Cardiotoxicity of Anticancer Drugs: Molecular Mechanisms and Strategies for Cardioprotection

Untargeted metabolomics reveal the biochemistry of chemotherapy-induced cardiotoxicity risk in a pediatric cohort of patients

Chemotherapy-induced cardiotoxicity (CIC) is a common adverse effect of antineoplastic drugs, manifesting in adult and paediatric populations. The biochemical background of CIC risk remains unclear. However, recent genomics studies linked the condition to specific gene polymorphisms. The application of metabolomics has the potential to improve our understanding of CIC risk, bridging the gap between the genetic predisposition, the chemotherapy and the onset of CIC. Accordingly, an untargeted metabolomics approach was implemented to determine correlations between patients' metabolomics profiles and the risk of CIC during or shortly following their chemotherapy. A UPLC-ESI-QTOF protocol was developed to analyse plasma samples of 89 paediatricpatients collected prior to the initiation of chemotherapy. The metabolomics data were integrated with the a posteriori knowledge of CIC expression in a post-hoc analysis. KODAMA, OPLS-DA, BORUTA, and FDR t-test were used as complementary classification and variables selection methodologies to point out metabolites with an increased probability of being CIC risk-related. An empirical scale of confidence for DIA identification was developed to assure results' reliability. All classification models succeeded in separating the CIC-risk patients. Overall, CIC-risk patients showed early alterations in pathways related to CVDs, inflammation, oxidation, folate deficiency, and inhibition of GSH production. The 3-hydroxy-9-hexadecenoylcarnitine was determined as a potential predictive biomarker.

Identification of Anticancer Drugs Associated With Cancer Therapy-Related Cardiac Dysfunction in Pediatrics-Analysis of the WHO Pharmacovigilance Database

AIMS

Cardiovascular toxicities associated with anticancer drugs constitute a significant concern for pediatric patients undergoing cancer treatment. Comprehensive data on the burden of cancer therapy-related cardiac dysfunction (CTRCD) are lacking, particularly for this high-risk population susceptible to develop myocardial toxicity. By analyzing VigiBase, the World Health Organization's individual case safety report database, we sought to determine anticancer drugs associated with CTRCD in pediatric patients.

METHODS AND RESULTS

To evaluate the association between 249 anticancer drugs labeled by the FDA or EMA and CTRCD reporting, we performed a disproportionality analysis, calculating multivariable adjusted reporting odds ratios (aROR) with their 95% confidence intervals (CI) across four pediatric age classes (0-27 days, 28 days to 23 months, 2-11 years, 12-17 years); ClinicalTrial registration number: NCT05602103. We identified 796 cases of CTRCD associated with at least one anticancer drug in VigiBase. Multivariate analysis across the pediatric age spectrum revealed 16 anticancer drugs significantly associated with CTRCD, of which 10 (63%) are primarily used for hematologic malignancies. Two drugs, a topoisomerase 1 inhibitor (topotecan) and cytotoxic antibiotics (dactinomycin), represented novel associations with CTRCD not previously documented in the literature.

CONCLUSION

Within VigiBase, we pinpointed 16 anticancer drugs significantly associated with CTRCD reporting in pediatrics. Our research validated several associations already thoroughly reported in children (such as with anthracyclines), and unveiled novel signals for systemic exposure to topotecan and dactinomycin. The relevance of these findings, especially considering the frequency of co-administration of agents and the lack of information regarding radiation exposure and chemotherapy dosage, would need to be evaluated in the context of clinical trials that use or have used these agents.

SiRNA-mediated knockdown of TOP2B protects hiPSC-derived cardiomyocytes from doxorubicin-induced toxicity

AIMS

Doxorubicin (Dox) is a potent chemotherapeutic agent, but its use is limited by cardiotoxicity, primarily due to the disruption of Topoisomerase-2 beta (TOP2B) activity. Dexrazoxane (Dex), an FDA-approved cardioprotective drug, alleviates Dox-induced toxicity but lacks heart-specific targeting. This study investigates siRNA-mediated TOP2B knockdown as a more targeted strategy to protect cardiomyocytes from Dox-induced damage.

MATERIALS AND METHODS

Human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) were treated with siRNA to knock down TOP2B and were then exposed to Dox. We compared the cardioprotective effects of siRNA-mediated knockdown to Dex treatment using cell viability, cell toxicity assay and electrophysiological evaluation was performed using a multielectrode array (MEA).

KEY FINDINGS

Our results demonstrate that TOP2B silencing significantly decreases apoptosis and improved cell viability, as compared to the Dex treatment. Additionally, electrophysiological assays using a Multielectrode Array (MEA) demonstrated enhanced contractility and conductivity in siRNA-treated hiPSC-CMs. Furthermore, transmission electron microscopy (TEM) data revealed that TOP2B knockdown preserves mitochondrial morphology and sarcomere structure, compared to Dox and Dex-treated groups.

SIGNIFICANCE

These findings suggest that siRNA-mediated TOP2B inhibition could provide a safer, more specific approach to mitigate Dox-induced cardiotoxicity.

A systematic review and meta-analysis of cardiovascular disease risk with degarelix and GnRH agonists in prostate cancer

BACKGROUND

Degarelix is a third-generation GnRH receptor antagonist approved for the treatment of prostate cancer, however, the decision to use a GnRH agonist or an antagonist depends on several factors. We aimed to perform a meta-analysis comparing the cardiovascular disease risk between degarelix and gonadotropin-releasing hormone agonists in patients with all stages of prostate cancer.

METHODS

Databases were searched for randomized control trials (RCTs) and observational studies that compared the risk of cardiovascular disease between degarelix and GnRH agonists in patients with prostate cancer. We computed for binary endpoints risk ratio (RR) or hazard ratio (HR) with 95% confidence intervals (CI) which were analyzed using a random-effects model.

RESULTS

A total of 15 studies were included with 123,969 patients and follow-up ranging from 3 to 13 months. Degarelix was associated with a significantly lower incidence of major adverse cardiovascular events (RR 0.59; 95% CI 0.41-0.84; p = 0.003; I2 = 84%). Incidence of stroke (RR 0.89; 95% CI 0.56-1.42; p = 0.62; I2 = 0%), all-cause mortality (RR 0.64; 95% CI 0.37-1.13; p = 0.12; I2 = 41%), hypertension (RR 0.71; 95% CI 0.48, 1.04; p = 0.08; I2 = 0%), myocardial infarction (HR 1.04; 95% CI 0·59-1·84; p = 0·86; I2 = 66%), heart failure (HR 0.79; 95% CI 0.38-1.62; p = 0.52; I2 = 79%) and arrhythmia (RR 0.63; 95% CI 0.28-1.41; p = 0.86; I2 = 37%), did not reach a statistically significant difference between groups.

CONCLUSION

In patients with prostate cancer, degarelix is associated with a significantly lower incidence of major adverse cardiovascular events.

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.

Cardio-Oncology and Breast Cancer Therapies

OPINION STATEMENT

Assessing cardiac risk prior to initiating breast cancer treatment, monitoring cardiac function during treatment, and implementing appropriate follow-up strategies are essential components of managing cardiotoxicity in breast cancer patients. A comprehensive cardiovascular evaluation should be conducted before treatment, including a detailed medical history, physical examination, and baseline cardiac imaging. Risk stratification tools can aid in determining the individual patient's risk profile. Close monitoring of cardiac function, including regular assessment of left ventricular ejection fraction (LVEF) and monitoring for signs and symptoms of cardiac dysfunction, is crucial during treatment. Prompt action should be taken if an adverse cardiovascular event is detected, including considering discontinuing or modifying the treatment regimen. Appropriate follow-up care is essential to monitor for long-term cardiac effects and optimize cardiovascular health in breast cancer survivors. Regular cardiovascular assessments, lifestyle modifications, and collaboration between healthcare professionals are important in managing cardiotoxicity effectively.

Multifaceted roles of neutrophils in cardiac disease

Neutrophils, the most abundant leukocytes in human blood, have long been recognized as critical first responders in the innate immune system's defense against pathogens. Some of the more notable innate antimicrobial properties of neutrophils include generation of superoxide free radicals like myeloperoxidase, production of proteases that reshape the extracellular matrix allowing for easier access to infected tissues, and release of neutrophil extracellular traps, extruded pieces of DNA that ensnare bacterial and fungi. These mechanisms developed to provide neutrophils with a vast array of specialized functions to provide the host defense against infection in an acute setting. However, emerging evidence over the past few decades has revealed a far more complex and nuanced role for these neutrophil-driven processes in various chronic conditions, particularly in cardiovascular diseases. The pathophysiology of cardiac diseases involves a complex interplay of hemodynamic, neurohumoral, and inflammatory factors. Neutrophils, as key mediators of inflammation, contribute significantly to this intricate network. Their involvement extends far beyond their classical role in pathogen clearance, encompassing diverse functions that can both exacerbate tissue damage and contribute to repair processes. Here, we consider the contributions of neutrophils to myocardial infarction, heart failure, cardiac arrhythmias, and nonischemic cardiomyopathies. Understanding these complex interactions is crucial for developing novel therapeutic strategies aimed at modulating neutrophil functions in these highly morbid cardiac diseases.

