Correlation between serum levels of cardiac troponin-T and the severity of the chronic cardiomyopathy induced by doxorubicin

Selenium protection from DNA damage and regulation of apoptosis signaling following cyclophosphamide induced cardiotoxicity in rats

We investigated the mechanism of the cardioprotective effect of selenium (Se) against cyclophosphamide (CPA) induced cardiotoxicity in rats. We divided 24 female Wistar albino rats into four groups. The control group was injected intraperitoneally (i.p.) with normal saline. The CPA group was injected i.p. with 200 mg/kg CPA. The Se group was injected i.p. with 1 mg/kg Se. The CPA + Se group was injected i.p. with 200 mg/kg CPA and 1 mg/kg Se. Rats were euthanized 24 h after injection and heart tissues were harvested. Histopathological examination revealed reduced severity of myocardial lesions in the CPA + Se group compared to CPA induced cardiotoxicity of the CPA group; this finding was confirmed by increased immunoreactivity of cardiac troponin-I (cTn-I) in the CPA + Se group compared to decreased cTn-I immunoreactivity in the CPA group. Administration of CPA increased the immunoreactivity of phosphorylated histone-2AX (γH2AX). Se reduced the CPA induced increase in γH2AX immunoreactivity. Se administration reversed the CPA induced increase of Bax and decrease of Bcl2 gene expressions. Our findings suggest that Se is cardioprotective by reducing DNA damage and regulating the genes responsible for apoptosis caused by CPA in rats.

Role of Cardiac Biomarkers in Monitoring Cardiotoxicity in Chemotherapy Patients

PURPOSE

This review aims to highlight the different types of chemotherapy-induced cardiotoxicity and will discuss the evidence base behind the use of different cardiac biomarkers to predict cardiovascular complications. Additionally, we will review the use of cardiac biomarkers to monitor cardiac outcomes and the role of cardioprotective medications in reducing cardiovascular side effects.

RECENT FINDINGS

Chemotherapy has been linked to an increased risk of cardiotoxicity and heart failure. Currently, patients receiving chemotherapy undergo echocardiogram before starting chemotherapy and every 6 months to monitor for any decline in cardiac function. We reviewed the current evidence and practice guidelines of monitoring chemotherapy cardiotoxicity.

SUMMARY

Cardio-oncology is a rapidly evolving subspecialty in cardiology, especially with the advent of new chemotherapeutic agents, which have cardiovascular side effects. Early detection of these effects is crucial to prevent life-threatening and irreversible cardiovascular outcomes. Monitoring troponin, pro-brain natriuretic peptide, and other cardiac biomarkers during chemotherapy will help to early detect cardiotoxicity.

Detection of right ventricular dysfunction by three - dimensional echocardiography and two - dimensional speckle tracking in breast cancer patients receiving anthracycline- based chemotherapy

BACKGROUND

Despite the cardiotoxic effect of anthracycline on the left ventricle (LV) was totally identified. The assessment of the anthracycline effect on the right ventricle(RV) by conventional echocardiography was a challenge due to its complex geometry. We aimed to evaluate the impact of anthracycline on the RV volume and function using 3 dimensional -echocardiography (3DE) and 2 dimensional -speckle tracking echocardiography (2D-STE) in patients with breast cancer.

METHODS

This prospective study was conducted on 66 female patients with breast cancer receiving anthracycline chemotherapy, in addition to full echocardiography, 2D-STE and 3DE evaluation of RV function and volume were done at baseline, after 4th cycle of chemotherapy, six and nine months after the end of chemotherapy.

RESULTS

Cardiotoxicity from anthracycline occurred in 18 patients whose LV ejection fraction became significantly reduced after 9 months of therapy according to that, the patients were divided into the non-cardiotoxic group (n:48) and the cardiotoxic group (n:18). At cardiotoxic group, 3D RV end-systolic volume, and 3D RV end-diastolic volume increased significantly at 6 months and continued till 9 months after the therapy end compared to baseline values (42.50 ± 5.98 vs. 50.44 ± 7.01, p = 0.005) and (86.78 ± 9.16 vs. 95.78 ± 9.23, p = 0.021).LV global longitudinal strain (GLS) showed a significant reduction early after 6 months of therapy, 2D GLS and free wall longitudinal strain (FWLS) of RV were significantly decreased at 6 months and continued till 9 months after therapy (-22.54 ± 0.79 vs. -19.53 ± 1.32, p = 0.001) and (-24.67 ± 1.27vs. -22.22 ± 1.41, p = 0.001) respectively. The variation of RV FWLS was a predictor of cardiotoxicity, the relative drop of RV FWLS > 19.3% had 83% sensitivity and 71% specificity, (AUC = 0.82) to identify patients who developed cardiotoxicity.

CONCLUSION

3DE is a promising modality in recognizing the early changes in RV volumes and minute alteration in RV function and 2D-STE is a reliable predictor of RV systolic dysfunction which identify the subclinical affliction.

CARDIOTOXICITY IN BREAST CANCER PATIENTS: RELATIONSHIP OF HS-TROPONIN T CHANGES AND HEART FUNCTION IN CANCER TREATMENT

Breast cancer patients (BC) have a high risk of cardiotoxicity (CT) due to a combination of cancer treatments.Cardiovascular (CV) complications lead to delay or withdrawal of BC therapy and worsen the survival. Therefore, it isimportant to detect CT at the early stages before the occurrence of cardiac dysfunction and heart failure (HF) signs.

OBJECTIVE

to study the dynamic changes of high-sensitivity (hs) troponin (Tn) T (hs-TnT) level in BC patients during cancer treatment with the use of chemotherapy and radiation therapy (RT) to predict and prevent CV complications during individualized management.

MATERIAL AND METHODS

40 BC patients were included in the pilot study. The analysis of the dynamic changes of hs-TnT and ejection fraction (EF) of the left ventricle (LV) was performed before and within 6 months of cancer treatment. Based on the data analysis, a definition of a significant increase in hs-TnT was developed and proposed. Therise of hs-TnT was calculated by the difference (%) between its baseline level and in the 6 months of cancer treatment. BC patients are grouped into tertiles according to the hs-TnT increase: group 1 - low level (0-50 %), group 2 -moderate level (> 50-100 %), and group 3 - high level (> 100 %).

RESULTS

Before the start of cancer treatment, LVEF did not differ significantly between groups (mean EF (62.6 ± 1.0) %)and the hs-TnT level was also within normal values (0.008±0.001 ng/ml). In 6 months of cancer treatment, LVEF waswithin the normal ranges and did not differ significantly in patients of group 1. However, in patients of groups 2and 3 - LVEF drop (δLV EF) was 5.7 % (р < 0.01) and 10.8 % (р < 0.01), consequently. According to the correlationanalysis, the percentage of increase in hs-TnT (δhs-TnT) was associated with δEF LV (r = 0.39, р < 0.05) and the useof anthracyclines (AC) (r = 0.37, р < 0.05). Using logistic regression and ROC analysis, the diagnostic threshold valueof the hs-TnT increase > 165 % was defined, which can be considered as a reliable marker of early biochemical CT,with a sensitivity of 99 % and a specificity of 56 %.

CONCLUSIONS

In BC patients, based on the level of hs-TnT increase, proposed a new early biochemical CT detectionmethod. Under the new approach, BC patients with hsTnT increase of > 165 % from baseline can be considered as areliable marker of early biochemical CT, with a sensitivity of 99 % and a specificity of 56 %.

