Variants in structural cardiac genes in patients with cancer therapy-related cardiac dysfunction after anthracycline chemotherapy: a case control study

BACKGROUND

Variants in cardiomyopathy genes have been identified in patients with cancer therapy-related cardiac dysfunction (CTRCD), suggesting a genetic predisposition for the development of CTRCD. The diagnostic yield of genetic testing in a CTRCD population compared to a cardiomyopathy patient cohort is not yet known and information on which genes should be assessed in this population is lacking.

METHODS

We retrospectively included 46 cancer patients with a history of anthracycline induced CTRCD (defined as a decrease in left ventricular ejection fraction (LVEF) to < 50% and a ≥ 10% reduction from baseline by echocardiography). Genetic testing was performed for 59 established cardiomyopathy genes. Only variants of uncertain significance and (likely) pathogenic variants were included. Diagnostic yield of genetic testing was compared with a matched cohort of patients with dilated cardiomyopathy (DCM, n = 46) and a matched cohort of patients without cardiac disease (n = 111).

RESULTS

Average LVEF at time of CTRCD diagnosis was 30.1 ± 11.0%. Patients were 52.9 ± 14.6 years old at time of diagnosis and 30 (65.2%) were female. Most patients were treated for breast cancer or lymphoma, with a median doxorubicin equivalent dose of 300 mg/m2 [112.5-540.0]. A genetic variant, either pathogenic, likely pathogenic or of uncertain significance, was identified in 29/46 (63.0%) of patients with CTRCD, which is similar to the DCM cohort (34/46, 73.9%, p = 0.262), but significantly higher than in the negative control cohort (47/111, 39.6%, p = 0.018). Variants in TTN were the most prevalent in the CTRCD cohort (43% of all variants). All (likely) pathogenic variants identified in the CTRCD cohort were truncating variants in TTN. There were no significant differences in severity of CTRCD and in recovery rate in variant-harbouring individuals versus non-variant harbouring individuals.

CONCLUSIONS

In this case-control study, cancer patients with anthracycline-induced CTRCD have an increased burden of genetic variants in cardiomyopathy genes, similar to a DCM cohort. If validated in larger prospective studies, integration of genetic data in risk prediction models for CTRCD may guide cancer treatment. Moreover, genetic results have important clinical impact, both for the patient in the setting of precision medicine, as for the family members that will receive genetic counselling.

Early Detection and Prediction of Anthracycline-Induced Cardiotoxicity - A Prospective Cohort Study

BACKGROUND

In the present study, we aimed to investigate whether early cardiac biomarker alterations and echocardiographic parameters, including left atrial (LA) strain, can predict anthracycline-induced cardiotoxicity (AIC) and thus develop a predictive risk score.Methods and Results: The AIC registry is a prospective, observational cohort study designed to gather serial echocardiographic and biomarker data before and after anthracycline chemotherapy. Cardiotoxicity was defined as a reduction in left ventricular ejection fraction (LVEF) ≥10 percentage points from baseline and <55%. In total, 383 patients (93% women; median age, 57 [46-66] years) completed the 2-year follow-up; 42 (11.0%) patients developed cardiotoxicity (median time to onset, 292 [175-440] days). Increases in cardiac troponin T (TnT) and B-type natriuretic peptide (BNP) and relative reductions in the left ventricular global longitudinal strain (LV GLS) and LA reservoir strain [LASr] at 3 months after anthracycline administration were independently associated with subsequent cardiotoxicity. A risk score containing 2 clinical variables (smoking and prior cardiovascular disease), 2 cardiac biomarkers at 3 months (TnT ≥0.019 ng/mL and BNP ≥31.1 pg/mL), 2 echocardiographic variables at 3 months (relative declines in LV GLS [≥6.5%], and LASr [≥7.5%]) was generated.

CONCLUSIONS

Early decline in LASr was independently associated with subsequent cardiotoxicity. The AIC risk score may provide useful prognostication in patients receiving anthracyclines.

Arterial Stiffness May Predict Subsequent Cancer Therapy-Related Cardiac Dysfunction in Breast Cancer Patients

Cancer therapy-related cardiac dysfunction (CTRCD) is still a serious problem. Existing risk scores are insufficient for risk classification, especially in low and medium-risk patients. This study aims to evaluate if arterial stiffness (AS) measurement, which is associated with most of the known risk factors, can be a useful parameter for predicting subsequent CTRCD in patients with breast cancer (BC). Patients with BC were included in the study. All patients' AS parameters such as pulse wave velocity (PWV), augmentation index (AIx), augmentation pressure (AP), and echocardiographic parameters were obtained before treatment. During treatment, echocardiographic follow-up with routine parameters and left ventricle global longitudinal strain (LVGLS) were measured. Patients were evaluated on whether CTRCD occurred or not. A total of 67 patients were analyzed. The mean age of the study population was 54.9 ± 11 years. Baseline characteristics were similar except for age. No CTRCD diagnosis was obtained according to left ventricle ejection fraction (LVEF) reduction, but 18 patients (26.8%) developed CTRCD regarding the decline in LVGLS. Left ventricle hypertrophy and diastolic dysfunction were more frequent in patients with CTRCD (p = 0.016 and p = 0.015, respectively). PWV, AIx, and AP as AS parameters were significantly higher in patients with CTRCD, but Alx@75 were not (p = 0.005, p = 0.034, p = 0.008, p = 0.077, respectively). A positive correlation between PWV and a decreased percent in LVGS (R = 0.607, p < 0.001) was observed. ROC curve analyses revealed an AUC of 0.747 (p = 0.02, 95% CI 0.632-0.832) for PWV. A PWV value of 9.2 m/s predicted CTRCD with 94% sensitivity and 73% specificity. AS measurement may be useful for predicting CTRCD in patients with low to medium-risk BC.