Overview of Oncology: Drug-Induced Cardiac Toxicity

Cancer medications can cause cardiac issues, which are difficult to treat in oncologic patients because of the risk of complications. In some cases, this may significantly impact their well-being and treatment outcomes. Overall, these complications fall under the term "drug induced cardiotoxicity", mainly due to chemotherapy drugs being specifically toxic to the heart, causing a decrease in the heart's capacity to pump blood efficiently and leading to a reduction in the left ventricular ejection fraction (LVEF), and subsequently possibly leading to heart failure. Anthracyclines, alkylating agents, and targeted therapies for cancer hold the potential of causing harmful effects on the heart. The incidence of heart-related issues varies from patient to patient and depends on multiple factors, including the type of medication, dosage, duration of the treatment, and pre-existing heart conditions. The underlying mechanism leading to oncologic-drug-induced cardiovascular harmful effects is quite complex. One particular group of drugs, called anthracyclines, have garnered attention due to their impact on oxidative stress and their ability to cause direct harm to heart muscle cells. Reactive oxygen species (ROS) cause harm by inducing damage and programmed cell death in heart cells. Conventional biomarkers alone can only indicate some degree of damage that has already occurred and, therefore, early detection is key. Novel methods like genetic profiling are being developed to detect individuals at risk, prior to the onset of clinical symptoms. Key management strategies-including early detection, personalized medicine approaches, and the use of novel biomarkers-play a crucial role in mitigating cardiotoxicity and improving patient outcomes. Identification of generated genetic alterations and the association to an increased likelihood of cardiotoxicity will allow treatment in a more personalized approach, aiming at decreasing rates of cardiac events while maintaining high oncological efficacy. Oncology drug-induced cardiotoxicity is managed through a combination of preventive strategies and therapeutic interventions from the union of cardiac and oncological knowledge.

Ischemic and non-ischemic myocardial injuries at autopsy- an overview for forensic pathologists

Cardiovascular diseases are major causes of morbidity and death worldwide, and most cardiac deaths are related to ischemic injury of the myocardium (myocardial infarction). As underlined in the current clinical definition and classification of myocardial infarctions, not all myocardial injuries are due to ischemia: irreversible injury, ending in necrosis, can be induced also by various other factors, such as infections, immune disorders, physical and chemical agents, and trauma. This is supported by clinical studies showing that elevated serum levels of cardiac troponins, as a measure of myocardial damage, are also a common finding in the non-ischemic types of myocardial injury. Forensic pathologists confronted with autopsy findings suggestive of myocardial injury should therefore realize that both ischemic and non-ischemic forms of myocardial death can be observed, and not only in natural but also non-natural deaths (intoxications, asphyxia, traumatic and iatrogenic deaths, and others). Distinguishing these different types of injuries and underlying diseases or circumstances of death is critical, not only to determine the cause and mechanism of death, but also to help investigate often challenging medico-legal scenarios. This article reviews the broad spectrum of ischemic and non-ischemic myocardial injuries in natural and violent deaths. From this perspective we propose a diagnostic approach to myocardial injuries in a forensic pathology context.

Cardioprotective effects of PARP inhibitors for platinum-agent induced cardiotoxicity

Poly(ADP-ribose) polymerase (PARP) inhibitors may have cardioprotective properties. This study aimed to evaluate the potential cardioprotective effects of PARP inhibitors in patients with epithelial ovarian cancer treated with platinum-based chemotherapeutic agents. A retrospective cohort study was conducted using the Health Insurance Review & Assessment Service claims database from January 2007 to July 2022. Eligible patients were those diagnosed with ovarian, primary peritoneal, or fallopian tube cancer who received platinum-based chemotherapy after 2017. Propensity score matching was employed to adjust for potential confounders, and logistic regression and Cox proportional hazards regression analyses were utilized to estimate the odds ratios, hazard ratios, and 95% confidence intervals (CIs) for the occurrence of cardiac adverse events, including myocardial infarction, cardiomyopathy, and heart failure. A total of 7,253 eligible patients were included in the study, of which 233 (3.2%) used PARP inhibitors. After propensity score matching, no significant cardioprotective effect was observed in the PARP inhibitor-exposed group compared to the non-exposed group (adjusted odds ratio, 0.753; 95% CI 0.275-2.059; adjusted hazard ratio, 0.601; 95% CI 0.228-1.584). Although no statistically significant cardioprotective effect of PARP inhibitors was found in this study, there was a directional trend suggesting that patients with gynecologic malignancies treated with platinum-based chemotherapy could potentially benefit from PARP inhibitors. Further research with larger sample sizes and longer follow-up periods is warranted to elucidate the role of PARP inhibitors in mitigating cardiac adverse events in this patient population.

AI and Smart Devices in Cardio-Oncology: Advancements in Cardiotoxicity Prediction and Cardiovascular Monitoring

The increasing prevalence of cardiovascular complications in cancer patients due to cardiotoxic treatments has necessitated advanced monitoring and predictive solutions. Cardio-oncology is an evolving interdisciplinary field that addresses these challenges by integrating artificial intelligence (AI) and smart cardiac devices. This comprehensive review explores the integration of artificial intelligence (AI) and smart cardiac devices in cardio-oncology, highlighting their role in improving cardiovascular risk assessment and the early detection and real-time monitoring of cardiotoxicity. AI-driven techniques, including machine learning (ML) and deep learning (DL), enhance risk stratification, optimize treatment decisions, and support personalized care for oncology patients at cardiovascular risk. Wearable ECG patches, biosensors, and AI-integrated implantable devices enable continuous cardiac surveillance and predictive analytics. While these advancements offer significant potential, challenges such as data standardization, regulatory approvals, and equitable access must be addressed. Further research, clinical validation, and multidisciplinary collaboration are essential to fully integrate AI-driven solutions into cardio-oncology practices and improve patient outcomes.

Cilostazol alleviates imatinib-induced myocardial injury in rats by modulating the TGF-β1/MAPK, SHC/Grb2/SOS signaling pathways and upregulating miRNA-195-5P

Tyrosine kinase inhibitors have revolutionized cancer treatment, yet their association with cardiotoxicity remains a challenge. While the pathophysiological consequences of imatinib therapy involve diverse pathways, our understanding of these mechanisms is limited. Cilostazol, a selective phosphodiesterase 3 inhibitor used in intermittent claudication treatment, is known for its antioxidant and anti-inflammatory effects. In this study, we aimed to counteract the cardiotoxic effects of imatinib by administering cilostazol, concurrently investigating the precise mechanisms underlying imatinib-induced myocardial injury. Twenty-eight male Wistar rats were categorized into four groups: control (2 mL/kg normal saline, orally), cilostazol (10 mg/kg, orally), imatinib (40 mg/kg, intraperitonially), and combination (cilostazol and imatinib). Daily treatments were administered for 28 consecutive days. Imatinib therapy induced oxidative stress, pro-inflammatory responses, and cardiotoxicity biomarkers, alongside dysregulation of various protein and gene expressions. The addition of cilostazol to imatinib mitigated these deleterious effects, notably restoring measured biomarkers close to normal values. Histopathological investigations corroborated the biochemical findings. The co-administration of cilostazol with imatinib effectively protects against imatinib-induced myocardial injury in rats, reducing oxidative stress, apoptotic and inflammatory biomarkers, and modulating protein, gene, and miRNA-195-5p expression levels. While promising for alleviating and protecting against myocardial injury in imatinib-treated patients, these findings necessitate further confirmation through clinical studies.

Anesthetic considerations in cancer care

PURPOSE OF REVIEW

Cancer burden remains a global medical and financial challenge. Advances in surgical management have resulted in increased oncological surgeries that often involve anesthetic administration. This review aims to inform on anesthetic considerations when caring for cancer patients in the perioperative period.

RECENT FINDINGS

There are various retrospective studies and, more recently, several randomized controlled trials that have explored whether the choice of anesthesia (total intravenous anesthesia vs. inhaled anesthetic) results in a significant difference in cancer outcomes, mortality, cancer recurrence, and metastasis. To date, no definitive proof has been made, and the current conclusion remains that the anesthetic technique does not influence survival or overall long-term outcomes.