Serum Biomarkers for the Detection of Cardiac Dysfunction in Childhood Cancers Receiving Anthracycline-Based Treatment

Anthracyclines are routinely used in cancer chemotherapy in many childhood cancers. A serious adverse effect of doxorubicin chemotherapy is cardiotoxicity which may lead to congestive heart failure for long-term survivors years after treatment. Currently, echocardiography is used to control the heart function during anthracyclines therapy. B-type natriuretic peptide (BNP) and NT-proBNP as well as cardiac troponins have been proposed as clinical markers for subclinical anthracycline-induced cardiotoxicity. The BNP and pro-BNP can be easily measured in plasma and initial data indicate that the NT-proBNP could be sensitive predictor for the development of congestive heart failure.

Development and Validation of a Diagnostic Nomogram to Predict the Anthracycline-Induced Early Cardiotoxicity in Children with Hematological Tumors

This study aimed to establish and validate an effective nomogram to predict the risk of cardiotoxicity in children after each anthracycline treatment. According to the inclusion and exclusion criteria, the eligible children were randomly divided into the training cohort (75%) and the validation cohort (25%). Least absolute shrinkage and selection operator (LASSO) regression was used to select the predictors and a nomogram was developed. Then, concordance index (C-index), the area under the curve (AUC), Hosmer-Lemeshow (H-L) test, and decision curve analysis (DCA) were employed to evaluate the performance and clinical utility of nomogram. Internal validation was processed to inspect the stability of the model. A total of 796 eligible children were included in this study and divided into a training set (n = 597) and a validation set (n = 199). LASSO regression analysis revealed that cumulative anthracycline dose, ejection fractions, NT-proBNP, and diastolic dysfunction were effective predictors of cardiotoxicity. The nomogram was established based on these variables. The C-index and the AUC of the predicting nomogram were 0.818 in the training cohort and 0.773 in the validation cohort, suggesting that the nomogram had good discrimination. The calibration curve of the nomogram presented no significant deviation from the reference line, and the P-value of the H-L test was 0.283, implying a preferable degree of calibration. The threshold of DCA also reflects that the nomogram is clinically useful. A nomogram was developed to predict anthracycline chemotherapy-induced cardiotoxicity in children with hematological tumors. The nomogram has a good prediction effect and can provide a reference for clinicians' diagnosis and treatment.

Cancer Therapy-Related Cardiac Dysfunction in Patients Treated with a Combination of an Immune Checkpoint Inhibitor and Doxorubicin

Backgrounds: There are scarce data on whether immune checkpoint inhibitors (ICIs) increase the risk of cardiac dysfunction when used with cardiotoxic agents. Thus, we evaluated cardiac dysfunction in patients with sarcoma receiving doxorubicin with or without ICI using echocardiography and left ventricular global longitudinal strain (LVGLS). Methods: A total of 95 patients were included in this study. Echocardiography and LVGLS were evaluated at baseline and follow-up (at 3 and 6 months of chemotherapy) and compared with the doxorubicin (Dox; n = 73) and concomitant ICI with doxorubicin (Dox-ICI; n = 22) groups. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a left ventricular ejection fraction (LVEF) drop of >10% and LVEF of <50% (definite CTRCD), LVEF drop of >10%, LVEF of ≥50%, and LVGLS relative reduction of >15% (probable CTRCD) at six months. Results: There were no significant differences in age, cumulative dose of doxorubicin, and cardiovascular risk factors between the two groups. At baseline, the LVEF was similar in the Dox and Dox-ICI groups (p = 0.493). In the Dox group, LVEF decreased to 59 ± 6% (Δ −7 ± 1.3%, p < 0.001) and LVGLS decreased from −17.3 ± 3.2% to −15.4 ± 3.2% (Δ −10.1 ± −1.9%, p < 0.001) at six months. In the Dox-ICI group, LVEF decreased to 55 ± 9% (Δ −9 ± 2.1%, p < 0.001), along with a significant decrease in LVGLS (from −18.6 ± 1.9% to −15.3 ± 3.6%, Δ −12.4 ± −2.4%, p < 0.001). Over a median follow-up of 192 days, there were no cases with clinical manifestations of fulminant myocarditis. In the Dox group, definite and probable CTRCD were observed in seven (10.1%) and five (7.4%) patients, respectively. In the Dox-ICI group, definite and probable CTRCD were observed in four (19%) and four (19%) patients, respectively. The total number of patients who developed CTRCD was significantly higher in the Dox-ICI group than in the Dox group (38.1% vs. 17.4%, p = 0.042). Serum troponin-T level was significantly higher in the Dox-ICI group than in the Dox group (53.3 vs. 27.5 pg/mL, p = 0.023). Conclusions: ICIs may increase the risk of CTRCD when used with cardiotoxic agents. CTRCD should be monitored in patients treated with ICIs by cardiac biomarkers and echocardiography, including LV-GLS.

Role of Cardiac Biomarkers in Cancer Patients

Simple Summary

Cardiac biomarkers have proved increasingly useful in the various branches of cardiology, not sparing the field of cardio-oncology. With specific reference to the latter subject, they have been investigated as predictors and/or diagnostic and monitoring tools, as well as prognostic factors, with the purpose of allowing the early prevention of many cardiovascular complications related to the direct action of some cancer types or related to the toxicity of its treatments. However, despite this great potential and excellent cost-effectiveness, their usefulness in some areas still seems to be limited due to lack of sufficient specificity or sensitivity. In fact, in clinical practice, while their use is nowadays standard in some circumstances, evidence does not yet support their routine use in other cases.

Abstract

In patients with cancer—and especially some specific subtypes—the heart can be pathologically affected due to the direct action of the tumor or its secretion products or due to the toxicity of some oncological treatments. Cardiac biomarkers have been investigated as inexpensive and easily accessible tools for prediction, early diagnosis, monitoring, or prognosis of various forms of cancer-related cardiac diseases. However, their clinical usefulness was not always clearly demonstrated in every area of cardioncology. For the identification of anthracycline related cardiotoxicity in the very early stages troponins proved to be more efficient detectors than imaging methods. Nevertheless, the lack of a standardized dosage methodology and of cardiotoxicity specific thresholds, do not yet allow to outline the precise way to employ them in clinical routine and to incorporate them into appropriate diagnostic or managing algorithms. Cardiac biomarkers proved also effective in patients with primary cardiac amyloidosis, in which both troponins and natriuretic peptides were able to predict adverse outcome, and carcinoid heart disease, where a precise diagnostic cut-off for N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was identified to screen patients with valvular involvement. Likewise, NT-proBNP proved to be an excellent predictor of postoperative atrial fibrillation (POAF). On the contrary, evidence is still not sufficient to promote the routine use of cardiac biomarkers to early diagnose myocarditis due to immune check points inhibitors (ICIs), radiotherapy induced cardiotoxicity and cardiac complications related to androgenetic deprivation. In this review we present all the evidence gathered so far regarding the usefulness and limitations of these relatively inexpensive diagnostic tools in the field of cardio-oncology.

Ameliorative role of Ulva extract against heavy metal mixture-induced cardiovascular through oxidative/antioxidant pathways and inflammatory biomarkers

The current study investigates the therapeutic and curative effect of Ulva lactuca polyphenolic extract (ULPE) in general and particularly polyphenolics compounds against heavy metal mixture (HME). The toxicity behind heavy metal is due to oxidative stress resulted from heavy metals pollution or administration through contaminated food (vegetables, water, and fish). Heavy metal toxicity plays a major role in different cardiovascular diseases. The objective of this study is aimed to examine the protective effect of ULPE against heavy metal mixture induced cardiovascular diseases through oxidative/antioxidant and inflammatory pathways. Sixty male rats (Sprague-Dawley) were assigned to six groups. Group I served as the control, group II served as the induced group receiving subcutaneously for 7 days 0.25 mg/100 gm body weight/day heavy metal mixtures (Equal concentration of Ni, Cd, Co and Hg chloride, and Pb acetate), group III received (i.p.) ULPE of dose 30 mg for 15 days, group IV served as the protected group pretreated with ULPE for 15 days as a protection dose, and then treated with the heavy metal-mixture, group V served as protected standard group pretreated with vitamin C (VitC ) (50 mg/Kg) and then treated with the heavy metal-mixture, and group VI served as standard group treated with VitC (50 mg/Kg). The main pathological changes within the heart revealed heart inflammation after heavy-metal mixtures administrations. On contrast to the protected group treated with ULPE (group IV), the protection group (group II) showed a significant increase in the antioxidant as well as anti-inflammatory biomarker. The cardiovascular biomarkers (Troponin T, CRP, and BNP) showed similar attitude elevations in induction group and decreased greatly in protection and VitC group. The antioxidant and the anti-inflammatory activities of ULPE are a consequence of their higher polyphenolic contents as well as marine secondary metabolites which are confirmed using qualitative and quantitative analysis. From the current result, we concluded that ULPE possesses a cardiovascular protective agent as a result of highly contents of different bioactive secondary metabolites which have antioxidant as well as free-radical scavenging and anti-inflammatory activates. Showed the mechanism of ULPE as cardioprotective against heavy metal mixture.

