviated by pretreatment with 1 μmol/L of empagliflozin. Doxorubicin also markedly induced Ca2+ handling disorders, including decreased Ca2+ transients, prolonged Ca2+ transient decay time, enhanced frequency of Ca2+ sparks, and decreased Ca2+ content in the sarcoplasmic reticulum. These dysregulations were improved by pretreatment with empagliflozin. Moreover, empagliflozin effectively inhibited doxorubicin-induced mitochondrial ROS production in isolated myocytes and rescued doxorubicin-induced oxidation of Ca2+/calmodulin-dependent protein kinase II (ox-CaMKII) and CaMKII-dependent phosphorylation of RyR2. Similarly, preincubation with 10 μmol/L Mito-TEMPO mimicked the protective effects of empagliflozin. Collectively, Empagliflozin ameliorated the doxorubicin-induced contraction malfunction and Ca2+-handling disorders. These findings suggest that empagliflozin alleviates Ca2+-handling disorders by improving ROS production in the mitochondria and alleviating the enhanced oxidative CaMKII signaling pathway induced by doxorubicin.

Efficacy of SGLT2 inhibitors for anthracycline-induced cardiotoxicity: a meta-analysis in cancer patients

Aim: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) lower anthracycline-induced cardiotoxicity.Methods: PubMed and Google Scholar were searched until September 2023 for studies regarding SGLT2i for treating anthracycline-induced cardiotoxicity. Overall mortality and cardiovascular events were considered. Using a random-effects model, data pooled RR and HR at a 95% confidence interval (CI).Results: 3 cohort studies were identified, analyzing 2817 patients. Results display a significant reduction in overall mortality [RR = 0.52 (0.33-0.82); p = 0.005; I2= 32%], HF hospitalization [RR = 0.20 (0.04-1.02); p = 0.05; I2= 0%] and no significant reduction in HF incidence [RR = 0.50 (0.20-1.16); p = 0.11, I2= 0%].Conclusion: SGLT2i mitigates mortality and hospitalization due to heart failure, improving cancer patient's chances of survival by undergoing anthracycline treatment.

Are Sodium-Glucose Cotransporter-2 Inhibitors the Cherry on Top of Cardio-Oncology Care?

The increasing aging of the population combined with improvements in cancer detection and care has significantly improved the survival and quality of life of cancer patients. These benefits are hampered by the increase of cardiovascular diseases being heart failure the most frequent manifestation of cardiotoxicity and becoming the major cause of morbidity and mortality among cancer survivor. Current strategies to prevent cardiotoxicity involves different approaches such as optimal management of CV risk factors, use of statins and/or neurohormonal medications, and, in some cases, even the use of chelating agents. As a class, SGLT2-i have revolutionized the therapeutic horizon of HF patients independently of their ejection fraction or glycemic status. There is an abundance of data from translational and observational clinical studies supporting a potential beneficial role of SGLT2-i in mitigating the cardiotoxic effects of cancer patients receiving anthracyclines. These findings underscore the need for more robust clinical trials to investigate the effect on cardiovascular outcomes of the prophylactic SGLT2-i treatment in patients undergoing cancer treatment.

Cardioprotective Potential of Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Cancer Treated With Anthracyclines: An Observational Study

Anthracyclines are pivotal in cancer treatment, yet their clinical utility is hindered by the risk of cardiotoxicity. Preclinical studies highlight the effectiveness of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in mitigating anthracycline-induced cardiotoxicity. Nonetheless, the translation of these findings to clinical practice remains uncertain. This study aims to evaluate the safety and potential of SGLT2i for preventing cardiotoxicity in patients with cancer, without preexisting heart failure (HF), receiving anthracyclines therapy. Using the TriNetX Global Research Network, patients with cancer, without previous HF diagnosis, receiving anthracycline therapy were identified and classified into 2 groups based on SGLT2i usage. A 1:1 propensity score matching was used to control for baseline characteristics between the 2 groups. Patients were followed for 2 years. The primary end point was new-onset HF, and the secondary end points were HF exacerbation, new-onset arrhythmia, myocardial infarction, all-cause mortality, and all-cause hospitalization. Safety outcomes included acute renal failure and creatinine levels. A total of 79,074 patients were identified, and 1,412 were included post-matching (706 in each group). They comprised 53% females, 62% White, with a mean age of 62.5 ± 11.4 years. Over the 2-year follow-up period, patients on SGLT2i had lower rates of new-onset HF (hazard ratio 0.147, 95% confidence interval 0.073 to 0.294) and arrhythmia (hazard ratio 0.397, 95% confidence interval 0.227 to 0.692) compared with those not on SGLT2i. The incidence of all-cause mortality, myocardial infarction, all-cause hospitalization, and safety outcomes were similar between both groups. In conclusion, among patients with cancer receiving anthracycline therapy without preexisting HF, SGLT2i use demonstrates both safety and effectiveness in reducing anthracycline-induced cardiotoxicity, with a decreased incidence of new-onset HF, HF exacerbation, and arrhythmias.

Breast Cancer and Therapy-Related Cardiovascular Toxicity

The global incidence of breast cancer is on the rise, a trend also observed in South Korea. However, thanks to the rapid advancements in anticancer therapies, survival rates are improving. Consequently, post-treatment health and quality of life for breast cancer survivors are emerging as significant concerns, particularly regarding treatment-related cardiotoxicity. In this review, we delve into the cardiovascular complications associated with breast cancer treatment, explore surveillance protocols for early detection and diagnosis of late complications, and discuss protective strategies against cardiotoxicity in breast cancer patients undergoing anticancer therapy, drawing from multiple guidelines.