SUMMARY

Comprehensive risk assessment is essential in cancer patients before elective surgeries due to a variety of concerns such as malnutrition, aspiration risk, postradiation airway compromise, and antineoplastic systemic effects. Oncologic patients' exposure to chemotherapy and radiation causes immunosuppression and multiorgan toxicity that places them at increased perioperative risk for morbidity and mortality. Other concerns include the challenges of adequate pain management and pre-existing chronic pain.

The Application and Molecular Mechanisms of Mitochondria-Targeted Antioxidants in Chemotherapy-Induced Cardiac Injury

Chemotherapeutic agents play a crucial role in cancer treatment. However, their use is often associated with significant adverse effects, particularly cardiotoxicity. Drugs such as anthracyclines (e.g., doxorubicin) and platinum-based agents (e.g., cisplatin) cause mitochondrial damage, which is one of the main mechanisms underlying cardiotoxicity. These drugs induce oxidative stress, leading to an increase in reactive oxygen species (ROS), which in turn damage the mitochondria in cardiomyocytes, resulting in impaired cardiac function and heart failure. Mitochondria-targeted antioxidants (MTAs) have emerged as a promising cardioprotective strategy, offering a potential solution. These agents efficiently scavenge ROS within the mitochondria, protecting cardiomyocytes from oxidative damage. Recent studies have shown that MTAs, such as elamipretide, SkQ1, CoQ10, and melatonin, significantly mitigate chemotherapy-induced cardiotoxicity. These antioxidants not only reduce oxidative damage but also help maintain mitochondrial structure and function, stabilize mitochondrial membrane potential, and prevent excessive opening of the mitochondrial permeability transition pore, thus preventing apoptosis and cardiac dysfunction. In this review, we integrate recent findings to elucidate the mechanisms of chemotherapy-induced cardiotoxicity and highlight the substantial therapeutic potential of MTAs in reducing chemotherapy-induced heart damage. These agents are expected to offer safer and more effective treatment options for cancer patients in clinical practice.

Cardiotoxicity in platinum-based chemotherapy: Mechanisms, manifestations, and management

Platinum-based chemotherapy, a cornerstone in the treatment of various malignancies, is often limited by its potential cardiotoxic effects. Understanding these effects is crucial for optimizing patient outcomes and guiding treatment decisions. This review explores the mechanisms, clinical manifestations, detection, management, and future directions in the research of cardiotoxicity associated with platinum-based chemotherapy. The mechanisms discussed here include oxidative stress, reactive oxygen species production, DNA damage, and alterations in signaling pathways. Clinical manifestations range from mild symptoms to severe complications, including Takotsubo cardiomyopathy, as highlighted by recent case studies. The role of diagnostic tools such as echocardiography, cardiac magnetic resonance imaging, and cardiac biomarkers in early detection is emphasized, underscoring the importance of regular cardiac monitoring. Management strategies focus on cardioprotective agents, alternative chemotherapy regimens, and emerging therapeutic approaches, including the potential of nano liposomal and cubosomal formulations. The review also delves into the future of personalized medicine in predicting and managing cardiotoxicity, advocating for ongoing research to mitigate these adverse effects. This comprehensive overview aims to enhance the understanding of cardiotoxicity in platinum-based chemotherapy, informing clinical practices and promoting patient-centric care.

Chamomile Extract Reduces Cardiac Toxicity in Female Mice with Ehrlich Solid Carcinoma

Cancer is the most serious disorder that may affect a person and is also the leading cause of mortality. Worldwide, breast cancer continues to be the leading cause of cancer-related deaths in women. The popularity of treating diseases using alternative and complementary medicines has increased in recent decades; many of these are derived from plants. Chamomile has a beneficial effect in treating many diseases, there for the purpose of this work is to study how chamomile protect against cardiac damage and toxicity brought on by Ehrlich solid tumor (EST) in adult female mice. 40 female mice were distributed in 4 groups (control, chamomile, EST, EST+chamomile). The research results indicated that EST caused significant alterations in cardiac function and structure. EST induced a significant elevation in serum creatine kinase (CK), creatine kinase MB (CK-MB), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), and myoglobin (MB), potassium, chloride ions, cholesterol, triglycerides, low-density lipoprotein (LDL), cardiac tissue damage, apoptotic P53 and Caspase 3 expressions while levels of sodium ions and high-density lipoprotein (HDL) were significantly decreased. Treatments of EST with chamomile improved the biochemical, histopathological, and Immunohistochemical alterations. This suggests that chamomile may be useful as an adjuvant for the treatment and prevention of cardiac toxicity.

Casual effect of ulcerative colitis on chronic heart failure: results from a bidirectional Mendelian randomization study

This study aimed to detect the causal effect of ulcerative colitis (UC) on heart failure. A bidirectional two-sample Mendelian randomization (MR) analysis was performed. The causal impact of UC on heart failure was determined via MR by performing a genome-wide association study in which 4 UCs descending from European ancestors were set as individual exposures. The inverse-variance weighted (IVW) method was used as the main method, and 4 other methods were set as assistant parameters. Susbequently, the MR results were combined with meta-analysis results. The MR Egger method was employed to investigate pleiotropy. The leave-one-out method was utilized for sensitivity analysis. Furthermore, a reverse-directional study was conducted. There was evidence of the causal effect of UC on heart failure in MR estimates using 4 UC datasets. The IVW method revealed that the odds ratio (OR) = 1.03, 95% confidence interval (CI) = 1.01-1.06, P = 0.0441 when the first UC dataset was used; OR = 1.03, 95% CI = 1.01-1.05, P = 0.0445 when the second UC dataset was used; OR = 2046, 95% CI = 1.37-3.05E + 06, P = 0.0409 when the third UC dataset was used; and OR = 8.12E + 04, 95% CI = 29.09-2.27E + 08, P = 0.0052 when the fourth UC dataset was used. A meta-analysis of 4 MR studies revealed that UC had a statistically significant causal effect on heart failure (OR = 1.03, 95% CI = 1.01-1.05; P = 0.0074). Reverse MR analysis revealed that heart failure did not have a causal effect on UC. There was no pleiotropy. This MR study demonstrated that UC had a causal effect on heart failure and that there was no reverse causal effect.

Design and Synthesis of Topoisomerases-Histone Deacetylase Dual Targeted Quinoline-Bridged Hydroxamates as Anticancer Agents

The multifactorial nature of cancer requires treatment that involves simultaneous targeting of associated overexpressed proteins and cell signaling pathways, possibly leading to synergistic effects. Herein, we present a systematic study that involves the simultaneous inhibition of human topoisomerases (hTopos) and histone deacetylases (HDACs) by multitargeted quinoline-bridged hydroxamic acid derivatives. These compounds were rationally designed considering pharmacophoric features and catalytic sites of the cross-talk proteins, synthesized, and assessed for their anticancer potential. Our findings revealed that the compound 5c significantly produced anticancer effects in vitro and in vivo by reducing the tumor growth and its size in the A549 cell-induced lung cancer xenograft model through multiple mechanisms, primarily by multi-inhibition of hTopoI/II and HDACs, especially HDAC1 via atypical binding. The present paper discusses detailed mechanistic biological investigations, structure-activity effects supported by computational docking studies, and DMPK studies and provides future scope for lead optimization and modification.

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.

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.

Combined Graphene Oxide with 2-Methoxyestradiol for Effective Anticancer Therapy in-vitro Model

Introduction

This article describes the invention of graphene oxide (GO) or reduced graphene oxide (rGO) functionalised with 2-methoxy estradiol. The presence of polar hydroxyl groups enables the binding of 2-ME to GO/rGO through hydrogen bonds with epoxy and hydroxyl groups located on the surface and carbonyl and carboxyl groups located at the edges of graphene flake sheets.

Methods

The patented method of producing the subject of the invention and the research results regarding its anticancer effectiveness via cytotoxicity in an in vivo model (against A375 melanoma and 143B osteosarcoma cells) are described.

Results

It was shown that the inhibition of PTP1B phosphotyrosine phosphatase is one of the mechanisms of action of GO functionalised with 2-ME (GO-2-ME). This is a very important result, considering the fact that 2-ME itself has no inhibitory properties against this phosphatase.

Discussion

Graphene oxide flakes embroidered with 2-methoxyestradiol molecules may be a promising solution, bringing a new and important effect in the form of improving the bioavailability of the therapeutic substance, ie 2-ME. An appropriate dosage of GO-2-ME/rGO-2-ME, in which GO/rGO is a carrier of 2-methoxyestradiol (2-ME), can ensure effective penetration of the active substance through biological boundaries/membranes and controlled modification of cell signalling, ultimately leading to the selective elimination of malignant cells.