Transplantation for chemotherapy-induced cardiomyopathy-case series and review of current practice

Multimodality therapies have improved the survival after tumors like Ewing's sarcoma and breast cancer. However, cardiotoxicity following chemotherapy remains an important concern. We report a case series of four patients who presented to our heart team with severe dilated cardiomyopathy along with biventricular involvement. Two of the patients were females and had breast cancer for which they were treated with trastuzumab and had developed chemotherapy induced cardiomyopathy (CCMP). The other two patients were males who had Ewing's sarcoma who developed CCMP following treatment with doxorubicin.

Prediction of doxorubicin cardiotoxicity by early detection of subclinical right ventricular dysfunction

BACKGROUND

Doxorubicin remains one of the most common causes of cardiotoxicity in patients with lymphoma, leading to significant morbidity and mortality. Early decline in left ventricular (LV) ejection fraction predicts chemotherapy-induced cardiotoxicity and mortality, but limited data exist on doxorubicin-induced subclinical right ventricular (RV) dysfunction. We investigated dose-dependent subclinical doxorubicin-induced RV dysfunction in lymphoma patients.

METHODS

Thirty-five patients with adult lymphoma treated with doxorubicin were studied. All patients had normal baseline LV ejection fraction (LVEF > 55%), and no known cardiopulmonary disease. We studied the dose-dependent effect of doxorubicin on RV strain by 2D speckle-tracking echocardiography (STE) using a vendor-independent software (TomTec). Images were analyzed offline by two independent observers blinded to the clinical characteristics of the study population. Baseline LVEF, RV fractional area change (RV FAC), RV free wall strain (RV FWS), and RV global longitudinal strain (RV GLS) were measured prior to chemotherapy initiation and compared with echo studies obtained at a 6-month follow-up interval. Patients served as their own controls. Comparisons between pre- and post-therapy were achieved using paired Student's t-tests or Chi-Square test.

RESULTS

The Interobserver Intraclass Correlation Coefficient for RV GLS, RV FAC and RV FWS, was 0.87, 0.81 and 0.79, respectively. The mean age was 51 ± 13 years, 40% women, 60% white. The mean cumulative doxorubicin dose was 239 ± 104 mg m- 2. There was there was significant decline in RV FAC (47.3 ± 4.4% vs. 43.7 ± 3.9%), RV FWS (- 24.9 ± 3.3 vs. -22.2 ± 2.9), and RV GLS (- 22.4 ± 4.1 vs. -20.6 ± 3.4) (all p < 0.01); but no significant decline in LVEF during the 6-month follow up (63.3 ± 6.2% vs. 61.6 ± 11.1%, p = 0.374). At cumulative doxorubicin dose ≥200 mg m- 2 we found a significant decline in RV FAC (47.0 ± 4.7% vs. 42.2 ± 3.1%, p < 0.01), RV FWS (- 24.6 ± 3.6 vs. -21.5 ± 2.4, p < 0.01), and RV GLS (- 22.3 ± 4.5 vs. -20.1 ± 2.9, p = 0.03).

CONCLUSION

In this cohort of adult lymphoma patients, doxorubicin-based therapy was associated with subclinical RV dysfunction, but not LV dysfunction, at a cumulative dose ≥200 mg m- 2. Additional studies evaluating the long-term prognostic implications of RV dysfunction in this population are essential.

The role of metabolic diseases in cardiotoxicity associated with cancer therapy: What we know, what we would know

Metabolic diseases, such as obesity and type 2 diabetes, are known risk factors for cardiovascular (CV) diseases. Thus, patients with those comorbidities could be at increased risk of experiencing cardiotoxicity related to treatment with Anthracyclines and the other new generation targeted anticancer drugs. However, investigations addressing the mechanisms underlying the development of CV complications and poor outcome in such cohort of patients are still few and controversial. Given the importance of a personalized approach against chemotherapy-induced cardiomyopathy, this review summarizes our current knowledge on the pathophysiology of chemotherapy-induced cardiomyopathy and its association with obesity and type 2 diabetes. Along with clinical evidences, future perspectives of preclinical research around this field and its role in addressing important open questions, including the development of more proactive strategies for prevention, and treatment of cardiotoxicity during and after chemotherapy in the presence of metabolic diseases, is also presented.

Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.

Detection of subclinical cardiotoxicity in sarcoma patients receiving continuous doxorubicin infusion or pre-treatment with dexrazoxane before bolus doxorubicin

Background

Continuous infusion of doxorubicin or dexrazoxane pre-treatment prior to bolus doxorubicin are proven strategies to protect against doxorubicin-induced cardiotoxicity. Recently, global longitudinal peak systolic strain (GLS) measured with speckle tracking echocardiography (STE) and high-sensitivity troponin T (hs-TnT) have been validated as sensitive indicators of doxorubicin-induced cardiotoxicity. Here, we asked whether changes in hs-TnT and/or GLS can be detected in patients who were treated with continuous infusion of doxorubicin or pre-treated with dexrazoxane followed by bolus doxorubicin.

Methods

Twenty-nine patients with newly diagnosed sarcoma were assigned to receive either 72-h doxorubicin infusion or dexrazoxane pre-treatment before bolus doxorubicin. Eight patients received dexrazoxane pre-treatment; eleven patients received continuous doxorubicin infusion; ten patients crossed over from continuous infusion to dexrazoxane. Bloods were collected for hs-TnT at baseline, 24 h or 72 h after initiation of doxorubicin treatment in each chemotherapy cycle. All blood samples were assayed in batch using hs-TnT kit from Roche diagnostics. 2D Echo and STE were performed before doxorubicin, after cycle 3, and at the end of chemotherapy.

Results

Seven patients in the cross-over group have at least one hs-TnT measurement between 5 ng/L to 10 ng/L during and after chemotherapy. Ten patients have at least one hs-TnT measurement above 10 ng/ml during and after chemotherapy (six in dexrazoxane group, three in continuous infusion group, one in cross-over group). The average hs-TnT level increases with each additional cycle of doxorubicin treatment. Eight patients had a more than 5% reduction in LVEF at the end of chemotherapy (four in dexrazoxane group, three in continuous infusion group, and one in cross-over group). Four out of these eight patients had a change of GLS by more than 15% (three in the dexrazoxane group).

Conclusion

Elevation in hs-TnT levels were observed in more than 59% of patients who had received either continuous doxorubicin infusion or dexrazoxane pre-treatment before bolus doxorubicin. However, changes in LVEF and GLS were less frequently observed. Thus, continuous doxorubicin infusion or dexrazoxane pre-treatment do not completely ameliorate subclinical doxorubicin-induced cardiotoxicity as detected by more sensitive techniques.