Multicore, SDS-Based Polyelectrolyte Nanocapsules as Novel Nanocarriers for Paclitaxel to Reduce Cardiotoxicity by Protecting the Mitochondria

The clinical application of paclitaxel (PTX), a widely used anticancer drug, is constrained by cardiac arrhythmias and disruptions in vascular homeostasis. To mitigate the non-specific, high toxicity of PTX towards cardiomyocytes, we propose the application of newly synthesized SDS-based polyelectrolyte multicore nanocapsules. This study aims to verify the hypothesis that SDS-based NCs can mitigate the cytotoxic effects of PTX on cardiac cells and serve as effective nanocarriers for this drug. We investigated two types of multicore NCs with differing polyelectrolyte coatings: poly-L-lysine (PLL) and a combination of PLL with poly-L-glutamic acid (PGA). The cytotoxicity of the formulated nanosystems was evaluated using HL-1 cardiomyocytes. Oxygraphy, flow cytometry, spectrophotometry, spectrofluorimetry, fluorescence microscopy, and RT-PCR were employed to assess disruptions in cardiac cellular homeostasis. Our data revealed that, among the tested NCs, SDS/PLL/PGA/PTX exhibited reduced cardiotoxicity and were better tolerated by HL-1 cardiomyocytes compared to SDS/PLL/PTX or PTX alone. In addition, SDS/PLL/PGA/PTX showed a marginal disruption of mitochondria's homeostasis, and no changes in APT level and intracellular calcium concentrations were observed. These findings underscore the potential of SDS-based multicore nanocarriers in anticancer therapy, particularly due to diminished cardiotoxicity and long-term stability in the biological fluids.

[Cardiotoxicity risk assessment of anticancer drugs by focusing on mitochondrial quality of human iPS cell-derived cardiomyocytes]

Currently, a variety of anticancer agents are used in the treatment of cancer. Since anticancer agents are used continuously over a long time, they carry the risk of side effects. One of the major side effects is cardiac dysfunction. For example, doxorubicin, an anthracycline-type anticancer agent, is clinically restricted because of its dose-dependent cardiotoxicity. Cardiotoxicity includes decreased ejection fraction, arrhythmias, and congestive heart failure, all of which are associated with high mortality rates. Therefore, it is important to assess the risk of cardiotoxicity of anticancer agents in advance. Cardiomyocytes require energy to beat and retain an abundance of mitochondria. We established quantitative measurements of mitochondrial length and respiratory activities using cardiomyocytes. We found that exposure of human iPS cell-derived cardiomyocytes (hiPSC-CMs) to anticancer agents with reported cardiotoxicity enhanced mitochondrial hyperfission and the oxygen consumption rate was significantly reduced. Knockdown of dynamin-related protein 1 (Drp1), mitochondrial fission-accelerating GTP-binding protein, suppressed mitochondrial hyperfission in hiPSC-CMs. This indicates that visualizing mitochondrial functions in hiPSC-CMs will be helpful in assessing the risk of cardiotoxicity caused by anticancer agents and that maintaining mitochondrial quality will become a new strategy to reduce anticancer agents-induced cardiotoxicity. In this review, we present the evaluation of cardiotoxicity targeting mitochondrial quality in anticancer agents, using osimertinib, a non-small cell lung cancer drug, as an example.

Unveiling the Complexities: Exploring Mechanisms of Anthracyclineinduced Cardiotoxicity

The coexistence of cancer and heart disease, both prominent causes of illness and death, is further exacerbated by the detrimental impact of chemotherapy. Anthracycline-induced cardiotoxicity is an unfortunate side effect of highly effective therapy in treating different types of cancer; it presents a significant challenge for both clinicians and patients due to the considerable risk of cardiotoxicity. Despite significant progress in understanding these mechanisms, challenges persist in identifying effective preventive and therapeutic strategies, rendering it a subject of continued research even after three decades of intensive global investigation. The molecular targets and signaling pathways explored provide insights for developing targeted therapies, emphasizing the need for continued research to bridge the gap between preclinical understanding and clinical applications. This review provides a comprehensive exploration of the intricate mechanisms underlying anthracycline-induced cardiotoxicity, elucidating the interplay of various signaling pathways leading to adverse cellular events, including cardiotoxicity and death. It highlights the extensive involvement of pathways associated with oxidative stress, inflammation, apoptosis, and cellular stress responses, offering insights into potential and unexplored targets for therapeutic intervention in mitigating anthracycline-induced cardiac complications. A comprehensive understanding of the interplay between anthracyclines and these complexes signaling pathways is crucial for developing strategies to prevent or mitigate the associated cardiotoxicity. Further research is needed to outline the specific contributions of these pathways and identify potential therapeutic targets to improve the safety and efficacy of anthracycline-based cancer treatment. Ultimately, advancements in understanding anthracycline-induced cardiotoxicity mechanisms will facilitate the development of more efficacious preventive and treatment approaches, thereby improving outcomes for cancer patients undergoing anthracycline-based chemotherapy.

Next-Gen Therapeutics: Pioneering Drug Discovery with iPSCs, Genomics, AI, and Clinical Trials in a Dish

In the high-stakes arena of drug discovery, the journey from bench to bedside is hindered by a daunting 92% failure rate, primarily due to unpredicted toxicities and inadequate therapeutic efficacy in clinical trials. The FDA Modernization Act 2.0 heralds a transformative approach, advocating for the integration of alternative methods to conventional animal testing, including cell-based assays that employ human induced pluripotent stem cell (iPSC)-derived organoids, and organ-on-a-chip technologies, in conjunction with sophisticated artificial intelligence (AI) methodologies. Our review explores the innovative capacity of iPSC-derived clinical trial in a dish models designed for cardiovascular disease research. We also highlight how integrating iPSC technology with AI can accelerate the identification of viable therapeutic candidates, streamline drug screening, and pave the way toward more personalized medicine. Through this, we provide a comprehensive overview of the current landscape and future implications of iPSC and AI applications being navigated by the research community and pharmaceutical industry.

Irreversible cardiotoxicity induced by trastuzumab: a systematic review based on a pharmacovigilance case report

Irreversible cardiotoxicity (IC) induced by trastuzumab (TZB) is a rare but serious adverse event. As a result, its characteristics and the specific factors related to exposure remain poorly understood. This study aims to synthesize and evaluate the existing evidence on IC. We presented a pharmacovigilance case of long-term IC and conducted a systematic review (SR) of the clinical manifestations of cases reported worldwide. We reported the case using the CARE guidelines checklist and assessed the causality using the modified Algorithm of Karch and Lasagna. Following PRISMA guidelines, we conducted the SR using defined terms in PubMed, Embase, Scopus, and Web of Science from inception until June 2023. This SR included five case reports, including the pharmacovigilance case reported by us. While patients exhibited different severe clinical characteristics, receiving TZB at a 6 mg/kg dose was consistent. Despite varying treatment durations, the median time of IC diagnosis was 10 months, and the average difference between the basal and the final left ventricular ejection fraction was roughly 30%. According to the modified Karch and Lasagna algorithm, all cases were ranged from possible to probable. While TZB is generally considered a reversible cardiotoxic antineoplastic, clinicians and regulators must be aware of the potential IC risk with long-term manifestations. Vigilant cardiac monitoring and further research are crucial to better understanding and managing this serious adverse event.

Post-transplant cyclophosphamide-induced cardiotoxicity: A comprehensive review

Cyclophosphamide-induced cardiotoxicity, associated with its toxic metabolite acrolein, is a significant concern and unresolved issue, especially when cyclophosphamide is administrated in high doses. However, cardiotoxicity following low-dose cyclophosphamide has been also documented, especially in post-hematopoietic stem cell transplantation (post-HSCT) settings. Despite the involvement of multiple signaling pathways in cyclophosphamide-induced cardiomyopathy, the exact underlying mechanisms remain to be fully elucidated. This review outlines the current challenges of cyclophosphamide therapy in HSCT recipients. In addition, the promising therapeutic approaches by targeting acrolein's anti-angiogenic effect were thoroughly discussed to better manage post-HSCT cyclophosphamide-induced cardiotoxicity.