The cardiotoxicity effect of different chemotherapeutic regimens in Iraqi patients with breast cancer: A follow up study

Introduction

Breast cancer is the first in ranking among cancers in Iraq. Anthracyclines, cyclophosphamide and taxane are the most active chemotherapeutic regimens used. Anthracyclines induced cardiotoxicity through free radical formation while there is no full understanding about that of cyclophosphamide, but it thought that it may cause direct cardiac muscle damage. While, taxane induced cardiotoxicity through coronary vasoconstriction and oxidative stress. Thus; it is very important to study changes in the cardiac biomarkers as they were the most reliable and sensitive markers associated with cardiotoxicity.

Aim

This research was designed to carry out investigations on the cardiotoxicity effects of these chemotherapeutic drugs in Iraqi patients with breast cancer.

Materials and methods

This research was performed at the Department of Biochemistry, Medicine College, Baghdad University and at the Oncology Department of the Teaching Hospital, Baghdad - Iraq, during the period from May 2018 to October 2018. It was carried out on 56 women with undisturbed menstrual cycle (25–45 years), These women were divided into 3 groups: GI was of 29 women with primary breast cancer without starting any kind of chemotherapy, GII: the same 29 women of GI after finishing 4 cycles of anthracyclines (course 1) and GIII: which involved another 27 women after finishing both course 1 and course 2 (4 cycles of taxanes). Investigations included serum measurements of high sensitive cardiac troponin (hs-cTn), NT-pro-brain natriuretic peptide (NT-ProBNP), and high sensitive- C reactive protein (hs-CRP) by using ELISA technique. The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 23, when the P-values were less than 0.05, it was considered as significant.

Results

The mean (±SEM) value of the serum hs-CRP levels was decreased significantly in GIII in comparison to both GI (p = 0.004) and GII (p = 0.049) while there was no significant difference between GI and GII. Also, there was no significant difference in the mean (±SEM) value of the serum hs-cTn and the serum NT-PROBNP levels between all groups. The results also showed that there was a significant negative correlation between BMI values and serum NT-proBNP levels in GI (r = −0.435, p = 0.018), GII (r = −0.438, p = 0.018), and GIII (r = −0.384, p = 0.048). In GI, there was also a significant positive correlation between BMI and serum hs-CRP levels (r = 0.395, p = 0.034). Also, there was a significant positive correlation between serum hs-cTn levels and NT-proBNP levels in GI (r = 0.416, p = 0.025) and GII (r = 0.467, p = 0.011). Moreover, there was a significant negative correlation between the serum hs-cTn levels and serum hs- CRP concentrations (r = −0.397, p = 0.040) in GIII.

Conclusion

This study had concluded insignificant changes of cardiac biochemical markers during the chemotherapeutic treatment and that chemotherapy-induced cardiotoxicity is negligible.

Anthracycline-induced cardiotoxicity in the chemotherapy treatment of breast cancer: Preventive strategies and treatment

Anthracyclines are highly effective chemotherapeutic agents, used for a wide variety of malignancies. Cardiotoxicity is a well-recognized side effect of anthracycline therapy that limits the total amount of drug administered and can cause heart failure in some patients. Most experimental data support oxidative stress as the etiology of anthracycline-induced cardiotoxicity. The objective of this paper was to provide a review of the clinical classification, risk factors, monitoring and prevention of anthracycline-induced cardiotoxicity in patients with breast cancer.

Cardiac Troponins are Among Targets of Doxorubicin-Induced Cardiotoxicity in hiPCS-CMs

Modern diagnostic strategies for early recognition of cancer therapeutics-related cardiac dysfunction involve cardiac troponins measurement. Still, the role of other markers of cardiotoxicity is still unclear. The present study was designed to investigate dynamics of response of human cardiomyocytes derived from induced pluripotent stem cells (hiPCS-CMs) to doxorubicin with the special emphasis on their morphological changes in relation to expression and organization of troponins. The hiPCS-CMs were treated with doxorubicin concentrations (1 and 0.3 µM) for 48 h and followed for next up to 6 days. Exposure of hiPCS-CMs to 1 µM doxorubicininduced suppression of both cardiac troponin T (cTnT) and cardiac troponin I (cTnI) gene expression. Conversely, lower 0.3 µM doxorubicin concentration produced no significant changes in the expression of aforementioned genes. However, the intracellular topography, arrangement, and abundance of cardiac troponin proteins markedly changed after both doxorubicin concentrations. In particular, at 48 h of treatment, both cTnT and cTnI bundles started to reorganize, with some of them forming compacted shapes extending outwards and protruding outside the cells. At later intervals (72 h and onwards), the whole troponin network collapsed and became highly disorganized following, to some degree, overall changes in the cellular shape. Moreover, membrane permeability of cardiomyocytes was increased, and intracellular mitochondrial network rearranged and hypofunctional. Together, our results demonstrate complex effects of clinically relevant doxorubicin concentrations on hiPCS-CM cells including changes in cTnT and cTnI, but also in other cellular compartments contributing to the overall cytotoxicity of this class of cytostatics.

Anthracycline-induced cardiotoxicity in diffuse large B-cell lymphoma: NT-proBNP and cardiovascular score for risk stratification

OBJECTIVE

To evaluate the role of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and a cardiovascular (CV) risk score named FRESCO for predicting anthracycline-induced cardiotoxicity (AIC) in diffuse large B-cell lymphoma (DLBCL).

METHODS

A total of 130 consecutive DLBCL patients treated in first-line with anthracycline-containing immunochemotherapy. Competitive risk between NT-proBNP, FRESCO, and time to AIC was considered.

RESULTS

Cumulative incidence of AIC was 12.2% and 17.5% at 1 and 5 years, respectively. Median time to development cardiotoxicity was 6.4 months, with half of the cases showing heart failure and the other half silent AIC. Both NT-proBNP levels and FRESCO score were independently associated with higher risk of AIC (P = 0.001 and P = 0.03, respectively). Patients with NT-proBNP ≥600 pg/mL or those with FRESCO ≥4.5% had 3.97 or 2.54 times higher risk of AIC than those with lower values (P = 0.001 and P = 0.048, respectively). According to the previous cutoffs, three groups of patients with a significantly different risk of AIC could be identified (P < 0.0001).

CONCLUSIONS

Doxorubicin-containing chemotherapy is associated with increased risk of silent and overt AIC. Baseline NT-proBNP levels and FRESCO CV risk score are accurate predictors of AIC and can identify groups of patients at different risk, in which personalized cardiologic evaluation should be offered.

Physiological levels of chromogranin A prevent doxorubicin-induced cardiotoxicity without impairing its anticancer activity

The clinical use of doxorubicin (Doxo), a widely used anticancer chemotherapeutic drug, is limited by dose-dependent cardiotoxicity. We have investigated whether chromogranin A (CgA), a cardioregulatory protein released in the blood by the neuroendocrine system and by the heart itself, may contribute to regulation of the cardiotoxic and antitumor activities of Doxo. The effects of a physiologic dose of full-length recombinant CgA on Doxo-induced cardiotoxicity and antitumor activity were investigated in rats using in vivo and ex vivo models and in murine models of melanoma, fibrosarcoma, lymphoma, and lung cancer, respectively. The effect of Doxo on circulating levels of CgA was also investigated. In vivo and ex vivo mechanistic studies showed that CgA can prevent Doxo-induced heart inflammation, oxidative stress, apoptosis, fibrosis, and ischemic injury. On the other hand, CgA did not impair the anticancer activity of Doxo in all the murine models investigated. Furthermore, we observed that Doxo can reduce the intracardiac expression and release of CgA in the blood (i.e., an important cardioprotective agent). These findings suggest that administration of low-dose CgA to patients with low levels of endogenous CgA might represent a novel approach to prevent Doxo-induced adverse events without impairing antitumor effects.-Rocca, C., Scavello, F., Colombo, B., Gasparri, A. M., Dallatomasina, A., Granieri, M. C., Amelio, D., Pasqua, T., Cerra, M. C., Tota, B., Corti, A., Angelone, T. Physiological levels of chromogranin A prevent doxorubicin-induced cardiotoxicity without impairing its anticancer activity.

Cardiovascular variability and β-ARs gene expression at two stages of doxorubicin - Induced cardiomyopathy

Using comprehensive analysis of heart rate (HRV) and blood pressure (BPV) short-term variability we estimated the time course of changes of autonomic nervous system remodeling in two stages of doxorubicin-induced cardiomyopathy (DCM). We also investigated the level of gene expression of cardiac β-1 (β-1AR) and β-2 (β-2AR) adrenoceptors. Experiments were performed in adult male Wistar rats equipped with indwelling catheters for BP recording and blood withdrawal. A 15 mg/kg total cumulative dose of doxorubicin was injected i.p. to rats to induce DCM or saline for control (n=18). Rats were assessed for general toxicity, cardiovascular hemodynamic and echocardiography before treatment (n=6), 35 days (DOX35; n=6) and 70 days (DOX70; n=6) post-treatment. HRV was evaluated by spectral analysis, Poincaré plots, sample and approximate entropy. Expression of β-1AR and β-2AR mRNA was evaluated by RT-qPCR. Doxorubicin-treated rats exhibited poor general condition and lower survival than saline-treated rats. In DOX35 rats, there were no echocardiography signs of decompensation, no increase in serum cardiac troponins, but there was an increase of HRV and decrease of HR complexity. In these rats typical microscopic signs of cardiotoxicity were seen along with over-expression of β-1AR mRNA. 70 days post-treatment echocardiography revealed signs of decompensation and serum cardiac troponin T was increased. At this stage BPV decreased. In conclusion, HRV increase matches transient over-expression of cardiac β-1AR mRNA in compensate stage of DCM while decompensate stage of DCM is characterized by a decrease of BPV and no changes in β-1AR and β-2AR gene expression.

Chemotherapeutic-Induced Cardiovascular Dysfunction: Physiological Effects, Early Detection-The Role of Telomerase to Counteract Mitochondrial Defects and Oxidative Stress

Although chemotherapeutics can be highly effective at targeting malignancies, their ability to trigger cardiovascular morbidity is clinically significant. Chemotherapy can adversely affect cardiovascular physiology, resulting in the development of cardiomyopathy, heart failure and microvascular defects. Specifically, anthracyclines are known to cause an excessive buildup of free radical species and mitochondrial DNA damage (_mtDNA) that can lead to oxidative stress-induced cardiovascular apoptosis. Therefore, oncologists and cardiologists maintain a network of communication when dealing with patients during treatment in order to treat and prevent chemotherapy-induced cardiovascular damage; however, there is a need to discover more accurate biomarkers and therapeutics to combat and predict the onset of cardiovascular side effects. Telomerase, originally discovered to promote cellular proliferation, has recently emerged as a potential mechanism to counteract mitochondrial defects and restore healthy mitochondrial vascular phenotypes. This review details mechanisms currently used to assess cardiovascular damage, such as C-reactive protein (CRP) and troponin levels, while also unearthing recently researched biomarkers, including circulating _mtDNA, telomere length and telomerase activity. Further, we explore a potential role of telomerase in the mitigation of mitochondrial reactive oxygen species and maintenance of _mtDNA integrity. Telomerase activity presents a promising indicator for the early detection and treatment of chemotherapy-derived cardiac damage.

Histamine 2 receptor antagonism elicits protection against doxorubicin-induced cardiotoxicity in rodent model

Doxorubicin (DOX), an anthracycline-based antibiotic, is regularly used in the management of carcinomas, and haematological malignancies have been downplayed in chemotherapy because of its ability to induce dilated cardiomyopathy (DCM). Dexrazoxane is approved to combat the cardiotoxicity, but limited by its adverse effects. Redox imbalance and reactive oxygen species generation plays major role in DOX-induced cardiotoxicity. Histamine, known to mediate various cardiovascular effects, but nevertheless the role of histamine or its receptors in DOX-induced DCM is remained obscure. Hence, this study is aimed to examine the effect of Famotidine (FAM), a H2 receptor antagonist on DOX-induced DCM in Wistar rats. Myocardial antioxidant status, stress and apoptosis markers, myocardial morphology and function were evaluated as the end points. Treatment with FAM has alleviated DOX doxorubicin-induced cardiotoxicity by reducing oxidative and nitrosative stress evident from lipid peroxidation and total nitrate-to-nitrite ratio, and enhanced the activity of super oxide dismutase. Cardiac stress markers like LDH and Na⁺-K⁺ATPase activities as well as CK-MB and Cardiac troponin levels were reduced by FAM treatment. It also normalised the myocardial function as assessed by 2D echocardiography and myocardial index. Treatment imparted anti-apoptotic effect as evident from decrease in myocardial caspase 3 and 9 activity and cleaved PARP expression. Effect of FAM is found to be comparable to the standard ACE inhibitor Captopril (CAP). The results from this study collectively suggest H2 receptor antagonism as a novel therapeutic strategy to impart biochemical, structural and functional improvement indicating its cardio-protective activity.

Aldose reductase inhibitor increases doxorubicin-sensitivity of colon cancer cells and decreases cardiotoxicity

Anthracycline drugs such as doxorubicin (DOX) and daunorubicin remain some of the most active wide-spectrum and cost-effective drugs in cancer therapy. However, colorectal cancer (CRC) cells are inherently resistant to anthracyclines which at higher doses cause cardiotoxicity. Our recent studies indicate that aldose reductase (AR) inhibitors such as fidarestat inhibit CRC growth in vitro and in vivo. Here, we show that treatment of CRC cells with fidarestat increases the efficacy of DOX-induced death in HT-29 and SW480 cells and in nude mice xenografts. AR inhibition also results in higher intracellular accumulation of DOX and decreases the expression of drug transporter proteins MDR1, MRP1, and ABCG2. Further, fidarestat also inhibits DOX-induced increase in troponin-I and various inflammatory markers in the serum and heart and restores cardiac function in mice. These results suggest that fidarestat could be used as adjuvant therapy to enhance DOX sensitivity of CRC cells and to reduce DOX-associated cardiotoxicity.

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

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

Doxorubicin-induced chronic dilated cardiomyopathy-the apoptosis hypothesis revisited

The chemotherapeutic agent doxorubicin (DOX) has significantly increased survival rates of pediatric and adult cancer patients. However, 10% of pediatric cancer survivors will 10-20 years later develop severe dilated cardiomyopathy (DCM), whereby the exact molecular mechanisms of disease progression after this long latency time remain puzzling. We here revisit the hypothesis that elevated apoptosis signaling or its increased likelihood after DOX exposure can lead to an impairment of cardiac function and cause a cardiac dilation. Based on recent literature evidence, we first argue why a dilated phenotype can occur when little apoptosis is detected. We then review findings suggesting that mature cardiomyocytes are protected against DOX-induced apoptosis downstream, but not upstream of mitochondrial outer membrane permeabilisation (MOMP). This lack of MOMP induction is proposed to alter the metabolic phenotype, induce hypertrophic remodeling, and lead to functional cardiac impairment even in the absence of cardiomyocyte apoptosis. We discuss findings that DOX exposure can lead to increased sensitivity to further cardiomyocyte apoptosis, which may cause a gradual loss in cardiomyocytes over time and a compensatory hypertrophic remodeling after treatment, potentially explaining the long lag time in disease onset. We finally note similarities between DOX-exposed cardiomyocytes and apoptosis-primed cancer cells and propose computational system biology as a tool to predict patient individual DOX doses. In conclusion, combining recent findings in rodent hearts and cardiomyocytes exposed to DOX with insights from apoptosis signal transduction allowed us to obtain a molecularly deeper insight in this delayed and still enigmatic pathology of DCM.