A review of cardioprotective effect of ginsenosides in chemotherapy-induced cardiotoxicity

Chemotherapy-induced cardiotoxicity is a significant concern in cancer treatment, as certain chemotherapeutic agents can have adverse effects on the cardiovascular system. This can lead to a range of cardiac complications, including heart failure, arrhythmias, myocardial dysfunction, pericardial complications, and vascular toxicity. Strategies to mitigate chemotherapy-induced cardiotoxicity may include the use of cardioprotective agents (e.g., dexrazoxane), dose adjustments, alternative treatment regimens, and the implementation of preventive measures, such as lifestyle modifications and the management of cardiovascular risk factors. Ginsenosides, the active compounds found in ginseng (Panax ginseng), have been studied for their potential cardioprotective effects in the context of chemotherapy-induced cardiotoxicity. In this review, we investigate the cardioprotective effect of ginsenosides in chemotherapy-induced cardiotoxicity. Ginsenosides have been shown to possess potent antioxidant properties, which can help mitigate the oxidative stress and inflammation associated with chemotherapy-induced cardiac injury. They can modulate the expression of antioxidant enzymes and reduce the production of reactive oxygen species, thereby protecting cardiomyocytes from damage. Ginsenosides can also inhibit apoptosis (programmed cell death) of cardiomyocytes, which is a key mechanism underlying chemotherapy-induced cardiotoxicity. Modulation of ion channels, improvement of lipid profiles, anti-platelet and anti-thrombotic effects, and promotion of angiogenesis and neovascularization are another important mechanisms behind potential effects of ginsenosides on cardiovascular health. Ginsenosides can improve various parameters of cardiac function, such as ejection fraction, fractional shortening, and cardiac output, in animal models of chemotherapy-induced cardiotoxicity. The cardioprotective effects of ginsenosides have been observed in preclinical studies using various chemotherapeutic agents, including doxorubicin, cisplatin, and 5-fluorouracil. However, more clinical studies are needed to fully elucidate the therapeutic potential of ginsenosides in preventing and managing chemotherapy-induced cardiotoxicity in cancer patients.

Drug-Induced Myocardial Infarction: A Review of Pharmacological Triggers and Pathophysiological Mechanisms

Myocardial infarction (MI) is a significant cardiovascular event caused by the decrease in or complete cessation of blood flow to a portion of the myocardium. It can arise from a variety of etiological factors, including pharmacological triggers. This review aims to explore the diverse drugs and substances that might lead to drug-induced myocardial infarction, focusing on their mechanisms of action and the pathophysiological processes involved. Various established and emerging pharmacological agents that could elevate the risk of myocardial infarction, such as nonsteroidal anti-inflammatory drugs, hormonal therapies, anticoagulants, and antipsychotic medications, are discussed. The role of drug-induced endothelial dysfunction, coronary artery spasm, and thrombosis are presented in order to highlight the underlying mechanisms. This review emphasizes the need for increased awareness among healthcare professionals to mitigate the risks associated with different pharmacological therapies to improve patient outcomes.

Small-molecule mediated MuRF1 inhibition protects from doxorubicin-induced cardiac atrophy and contractile dysfunction

Cancer chemotherapy induces cell stress in rapidly dividing cancer cells to trigger their growth arrest and apoptosis. However, adverse effects related to cardiotoxicity underpinned by a limited regenerative potential of the heart limits clinical application: In particular, chemotherapy with doxorubicin (DOXO) causes acute heart injury that can transition to persisting cardiomyopathy (DOXO-CM). Here, we tested if MuRF1 inhibition ("MuRFi") was able to attenuate DOXO-CM. To mimic DOXO chemotherapy, we treated mice over four weeks with five DOXO injections, resulting in a cumulative dosage of 25 mg/kg. At day 28, mice had lower body and heart weights, reduced cardiac cross-sectional myofibrillar areas (CSAs), and disturbed functional ejection fractions (EFs) and fractional shortenings (FS) as indicated by echocardiography (ECHO). In contrast, mice with a 1 g/kg Myomed#205 spiked diet, a previously described experimental MuRFi therapy, showed lower DOXO-CM at day 28, and also reduced acute DOXO cardiac injury at day 7 (single DOXO dose; 15 mg/kg). Underlying molecular signatures using Western blot (WB) assays showed at day 28 reduced phospho-AKT (AKTp) and phospo-4EBP1 (4 EBP1p) levels following DOXO that were normalized following MuRFi treatment. Taken together, our data suggest that MuRFi treatment is suitable to attenuate DOXO-CM by preserving AKTp and 4 EBP1p levels in DOXO stressed cardiomyocytes, thereby supporting de novo protein translation and cardiomyocyte survival under translational arrest stress.

Trace elements and metal nanoparticles: mechanistic approaches to mitigating chemotherapy-induced toxicity-a review of literature evidence

Anticancer chemotherapy (ACT) remains a cornerstone in cancer treatment, despite significant advances in pharmacology over recent decades. However, its associated side effect toxicity continues to pose a major concern for both oncology clinicians and patients, significantly impacting treatment protocols and patient quality of life. Current clinical strategies to mitigate ACT-induced toxicity have proven largely unsatisfactory, leaving a critical unmet need to block toxicity mechanisms without diminishing ACT's therapeutic efficacy. This review aims to document the molecular mechanisms underlying ACT toxicity and highlight research efforts exploring the protective effects of trace elements (TEs) and their nanoparticles (NPs) against these mechanisms. Our literature review reveals that the primary driver of ACT toxicity is redox imbalance, which triggers oxidative inflammation, apoptosis, endoplasmic reticulum stress, mitochondrial dysfunction, autophagy, and dysregulation of signaling pathways such as PI3K/mTOR/Akt. Studies suggest that TEs, including zinc, selenium, boron, manganese, and molybdenum, and their NPs, can potentially counteract ACT-induced toxicity by inhibiting oxidative stress-mediated pathways, including NF-κB/TLR4/MAPK/NLRP3, STAT-3/NLRP3, Bcl-2/Bid/p53/caspases, and LC3/Beclin-1/CHOP/ATG6, while also upregulating protective signaling pathways like Sirt1/PPAR-γ/PGC-1α/FOXO-3 and Nrf2/HO-1/ARE. However, evidence regarding the roles of lncRNA and the Wnt/β-catenin pathway in ACT toxicity remains inconsistent, and the impact of TEs and NPs on ACT efficacy is not fully understood. Further research is needed to confirm the protective effects of TEs and their NPs against ACT toxicity in cancer patients. In summary, TEs and their NPs present a promising avenue as adjuvant agents for preventing non-target organ toxicity induced by ACT.

The effects of acetylated cordycepin derivatives on promoting vascular angiogenesis and attenuating myocardial ischemic injury

Background

Enhanced angiogenesis following myocardial infarction (MI) is beneficial to preserve cardiac function. The present study aimed to investigate whether acetylated derivatives of cordycepin altered its original antitumor properties and exerted cardioprotective effects by promoting angiogenesis in vitro and in vivo.

Methods

Cordycepin and its derivatives with single (DA), double (DAA), and triple acetyl groups (DAAA) were assessed. The cell viability of leukemia U937 cells, malignant hepatoma Huh-7 cells, and human umbilical vascular endothelial cells (HUVECs) treated with cordycepin, DA, DAA, and DAAA were determined. The expression of β-catenin in U937 cells, as well as the expression of p65, p38 and other related signal regulators in HUVECs elicited by lipopolysaccharides (LPS) were also observed. Angiogenesis was determined by tube formation in HUVECs and Matrigel plug assay in mice. Cardiac function following administration of DAAA was evaluated in mice MI model simulated by coronary artery ligation.

Results

The inhibitory effects of cordycepin and its acetylated derivatives on U937 cells, Huh-7 cells, HUVECs, and the expression of β-catenin in U937 cells were mitigated with increasing acetylation. Intriguingly, DAAA preserved the cell viability of HUVECs compared to other acetylated derivatives. Although DAAA had a significantly diminished antitumor effect compared to cordycepin, it promoted angiogenesis in mice and tube formation in HUVECs and attenuated LPS-induced phosphorylation of p65 and p38. Additionally, administration of DAAA improved cardiac function following coronary artery ligation in mice.

Conclusion

DAAA could be considered a promising adjunctive therapy to prevent post-MI heart failure through promoting angiogenesis.

From cancer therapy to cardiac safety: the role of proteostasis in drug-induced cardiotoxicity

Drug-induced cardiotoxicity (DICT) poses a significant challenge in the prognosis of cancer patients, particularly with the use of antineoplastic agents like anthracyclines and targeted therapies such as trastuzumab. This review delves into the intricate interplay between drugs and proteins within cardiac cells, focusing on the role of proteostasis as a therapeutic target for mitigating cardiotoxicity. We explore the in vivo modeling of proteostasis, highlighting the complex intracellular environment and the emerging techniques for monitoring proteostasis. Additionally, we discuss how cardiotoxic drugs disrupt protein homeostasis through direct chemical denaturation, endoplasmic reticulum stress, unfolded protein response, chaperone dysfunction, impairment of the proteasome system, and dysregulation of autophagy. Finally, we provide insights into the applications of cardioprotective drugs targeting proteostasis to prevent cardiotoxicity and the adoption of structural proteomics to evaluate potential cardiotoxicity. By gaining a deeper understanding of the role of proteostasis underlying DICT, we can pave the way for the development of targeted therapeutic strategies to safeguard cardiac function while maximizing the therapeutic potential of antineoplastic drugs.