Can we find a good biochemical marker of early cardiotoxicity in children treated with haematopoietic stem cell transplantation?

Cardiotoxicity is one of the complications following haematopoietic stem cell transplantation (HSCT), but its diagnosis may be hampered due to the presence of different post-transplant comorbidities. The aim of the study was to assess the incidence of cardiac complications and the significance of biochemical markers (NT-proBNP, ANP, ET-1, and TnI) and ECHO systolic and diastolic parameters analysis in children treated with HSCT. Thirty consecutive children (median age 9.6 years) were included in the study. The control group consisted of 14 healthy children (median age of 10.9 years). None of the transplanted children developed clinical cardiotoxicity. Median ET-1 and NT-proBNP plasma levels were elevated when compared to controls in at least 3 out of 4 analysed time points, median ANP levels differed only in one time point, and no difference was found between median TnI values in all analysed time points. Echocardiographic systolic parameters were within the normal range, while median E/A ratio assessed before HSCT, on day +30, and +100 post-transplant was statistically lower in HSCT patients (respectively, 1.34, 1.37, and 1.42 vs. 1.73). It confirms the need for careful follow up in patients who have received chemotherapy and have been treated with HSCT.

Sex-related differential susceptibility to doxorubicin-induced cardiotoxicity in B6C3F1 mice

Sex is a risk factor for development of cardiotoxicity, induced by the anti-cancer drug, doxorubicin (DOX), in humans. To explore potential mechanisms underlying differential susceptibility to DOX between sexes, 8-week old male and female B6C3F₁ mice were dosed with 3mg/kg body weight DOX or an equivalent volume of saline via tail vein once a week for 6, 7, 8, and 9 consecutive weeks, resulting in 18, 21, 24, and 27mg/kg cumulative DOX doses, respectively. At necropsy, one week after each consecutive final dose, the extent of myocardial injury was greater in male mice compared to females as indicated by higher plasma concentrations of cardiac troponin T at all cumulative DOX doses with statistically significant differences between sexes at the 21 and 24mg/kg cumulative doses. A greater susceptibility to DOX in male mice was further confirmed by the presence of cytoplasmic vacuolization in cardiomyocytes, with left atrium being more vulnerable to DOX cardiotoxicity. The number of TUNEL-positive cardiomyocytes was mostly higher in DOX-treated male mice compared to female counterparts, showing a statistically significant sex-related difference only in left atrium at 21mg/kg cumulative dose. DOX-treated male mice also had an increased number of γ-H2A.X-positive (measure of DNA double-strand breaks) cardiomyocytes compared to female counterparts with a significant sex effect in the ventricle at 27mg/kg cumulative dose and right atrium at 21 and 27mg/kg cumulative doses. This newly established mouse model provides a means to identify biomarkers and access potential mechanisms underlying sex-related differences in DOX-induced cardiotoxicity.

The relationship between plasma hyaluronan levels and anthracycline-related cardiotoxicity in breast cancer patients

AIM

Anthracycline-derived antineoplastic agents are used as the main form of treatment in many malignant diseases, including breast cancer and childhood cancers. Cardiotoxicity is one of the most feared life-threatening complications of cancer therapy. In the present study, we aimed to investigate the relationship between plasma hyaluronan (HA) levels and anthracycline-induced cardiotoxicity.

MATERIALS AND METHODS

Fifty eight of 73 female patients who were diagnosed with breast cancer and treated with a chemotherapy regimen including anthracycline were enrolled in this study. Anamneses were taken from each patient before and after chemotherapy. Further, physical examinations, electrocardiography, and transthoracic echocardiography were performed, and plasma hyaluronan levels were determined by using ELISA assay for each patient before and after treatment.

RESULTS

Following anthracycline-based chemotherapy, the average left ventricular ejection fraction decreased (62.6±3.7% vs. 58.6±4.4%, p<0.001), and diastolic functions significantly deteriorated (p<0.001). However, troponin and hyaluronan levels significantly increased following chemotherapy [Troponin (ng/ml, mean±SD): before 0.01±0.002, after 0.037±0.02, p<0.001], [Plasma HA (ng/ml, mean±SD): before 41.3±5.4, after 70±8.5, p<0.001]. The increase in troponin values correlated with systolic dysfunction (p=0.002), but did not correlate with diastolic dysfunction (p=0.661). Significant correlations were found between systolic/diastolic dysfunction and plasma HA levels (r=0.417, p=0.001; r=0.339, p=0.009, respectively).

CONCLUSIONS

Both systolic and diastolic functions were significantly deteriorated after chemotherapy. In addition, plasma levels of HA and troponin increased after treatment. Further, both systolic and diastolic dysfunctions were found to correlate with serum HA levels. All these data suggest that HA might have a function on anthracycline-induced cardiotoxicity.

Cardiac Damage in Rodents after Exposure to Bis(2-chloroethoxy)methane

We report that an environmental agent, bis(2-chloroethoxy)methane (CEM), caused cardiac toxicity in male and female F344 rats and B6C3F1 mice exposed to the chemical by dermal administration at doses of 0, 50, 100, 200, 400 or 600 mg/kg 5 days a week for up to 14 weeks. Treatment-related deaths occurred in 10/10 male and 10/10 female rats at 600 mg/kg, in 2/10 female rats at 400 mg/kg, and in 3/10 female mice at 600 mg/kg. The heart lesions were more severe in rats than mice, and more severe in females than males. In rats, the no-observed-adverse-effect level (NOAEL) for the heart lesions was 200 mg/kg for males and 100 mg/kg for females; in mice, it was more than 600 mg/kg for males and 200 mg/kg for females. Multifocal, widespread vacuolization of the myocytes comprised the main morphological feature of the lesions, and only in rats was it accompanied by mononuclear cell infiltration, myocytic necrosis and atrial thrombosis. Hearts from male rats were immunohistochemically stained for troponin T (cTnT) protein. Loss of cytoplasmic cTnT correlated with histopathological damage only in the 600 mg/kg animals. CEM is metabolized to thiodiglycolic acid, a chemical that causes mitochondrial dysfunction. It is hypothesized that mitochondrial damage leads to the heart toxicity from bis(2-chloroethoxy)methane.

Pharmacokinetic-pharmacodynamic modelling of acute N-terminal pro B-type natriuretic peptide after doxorubicin infusion in breast cancer

AIMS

The aim of the present study was to develop a pharmacokinetic-pharmacodynamic (PK-PD) model to characterize the relationship between plasma doxorubicin and N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations within 48 h of doxorubicin treatment.

METHODS

The study enrolled 17 female patients with stages 1-3 breast cancer and receiving adjuvant doxorubicin (60 mg m(-2) ) and cyclophosphamide (600 mg m(-2) ) every 14 days for four cycles. In two consecutive cycles, plasma concentrations of doxorubicin, doxorubicinol, troponin and NT-proBNP were collected before infusion, and up to 48 h after the end of doxorubicin infusion. Nonlinear mixed-effects modelling was used to describe the PK-PD relationship of doxorubicin and NT-proBNP.

RESULTS

A three-compartment parent drug with a one-compartment metabolite model best described the PK of doxorubicin and doxorubicinol. Troponin concentrations remained similar to baseline. An indirect PD model with transit compartments best described the relationship of doxorubicin exposure and acute NT-proBNP response. Estimated PD parameters were associated with large between-subject variability (total assay variability 38.8-73.9%). Patient clinical factors, including the use of enalapril, were not observed to be significantly associated with doxorubicin PK or NT-proBNP PD variability.

CONCLUSION

The relationship between doxorubicin concentration and the acute NT-proBNP response was successfully described with a population PK-PD model. This model will serve as a valuable framework for future studies to identify clinical factors associated with the acute response to doxorubicin. Future studies are warranted to examine the relationship between this acute response and subsequent heart failure. Should such a relationship be established, this model could provide useful information on patients' susceptibility to doxorubicin-induced long-term cardiotoxicity.

Early change in left atrial function in patients treated with anthracyclines assessed by real-time three-dimensional echocardiography

Real-time three-dimensional echocardiography(RT-3DE) has allowed a better assessment of LA volumes and function. We sought to assess the early change in left atrial size and function in patients treated with anthracyclines using RT-3DE. 61 patients aged 44.9 ± 11.9 years with large B-cell non-Hodgkin lymphoma treated with doxorubicin were studied. Blood collection and echocardiography were performed at baseline and 1 day after completion of the chemotherapy. Global longitudinal strain (GLS), maximum, minimum and pre-atrial contraction LA volumes were measured and reservoir, conduit and booster pump function were assessed. Despite normal LVEF, passive emptying percent of total emptying (0.51 ± 0.14 vs. 0.40 ± 0.12, P < 0.001) and passive emptying index (0.29 ± 0.10 vs. 0.23 ± 0.06, P < 0.001) were remarkably reduced compared to baseline values, while active emptying percent of total emptying (0.49 ± 0.14 vs. 0.60 ± 0.12, P < 0.001) and active emptying index (0.41 ± 0.16 vs. 0.47 ± 0.16, P = 0.048) were increased. GLS (−21.64 ± 2.83 vs. −17.30 ± 2.50) was markedly reduced, cTnT levels was elevated from 0.005 ± 0.004 to 0.020 ± 0.026 ng/mL at the completion of chemotherapy (P all  < 0.001). Early LA functional change occur after doxorubicin exposure in patients with preserved LVEF, which could be detected by RT-3DE.

The interplay between genetic background and sexual dimorphism of doxorubicin-induced cardiotoxicity

Background

Doxorubicin (DOX) is a very effective anticancer medication that is commonly used to treat hematological malignancies and solid tumors. Nevertheless, DOX is known to have cardiotoxic effects that may lead to cardiac dysfunction and failure. In experimental studies, female animals have been shown to be protected against DOX-induced cardiotoxicity; however, the evidence of this sexual dimorphism is inconclusive in clinical studies. Therefore, we sought to investigate whether genetic background could influence the sexual dimorphism of DOX-induced cardiotoxicity.

Methods

Male and female Wistar Kyoto (WKY) and Spontaneous Hypertensive Heart Failure (SHHF) rats were used. DOX was administered in eight doses of 2 mg/kg/week and the rats were followed for an additional 12 weeks. Cardiac function was assessed by trans-thoracic echocardiography, systolic blood pressure was measured by the tail cuff method, and heart and kidney tissues were collected for histopathology.

Results

Female sex protected against DOX-induced weight loss and increase in blood pressure in the WKY rats, whereas it protected against DOX-induced cardiac dysfunction and the elevation of cardiac troponin in SHHF rats. In both strains, female sex was protective against DOX-induced nephrotoxicity. There was a strong correlation between DOX-induced renal pathology and DOX-induced cardiac dysfunction.

Conclusions

This study highlights the importance of studying the interaction between sex and genetic background to determine the risk of DOX-induced cardiotoxicity. In addition, our findings suggest that DOX-induced nephrotoxicity may play a role in DOX-induced cardiac dysfunction in rodent models.

Anthracycline or trastuzumab-related cardiotoxicity: do we have a predictive biomarker?

Chemotherapy-induced cardiotoxicity, is a well-known and potentially serious complication strongly impacting the quality of life and overall survival of breast cancer patients. The current diagnostic approach to detect cardiac damage is the estimation of left ventricular ejection fraction by echocardiography. However, this approach exhibits less sensitivity toward early prediction of cardiomyopathy, not allowing for preventive strategies. Measurement of serum cardiac-specific biomarkers can be a valid diagnostic tool for identifying patients prone to developing cardiotoxocity and in whom closer cardiac monitoring and preventive strategies are pivotal. In this article, we review work done on biomarkers in recent years, with an emphasis on troponin and B-type natriuretic peptide, which are currently the most studied in this field. We also briefly discuss current and emerging imaging techniques for early detection of cardiomyopathy.

MicroRNAs as early toxicity signatures of doxorubicin in human-induced pluripotent stem cell-derived cardiomyocytes

An in depth investigation at the genomic level is needed to identify early human-relevant cardiotoxicity biomarkers that are induced by drugs and environmental toxicants. The main objective of this study was to investigate the role of microRNAs (miRNAs) as cardiotoxicity biomarkers using human-induced pluripotent stem cell (hiPSC)-derived cardiomyocytes (CMs) that were exposed to doxorubicin (DOX) as a "gold standard" cardiotoxicant. hiPSC-CMs were exposed to 156 nM DOX for 2 days or for 6 days of repeated exposure, followed by drug washout and incubation in drug-free culture medium up to day 14 after the onset of exposure. The induced miRNAs were profiled using miRNA microarrays, and the analysis of the data was performed using the miRWalk 2.0 and DAVID bioinformatics tools. DOX induced early deregulation of 14 miRNAs (10 up-regulated and 4 down-regulated) and persistent up-regulation of 5 miRNAs during drug washout. Computational miRNA gene target predictions suggested that several DOX-responsive miRNAs might regulate the mRNA expression of genes involved in cardiac contractile function. The hiPSC-CMs exposed to DOX in a range from 39 to 156 nM did not show a significant release of the cytotoxicity marker lactate dehydrogenase (LDH) compared to controls. Quantitative real-time PCR analyses confirmed the early deregulation of miR-187-3p, miR-182-5p, miR-486-3p, miR-486-5p, miR-34a-3p, miR-4423-3p, miR-34c-3p, miR-34c-5p and miR-1303, and also the prolonged up-regulation of miR-182-5p, miR-4423-3p and miR-34c-5p. Thus, we identified and validated miRNAs showing differential DOX-responsive expression before the occurrence of cytotoxicity markers such as LDH, and these miRNAs also demonstrated the significant involvement in heart failure in patients and animal models. These results suggest that the DOX-induced deregulated miRNAs in human CMs may be used as early sensitive cardiotoxicity biomarkers for screening potential drugs and environmental cardiotoxicants with a similar mechanism of action.

Utilizing cardiac biomarkers to detect and prevent chemotherapy-induced cardiomyopathy

The success achieved in advances in cancer therapy has been marred by development of cardiotoxicity, which causes significant morbidity and mortality. This has led to the development of surveillance protocols for cardiotoxicity utilizing multimodality imaging techniques and investigation of various drugs to treat and prevent cardiotoxicity in this subset of patients. Cardiac biomarkers hold important diagnostic and prognostic value in various cardiac diseases. In this review, we discuss the use of biomarkers in patients receiving chemotherapy, highlighting data behind the use of troponin, B-type natriuretic peptide, and myeloperoxidase. We also discuss the use of dexrazoxane, angiotensin-converting enzyme inhibitors, and beta blockers in the treatment and prevention of chemotherapy-induced cardiotoxicity. Cardiac biomarkers may serve an important role in selecting patients that are at high risk of cardiotoxicity and can potentially be used to guide the administration of drugs to treat and prevent cardiotoxicity.

Experimental determination of diagnostic window of cardiac troponins in the development of chronic anthracycline cardiotoxicity and estimation of its predictive value

BACKGROUND

Cardiac troponins (cTns) seem to be more sensitive for the detection of anthracycline cardiotoxicity than the currently recommended method of monitoring LV systolic function. However, the optimal timing of blood sampling remains unknown. Hence, the aims of the present study were to determine the precise diagnostic window for cTns during the development of chronic anthracycline cardiotoxicity and to evaluate their predictive value.