AMPK activation; a potential strategy to mitigate TKI-induced cardiovascular toxicity

The introduction of Tyrosine Kinase Inhibitors (TKIs) has revolutionised cancer treatment, yet concerns regarding cardiovascular toxicity have surfaced. This piece delves into the interplay between AMP-activated protein kinase (AMPK) signalling and TKI-induced cardiovascular toxicity. The study unravels the intricate relationship between AMPK activation and TKI-induced cardiovascular toxicity, aiming to ascertain whether AMPK can play a strategic role in mitigating adverse effects. Beyond unravelling mechanistic insights, the research sets the stage for future therapeutic approaches, envisioning AMPK activation as a pivotal connection for balancing effective cancer treatment with cardiovascular well-being. As research advances, the potential of AMPK activation not only addresses challenges in TKI-induced cardiovascular toxicity but also shapes the future landscape of personalised anticancer therapies. The article explores the mechanisms of TKI-induced toxicity, AMPK's impact on cardiovascular health, and the potential therapeutic implications of AMPK activation in alleviating TKI-associated toxicities.

Breast cancer and cardiovascular health

Modern cancer therapies greatly improve clinical outcomes for both early and advanced breast cancer patients. However, these advances have raised concerns about potential short- and long-term toxicities, including cardiovascular toxicities. Therefore, understanding the common risk factors and underlying pathophysiological mechanisms contributing to cardiovascular toxicity is essential to ensure best breast cancer outcomes. While cardio-oncology has emerged as a sub-speciality to address these challenges, it is essential that all cardiologists recognize and understand the cardiovascular consequences of cancer therapy. This review aims to provide a comprehensive overview of the potential adverse cardiovascular effects associated with modern breast cancer therapies. A preventive, diagnostic, and therapeutic workflow to minimize the impact of cardiovascular toxicity on patient outcomes is presented. Key aspects of this workflow include regular monitoring of cardiovascular function, early detection and management of cancer therapy-related cardiovascular toxicities, and optimization of cardiovascular risk factor control. By highlighting the gaps in knowledge in some areas, this review aims to emphasize the critical role of cardio-oncology research in ensuring the holistic well-being of patients with breast cancer.

Interplay of ferroptosis, cuproptosis, and PANoptosis in cancer treatment-induced cardiotoxicity: Mechanisms and therapeutic implications

With the prolonged survival of individuals with cancer, the emergence of cardiovascular diseases (CVD) induced by cancer treatment has become a significant concern, ranking as the second leading cause of death among cancer survivors. This review explores three distinct types of programmed cell death (PCD): ferroptosis, cuproptosis, and PANoptosis, focusing on their roles in chemotherapy-induced cardiotoxicity. While ferroptosis and cuproptosis are triggered by excess iron and copper (Cu), PANoptosis is an inflammatory PCD with features of pyroptosis, apoptosis, and necroptosis. Recent studies reveal intricate connections among these PCD types, emphasizing the interplay between cuproptosis and ferroptosis. Notably, the role of intracellular Cu in promoting ferroptosis through GPX4 is highlighted. Additionally, ROS-induced PANoptosis is influenced by ferroptosis and cuproptosis, suggesting a complex interrelationship. This review provides insights into the molecular mechanisms of these PCD modalities and their distinct contributions to chemotherapy-induced cardiotoxicity. Furthermore, we discuss the potential application of cardioprotective drugs in managing these PCD types. This comprehensive analysis aims to advance the understanding, diagnosis, and therapeutic strategies for cardiotoxicity associated with cancer treatment.

Targeting the Renin-angiotensin-aldosterone System (RAAS) for Cardiovascular Protection and Enhanced Oncological Outcomes: Review

OPINION STATEMENT

The renin-angiotensin-aldosterone system (RAAS) is a crucial regulator of the cardiovascular system and a target for widely used therapeutic drugs. Dysregulation of RAAS, implicated in prevalent diseases like hypertension and heart failure, has recently gained attention in oncological contexts due to its role in tumor biology and cardiovascular toxicities (CVTs). Thus, RAAS inhibitors (RAASi) may be used as potential supplementary therapies in cancer treatment and CVT prevention. Oncological treatments have evolved significantly, impacting patient survival and safety profiles. However, they pose cardiovascular risks, necessitating strategies for mitigating adverse effects. The main drug classes used in oncology include anthracyclines, anti-HER2 therapies, immune checkpoint inhibitors (ICIs), and vascular endothelial growth factor (VEGF) signaling pathway inhibitors (VSPI). While effective against cancer, these drugs induce varying CVTs. RAASi adjunctive therapy shows promise in enhancing clinical outcomes and protecting the cardiovascular system. Understanding RAAS involvement in cancer and CVT can inform personalized treatment approaches and improve patient care.

Anti-SRP Antibodies and Myocarditis in Systemic Sclerosis Overlap Syndrome with Immune-Mediated Necrotizing Myositis (IMNM)

Overlap syndrome of systemic sclerosis and idiopathic inflammatory myopathies is an increasingly frequent entity, but the association with immune-mediated necrotizing myositis has rarely been described. While myositis or myopathy may be features of scleroderma, it is imperative to correctly diagnose an overlap syndrome of these two, since it can be considered a different entity with specific management and a worse prognosis. Anti-signal recognition particle (anti-SRP) antibodies target the striated muscle fiber and inhibit myoblast regeneration, resulting in myofiber atrophy and necrosis. Anti-SRP antibodies are specific in immune-mediated necrotizing myopathy characterized by myonecrosis and minimal inflammatory reaction, with proximal muscle weakness and typical extra-muscular manifestation. There are controversial data on the association of cardiac manifestations and the presence of these antibodies, and recent studies cannot prove a significant correlation between the two. Myocarditis is a complication with an unpredictable, potentially severe outcome from heart failure and dilated cardiomyopathy to fatality. It can be difficult to diagnose, and a myocardial biopsy can be problematic in daily practice; thus, most practitioners rely on cardiac magnetic resonance with suggestive images for the correct diagnosis. This paper seeks to address the challenges associated with the diagnosis and treatment of collagen diseases by evaluating the role of anti-SRP antibodies in the pathogenesis of cardiac involvement.

Early detection of chemotherapy-induced cardiotoxicity in breast cancer patients: a comprehensive analysis using speckle tracking echocardiography

Introduction

Chemotherapy-induced cardiotoxicity poses a significant challenge in the treatment of breast cancer, potentially compromising both the efficacy of cancer therapy and cardiac health of patients. This study aimed to enhance the early detection of cardiotoxic effects by integrating advanced imaging modalities and biomarker analysis, thereby facilitating timely interventions to mitigate cardiac risk.

Methods

A prospective cohort design was employed, enrolling breast cancer patients scheduled for potentially cardiotoxic chemotherapy regimens. The study utilized a comprehensive diagnostic toolkit, including echocardiography with strain imaging, cardiac MRI, and serial measurements of cardiac biomarkers such as high-sensitivity troponins and natriuretic peptides.

Results

The analysis revealed that subtle changes in myocardial strain parameters and early biomarker elevations were predictive of subsequent declines in left ventricular function, preceding conventional echocardiographic evidence of cardiotoxicity. Logistic regression analysis highlighted the additive predictive value of integrating biomarker data with advanced imaging findings to identify patients with the highest risk of significant cardiotoxicity.

Discussion

The study concluded that an integrated diagnostic approach, combining detailed imaging assessments with sensitive biomarker analysis, offers a superior strategy for the early detection of chemotherapy-induced cardiotoxicity in breast cancer patients. This proactive diagnostic strategy empowers clinicians to tailor cancer therapy more precisely, balancing oncologic efficacy with cardiovascular safety and underscores the importance of a multidisciplinary approach in the management of patients undergoing potentially cardiotoxic chemotherapy.

Takotsubo syndrome as an acute cardiac complication following combined chemotherapy

Background

Acute cardiac complications post-chemotherapy is rare. Stress cardiomyopathy, one of these complications, should be considered in differential diagnoses as its symptoms closely resemble those of acute myocardial infarction and can lead to mortality.

Objective

The objective of this paper is to describe Takotsubo syndrome (TTS) as an acute complication following combined chemotherapy in a patient with significant thromboembolic burden and metastatic cervical cancer.

Case

A 61-year-old female patient with a diagnosis of metastatic cervical cancer experienced acute chest pain. Elevated troponin levels and abnormalities in the electrocardiogram initially suggested an acute myocardial infarction, occurring after a chemotherapy session involving Carboplatin and Paclitaxel infusion. Although initial treatment targeted myocardial infarction, further diagnostic evaluations including coronary angiography and cardiac magnetic resonance imaging revealed no coronary artery disease but identified features consistent with stress cardiomyopathy, indicative of Takotsubo syndrome (TTS). This diagnosis led to an improvement in symptoms and a resolution of the acute changes observed.

Conclusion

Stress cardiomyopathy, particularly TTS, is being increasingly recognized as an acute complication associated with combined chemotherapy regimens. The potential cardiotoxic effects of these chemotherapy agents demand careful monitoring and evaluation in patients undergoing oncological treatment, underscoring the importance of integrating cardioprotective strategies into the management of these patients.

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.

The Therapeutic Mechanisms of Honey in Mitigating Toxicity from Anticancer Chemotherapy Toxicity: A Review

Within the domain of conventional oncochemotherapeutics, anticancer chemotherapy (AC) has emerged as a potent strategy for the treatment of cancers. AC is the mainstay strategy for solid and non-solid cancer treatment. Its mechanistic action targets the blockage of DNA transcription and the dysregulation of cell cycle machinery in cancer cells, leading to the activation of death pathways. However, the attendant side effect of toxicity inflicted by AC on healthy tissues presents a formidable challenge. The crucial culprit in the AC side effect of toxicity is unknown, although oxidative stress, mitochondrial impairment, inflammatory cascades, autophagy dysregulation, apoptosis, and certain aberrant signaling have been implicated. Honey is a natural bee product with significant health benefits and pharmacological properties. Interestingly, the literature reports that honey may proffer a protection mechanism for delicate tissue/organs against the side effect of toxicity from AC. Thus, this review delves into the prospective role of honey as an alleviator of the AC side effect of toxicity; it provides an elucidation of the mechanisms of AC toxicity and honey's molecular mechanisms of mitigation. The review endeavors to unravel the specific molecular cascades by which honey orchestrates its mitigating effects, with the overarching objective of refining its application as an adjuvant natural product. Honey supplementation prevents AC toxicity via the inhibition of oxidative stress, NF-κB-mediated inflammation, and caspase-dependent apoptosis cascades. Although there is a need for increased mechanistic studies, honey is a natural product that could mitigate the various toxicities induced by AC.

Neoadjuvant chemotherapy for advanced eyelid and periocular sebaceous gland carcinoma: a study of 25 cases

PURPOSE

To report the outcomes of platinum-based neoadjuvant chemotherapy (NACT) for eyelid and periocular sebaceous gland carcinoma (eSGC).

METHODS

Retrospective study of 25 patients.

RESULTS

The mean age at presentation of eSGC was 59 years. The mean tumor basal diameter was 46 mm. By the 8th edition of AJCC classification, tumors belonged T2 (n = 2, 8%), T3 (n = 6, 24%), and T4 (n = 17, 68%); N1 (n = 12,48%); and M1 (n = 1, 4%). NACT with 5-fluorouracil (5-FU) and cisplatin/carboplatin was administered in 21 (84%)/4 (16%) patients, respectively. The mean number of cycles of neoadjuvant systemic chemotherapy per patient was 2 (median, 3). The mean percentage reduction of tumor basal volume after neoadjuvant chemotherapy was 65% (median, 60%). After NACT, 12 (48%) patients underwent surgical treatment, 6 (12%) patients underwent EBRT, and 4 (8%) underwent adjuvant chemotherapy. A total of 11 (44%) patients were lost to follow-up during the course of treatment, of whom 3 died from metastatic disease. In 16 patients followed up for ≥ 3 months, complete tumor control was achieved in 11 (69%) patients, local tumor control in 14 (88%), and globe salvage in 7 (44%) at a mean follow-up of 25 months (median, 7 months; range, 3 to 110 months). No tumor recurrence was seen in any case. One (4%) serious adverse event of cardiotoxicity was noted.

CONCLUSION

Platinum-based NACT is a suitable option for eSGC with advanced tumors and locoregional metastasis. Adverse events are rare and in patients compliant with treatment, NACT-based combination therapy offers globe salvage and systemic tumor control.

Cardiovascular mortality in people with cancer compared to the general population: A systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of non-cancer death in cancer survivors, but the risk of CVD varies between cancers.

OBJECTIVES

To synthesise available evidence on patterns and magnitude of CVD mortality risk.

METHODS

A systematic search of Medline (OVID), CINAHL and Scopus databases from 01-January-2000 to 16-July-2023 of studies of people with cancer, reporting CVD mortality in cancer population compared with a reference population (e.g. general population) as standardised mortality ratios (SMR). Meta-analysis of SMRs across cancer and CVD types were pooled using a random-effects model to allow for heterogeneity of the true effect size across studies.

RESULTS

We identified 136 studies from 16 countries. Sample sizes ranged from 157 to 7,529,481. The majority (n = 98; 72%) were conducted in the United States, followed by Europe (n = 22; 16%). The most common cancers studied were gastrointestinal (n = 34 studies), haematological (n = 31) and breast (n = 29). A total of 876 CVD SMRs were extracted across diverse CVD conditions. Of those, the majority (535; 61%) indicated an increased risk of CVD death (SMR >1), 109 (12%) a lower risk of CVD death (SMR <1) and 232 (27%) an equivalent risk (95% CI of SMR included 1) compared to the general population. The meta-analysis of all reported SMRs showed an increased risk of CVD death (SMR = 1.55, 95% CI = 1.40-1.72) in cancer survivors compared with the general population. The SMR varied between CVD conditions and ranged from 1.36 (95% CI = 1.29-1.44) for heart diseases to 1.56 (95% CI = 1.39-1.76) for cerebrovascular diseases. SMR varied across cancer types, ranging from 1.14 (95% CI = 1.04-1.25) for testicular/germ cell tumours to 2.82 (95% CI = 2.20-3.63) for brain/central nervous system tumours.

CONCLUSIONS

Cancer survivors are at increased risk of premature CVD mortality compared to the general population, but the risk varies by cancer type and CVD. Future research should focus on understanding mechanisms behind the increased CVD risk to develop appropriate interventions.

Anticancer drugs and cardiotoxicity: the role of cardiomyocyte and non-cardiomyocyte cells

Cardiotoxicity can be defined as "chemically induced heart disease", which can occur with many different drug classes treating a range of diseases. It is the primary cause of drug attrition during pre-clinical development and withdrawal from the market. Drug induced cardiovascular toxicity can result from both functional effects with alteration of the contractile and electrical regulation in the heart and structural changes with morphological changes to cardiomyocytes and other cardiac cells. These adverse effects result in conditions such as arrhythmia or a more serious reduction in left ventricular ejection fraction (LVEF), which can lead to heart failure and death. Anticancer drugs can adversely affect cardiomyocyte function as well as cardiac fibroblasts and cardiac endothelial cells, interfering in autocrine and paracrine signalling between these cell types and ultimately altering cardiac cellular homeostasis. This review aims to highlight potential toxicity mechanisms involving cardiomyocytes and non-cardiomyocyte cells by first introducing the physiological roles of these cells within the myocardium and secondly, identifying the physiological pathways perturbed by anticancer drugs in these cells.

Co-morbid intersections of cancer and cardiovascular disease and targets for natural drug action: Reprogramming of lipid metabolism

Cancer and cardiovascular diseases are major contributors to global morbidity and mortality, and their seemingly separate pathologies are intricately intertwined. In the context of cancer, the cardiovascular disease encompasses not only the side effects arising from anti-tumor treatments but also the metabolic shifts induced by oncological conditions. A growing body of research indicates that lipid metabolic reprogramming serves as a distinctive hallmark of tumors. Furthermore, anomalies in lipid metabolism play a significant role in the development of cardiovascular disease. This study delves into the cardiac implications of lipid metabolic reprogramming within the cancer context, closely examining abnormalities in lipid metabolism present in tumors, cardiac tissue, and immune cells within the microenvironment. Additionally, we examined risk factors such as obesity and anti-tumor therapy. Despite progress, a gap remains in the availability of drugs targeting lipid metabolism modulation for treating tumors and mitigating cardiac risk, with limited advancement seen in prior studies. Here, we present a review of previous research on natural drugs that exhibit both shared and distinct therapeutic effects on tumors and cardiac health by modulating lipid metabolism. Our aim is to provide insights for potential drug development.