METHODS

Cardiotoxicity was induced in rabbits with daunorubicin (3mg/kg, weekly, for 8 weeks). Blood samples were collected 2-168 h after the 1st, 5th and 8th drug administrations, and concentrations of cTns were determined using highly sensitive assays: hs cTnT (Roche) and hs cTnI (Abbott).

RESULTS

The plasma levels of cTns progressively increased with the rising number of chemotherapy cycles. While only a mild non-significant increase in both cTn levels occurred after the first daunorubicin dose, a significant rise was observed after the 5th and 8th administrations. Two hours after these administrations, a significant increase occurred with a peak between 4-6h and a decline until 24h. Discrete cTn release continued even after cessation of the therapy. While greater variability of cTn levels was observed around the peak concentrations, the values did not correspond well with the severity of LV systolic dysfunction. Unlike AMI in cardiotoxicity, cTn elevations may be better associated with cumulative dose and concentrations at steady state than cmax.

CONCLUSIONS

To the best of our knowledge, this is the first study to precisely describe the diagnostic window and predictive value of cTns in anthracycline cardiotoxicity.

Chemotherapy-related Cardiomyopathy

Advances in chemotherapeutic agents have resulted in significantly improved cancer survival rates. Cardiac toxicity, however, has emerged as a leading cause of morbidity, both during and years after treatment. One of the most common manifestations of cardiotoxicity is that of heart failure and left ventricular systolic dysfunction. In this review, current opinions and guidelines in this field are discussed, with particular focus on the most common culprits, the anthracyclines, and the monoclonal antibody, trastuzumab.

Identifying cancer patients at risk for cardiotoxicity

Improvements in therapies have significantly changed survival of cancer patients. However, the clinical history and oncologic treatment put cancer patients at higher risk for developing cardiovascular problems. Anthracyclines, but also the targeted therapy and angiogenesis inhibitors, are all treatments associated with cardiotoxicity. The most common adverse event is a reduction in left ventricular ejection fraction that may progress to overt heart failure. Recognition of a cardiac impairment during or after a potential cardiotoxic treatment requires a stringent assessment of clinical symptoms and signs of heart failure associated with an evaluation of the left ventricular ejection fraction, which, however, detects the damage already installed. Circulating cardiac biomarkers are promising in detecting cardiotoxicity and will likely change the approach for identifying patients at risk.

Heart failure and chemotherapeutic agents

Advances in chemotherapeutic agents over the past two decades have resulted in significantly improved cancer survival rates. Cardiac toxicity, however, has emerged as a leading cause of morbidity, both during and years after treatment. One of the most common manifestations of cardiotoxicity is that of heart failure and left ventricular systolic dysfunction. Consequently, the field of cardio-oncology is a rapidly emerging field of sub-specialty, with growing research interests in all aspects of management. In this review, current opinions and guidelines in this field are discussed, with particular focus on the most common culprits, the anthracyclines and the monoclonal antibody, trastuzumab.

Use of biomarkers for the assessment of chemotherapy-induced cardiac toxicity

OBJECTIVES

To review the evidence for the use of various biomarkers in the detection of chemotherapy associated cardiac damage.

DESIGN AND METHODS

Pubmed.gov was queried using the search words chemotherapy and cardiac biomarkers with the filters of past 10years, humans, and English language. An emphasis was placed on obtaining primary research articles looking at the utility of biomarkers for the detection of chemotherapy-mediated cardiac injury.

RESULTS

Biomarkers may help identify patients undergoing treatment who are at high risk for cardiotoxicity and may assist in identification of a low risk cohort that does not necessitate continued intensive screening. cTn assays are the best studied biomarkers in this context and may represent a promising and potentially valuable modality for detecting cardiac toxicity in patients undergoing chemotherapy. Monitoring cTnI levels may provide information regarding the development of cardiac toxicity before left ventricular dysfunction becomes apparent on echocardiography or via clinical symptoms. A host of other biomarkers have been evaluated for their utility in the field of chemotherapy related cardiac toxicity with intermittent success; further trials are necessary to determine what role they may end up playing for prediction and prognostication in this setting.

CONCLUSIONS

Biomarkers represent an exciting potential complement or replacement for echocardiographic monitoring of chemotherapy related cardiac toxicity which may allow for earlier realization of the degree of cardiac damage occurring during treatment, creating the opportunity for more timely modulation of therapy.

Prognostic role of troponin and natriuretic peptides as biomarkers for deterioration of left ventricular ejection fraction after chemotherapy

Cardiotoxicity due to anthracyclines, trastuzumab and other potential cardiotoxic drugs is still a problem of modern chemotherapy. For years researchers have tried to find biological markers that can predict changes in the heart. The most thoroughly tested markers are troponin and natriuretic peptides. Some studies have proven that these markers can indeed be useful. In studies which have shown the predictive role of troponin I the assessment of this marker was performed very frequently. It is not possible to carry out such serial measurements in many centers because of typical 1-day hospital stay times. The predictive role of natriuretic peptides still needs further investigation. This review considers the newest research from recent years.

Early biomarkers of doxorubicin-induced heart injury in a mouse model

Cardiac troponins, which are used as myocardial injury markers, are released in plasma only after tissue damage has occurred. Therefore, there is a need for identification of biomarkers of earlier events in cardiac injury to limit the extent of damage. To accomplish this, expression profiling of 1179 unique microRNAs (miRNAs) was performed in a chronic cardiotoxicity mouse model developed in our laboratory. Male B6C3F1 mice were injected intravenously with 3mg/kg doxorubicin (DOX; an anti-cancer drug), or saline once a week for 2, 3, 4, 6, and 8weeks, resulting in cumulative DOX doses of 6, 9, 12, 18, and 24mg/kg, respectively. Mice were euthanized a week after the last dose. Cardiac injury was evidenced in mice exposed to 18mg/kg and higher cumulative DOX dose whereas examination of hearts by light microscopy revealed cardiac lesions at 24mg/kg DOX. Also, 24 miRNAs were differentially expressed in mouse hearts, with the expression of 1, 1, 2, 8, and 21 miRNAs altered at 6, 9, 12, 18, and 24mg/kg DOX, respectively. A pro-apoptotic miR-34a was the only miRNA that was up-regulated at all cumulative DOX doses and showed a significant dose-related response. Up-regulation of miR-34a at 6mg/kg DOX may suggest apoptosis as an early molecular change in the hearts of DOX-treated mice. At 12mg/kg DOX, up-regulation of miR-34a was associated with down-regulation of hypertrophy-related miR-150; changes observed before cardiac injury. These findings may lead to the development of biomarkers of earlier events in DOX-induced cardiotoxicity that occur before the release of cardiac troponins.

Serum biomarkers for the detection of cardiac toxicity after chemotherapy and radiation therapy in breast cancer patients

Multi-modality cancer treatments that include chemotherapy, radiation therapy, and targeted agents are highly effective therapies. Their use, especially in combination, is limited by the risk of significant cardiac toxicity. The current paradigm for minimizing cardiac morbidity, based on serial cardiac function monitoring, is suboptimal. An alternative approach based on biomarker testing, has emerged as a promising adjunct and a potential substitute to routine echocardiography. Biomarkers, most prominently cardiac troponins and natriuretic peptides, have been evaluated for their ability to describe the risk of potential cardiac dysfunction in clinically asymptomatic patients. Early rises in cardiac troponin concentrations have consistently predicted the risk and severity of significant cardiac events in patients treated with anthracycline-based chemotherapy. Biomarkers represent a novel, efficient, and robust clinical decision tool for the management of cancer therapy-induced cardiotoxicity. This article aims to review the clinical evidence that supports the use of established biomarkers such as cardiac troponins and natriuretic peptides, as well as emerging data on proposed biomarkers.