Mechanisms of Cardiovascular Toxicities Induced by Cancer Therapies and Promising Biomarkers for Their Prediction: A Scoping Review

AIM

With the advancement of anti-cancer medicine, cardiovascular toxicities due to cancer therapies are common in oncology patients, resulting in increased mortality and economic burden. Cardiovascular toxicities caused by cancer therapies include different severities of cardiomyopathy, arrhythmia, myocardial ischaemia, hypertension, and thrombosis, which may lead to left ventricular dysfunction and heart failure. This scoping review aimed to summarise the mechanisms of cardiovascular toxicities following various anti-cancer treatments and potential predictive biomarkers for early detection.

METHODS

PubMed, Cochrane, Embase, Web of Science, Scopus, and CINAHL databases were searched for original studies written in English related to the mechanisms of cardiovascular toxicity induced by anti-cancer therapies, including chemotherapy, targeted therapy, immunotherapy, radiation therapy, and relevant biomarkers. The search and title/abstract screening were conducted independently by two reviewers, and the final analysed full texts achieved the consensus of the two reviewers.

RESULTS

A total of 240 studies were identified based on their titles and abstracts. In total, 107 full-text articles were included in the analysis. Cardiomyocyte and endothelial cell apoptosis caused by oxidative stress injury, activation of cell apoptosis, blocking of normal cardiovascular protection signalling pathways, overactivation of immune cells, and myocardial remodelling were the main mechanisms. Promising biomarkers for anti-cancer therapies related to cardiovascular toxicity included placental growth factor, microRNAs, galectin-3, and myeloperoxidase for the early detection of cardiovascular toxicity.

CONCLUSION

Understanding the mechanisms of cardiovascular toxicity following various anti-cancer treatments could provide implications for future personalised treatment methods to protect cardiovascular function. Furthermore, specific early sensitive and stable biomarkers of cardiovascular system damage need to be identified to predict reversible damage to the cardiovascular system and improve the effects of anti-cancer agents.

Cardiotoxicity in Cancer Patients: The Prevalence, Risk Factors, and Cardioprotective Measures in a Cancer Centre in Saudi Arabia

BACKGROUND

Chemotherapy-related cardiotoxicity can exhibit several patterns of functional, structural, and vascular complications. This study aims to identify the patterns and the factors associated with cardiotoxicity in cancer patients.

METHOD

A retrospective cross-sectional analysis of 96 adult cancer patients undergoing anticancer therapy was investigated at King Khalid Hospital in Najran, Saudi Arabia, from May 2022 to April 2023. The data on patient and cancer characteristics, treatment, and outcomes were collected and analyzed. Factors associated with cardiotoxicity were investigated through univariate analyses using odds ratio (OR) and 95% confidence interval (CI).

RESULTS

 Among the 96 cancer patients in the study, cardiotoxicity occurred in 12 individuals (12.5%). The mean age was 57.0 ± 13.3 years (range: 32-81 years), with 32 (33.3%) being above 65 years. The most common comorbidities were diabetes (n=48; 50%), followed by hypertension (n=32; 33.3%), and dyslipidemia (n=20; 20.8%). The most common cancers were gastrointestinal cancer (n=32; 33.3%), followed by breast cancer (n=22; 22.9%) and lymphoma (n=14; 14.6%). Females were disproportionately affected (64.6%), with 57.3% of them in the metastatic stage. The majority of patients (90.6%) had normal ejection fraction before chemotherapy initiation. In univariate analysis, current smoking (OR: 7.00; 95%CI: 1.94-25.25, p= 0.003), history of percutaneous cardiac intervention (OR: 40.24; 95%CI: 1.80-896.26, p= 0.019), diabetes (OR: 6.05; 95%CI: 1.24-29.32, p= 0.025), renal failure (OR: 8.20; 95%CI: 0.91-74.88, p= 0.046), dyslipidemia (OR: 5.00; 95 CI: 1.38-18.32, p=0.012), anthracycline use (OR: 18.33; 95%CI: 4.36-126.55, p <0.001), trastuzumab use (OR: 25.00; 95%CI: 6.25-129.86, p < 0.001), and increased chemotherapy cycles number (> 10 cycles) (OR: 73.00; 95%CI: 8.56- 622.36, p < 0.001) were associated with cardiotoxicity. Additionally, beta-blocker use was associated with lower rates of cardiotoxicity (OR: 0.17; 95%CI: 0.036-0.84, p= 0.029).

CONCLUSIONS

The incidence of cardiotoxicity among cancer patients treated with chemotherapy is modest, difficult to predict, and independent of baseline cardiac systolic functions. Factors associated with cardiotoxicity include smoking, history of percutaneous cardiac intervention, diabetes, renal failure, dyslipidemia, anthracycline or trastuzumab use, and increased chemotherapy cycle numbers. A combination of various anticancer drugs and chemotherapy may dramatically raise the risk of cardiotoxicity in cancer patients. As a result, patients receiving high-risk cardiotoxic drugs should be monitored with caution to avoid drug-related cardiotoxicity. Furthermore, proactive treatment techniques aiming at reducing the possible cardiotoxic effects of anticancer therapy are critical.

Cardio-Oncoimmunology: Cardiac Toxicity, Cardiovascular Hypersensitivity, and Kounis Syndrome

Cancer therapy can result in acute cardiac events, such as coronary artery spasm, acute myocardial infarction, thromboembolism, myocarditis, bradycardia, tachyarrhythmias, atrio-ventricular blocks, QT prolongation, torsades de pointes, pericardial effusion, and hypotension, as well as chronic conditions, such as hypertension, and systolic and diastolic left ventricular dysfunction presenting clinically as heart failure or cardiomyopathy. In cardio-oncology, when referring to cardiac toxicity and cardiovascular hypersensitivity, there is a great deal of misunderstanding. When a dose-related cardiovascular side effect continues even after the causative medication is stopped, it is referred to as a cardiotoxicity. A fibrotic response is the ultimate outcome of cardiac toxicity, which is defined as a dose-related cardiovascular adverse impact that lasts even after the causative treatment is stopped. Cardiotoxicity can occur after a single or brief exposure. On the other hand, the term cardiac or cardiovascular hypersensitivity describes an inflammatory reaction that is not dose-dependent, can occur at any point during therapy, even at very low medication dosages, and can present as Kounis syndrome. It may also be accompanied by anti-drug antibodies and tryptase levels. In this comprehensive review, we present the current views on cardiac toxicity and cardiovascular hypersensitivity, together with the reviewed cardiac literature on the chemotherapeutic agents inducing hypersensitivity reactions. Cardiac hypersensitivity seems to be the pathophysiologic basis of coronary artery spasm, acute coronary syndromes such as Kounis syndrome, and myocarditis caused by cancer therapy.

Drug-induced cardiac toxicity and adverse drug reactions, a narrative review

Drug-induced cardiotoxicity is a primary concern in both drug development and clinical practice. Although the heart is not a common target for adverse drug reactions, some drugs still cause various adverse cardiac events, with sometimes severe consequences. Direct cardiac toxicity encompasses functional and structural changes of the cardiovascular system due to possible exposure to medicines. This phenomenon extends beyond cardiovascular drugs to include non-cardiovascular drugs including anticancer drugs such as tyrosine kinase inhibitors, anthracyclines and immune checkpoint inhibitors (ICIs), as well as various antipsychotics, venlafaxine, and even some antibiotics (such as macrolides). Cardiac ADRs comprise an array of effects, ranging from heart failure and myocardial ischemia to valvular disease, thrombosis, myocarditis, pericarditis, arrhythmias, and conduction abnormalities. The underlying mechanisms may include disturbances of ionic processes, induction of cellular damage via impaired mitochondrial function, and even hypercoagulability. To mitigate the impact of drug-induced cardiotoxicity, multi-stage evaluation guidelines have been established, following the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines for in vitro and in vivo testing. Despite preclinical safeguards, post-marketing surveillance remains critical, as certain cardiotoxic drugs may escape initial scrutiny. Indeed, historical data show that cardiovascular ADRs contribute to almost 10% of market withdrawals. The impact of drug-induced cardiotoxicity on cardiac issues, particularly heart failure, is often underestimated, with incidence rates ranging from 11.0% to over 20.0%. We here comprehensively examine different patterns of drug-induced cardiotoxicity, highlighting current concerns and emerging pharmacovigilance signals. Understanding the underlying mechanisms and the associated risk factors is critical in order to promptly identify, effectively manage, and proactively prevent drug-induced cardiac adverse events. Collaborative efforts between physicians and cardiologists, coupled with thorough assessment and close monitoring, are essential to ensuring patient safety in the face of potential drug-induced cardiotoxicity.