The cardioprotective potential of sodium-glucose cotransporter 2-inhibitors in breast cancer therapy-related cardiac dysfunction - A systematic review

BACKGROUND

Sodium-glucose cotransporter 2-inhibitors (SGLT2i) improve cardiovascular outcomes including reduction in risk of first hospitalisation for heart failure (HF), worsening HF and cardiovascular death regardless of HF or diabetes mellitus (DM) status. It is not known whether SGLT2i can prevent the development of incident HF or reduce the risk of HF in patients receiving trastuzumab with or without other concurrent anti-HER2 agent or sequential anthracycline for treatment of HER2 positive breast cancer. Patients with active malignancy or recent history of malignancy were excluded from participating in the main cardiovascular outcome trials involving SGLT2i.

AIM

A systematic review was performed to objectively assess published literature on the cardioprotective effects of SGLT2i in breast cancer treatment-related cardiotoxicity.

METHODS

Systematic searches of Embase, Medline, The Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases were performed. Titles and abstracts were screened separately by two cardio-oncologists (JHC, WTC). Full texts of potentially eligible records were then assessed separately by JHC and WTC before inclusion into review upon joint agreement.

RESULTS

479 records were identified from 3 databases (MEDLINE=51, EMBASE=408, CENTRAL=13) and 1 registry (Clinicaltrials.gov=7). 460 records were excluded based on title and abstract (including duplicates). 19 full text reports were assessed for eligibility and included in review (basic science/animal study paper 2, Clinicaltrials.gov randomised controlled trial submission 1 (currently recruiting), basic science/animal study conference abstract 5, case report 2, review 3, editorial comment 2, clinical guidelines 1, retrospective/registry-based conference abstract 3).

CONCLUSION

Cardiotoxicity is the most common dose-limiting toxicity associated with trastuzumab. Discontinuation of trastuzumab however, can lead to worse cancer outcomes. There have been case reports, registry-based, retrospective cohort-based and mechanistic studies suggesting the cardioprotective potential of SGLT2i in cancer therapy-related cardiac dysfunction (CTRCD). Based on these, there is now a call for randomised controlled trials to be performed in this patient cohort to advise guideline-directed therapy for CTRCD, which will in turn also provide detailed safety information and improve cancer and cardiovascular outcomes.

Effect of variable left ventricular ejection fraction assessed by equilibrium radionuclide angiocardiography using different software packages on the diagnosis of cardiotoxicity in patients with cancer

BACKGROUND

The equilibrium radionuclide angiocardiography (ERNA) scan is an established imaging modality for assessing left ventricular ejection fraction (LVEF) in oncology patients. This study aimed to explore the interchangeability of two commercially available software packages (MIM and JS) for LVEF measurement for a cancer-therapy-related cardiac dysfunction (CTRCD) diagnosis.

METHODS

This is a single-center retrospective study among 322 patients who underwent ERNA scans. A total of 582 scans were re-processed using MIM and JS for cross-sectional and longitudinal LVEF measurements.

RESULTS

The median LVEF for MIM and JS were 56% and 66%, respectively (P < 0.001). LVEF processed by JS was 9.91% higher than by MIM. In 87 patients with longitudinal ERNA scans, serial studies processed by MIM were classified as having CTRCD in a higher proportion than serial studies processed by JS (26.4% vs 11.4%, P = 0.020). There were no significant differences in intra- or inter-observer LVEF measurement variability (R = 0.99, P < 0.001).

CONCLUSIONS

Software packages for processing ERNA studies are not interchangeable; thus, reports of ERNA studies should include details on the post-processing software. Serial ERNA studies should be processed on the same software when feasible to avoid discrepancies in the diagnosis and management of CTRCD.

Activation recovery interval as an electrocardiographic repolarization index to detect doxorubicin-induced cardiotoxicity

BACKGROUND

It has been reported that early detection and treatment of cancer therapy- related cardiac dysfunction (CTRCD) improves its prognosis. The detailed relationships between electrocardiographic repolarization indices and decreased left ventricular function in CTRCD have not been elucidated. We closely assessed such relationships in patients with doxorubicin (DOX)-induced CTRCD.

METHODS

This retrospective, single-center, cohort study included 471 consecutive patients with malignant lymphoma who received chemotherapy including DOX. Of them, 17 patients with CTRCD and 68 patients without CTRCD who underwent 12‑lead electrocardiogram and an echocardiogram before and after chemotherapy were eventually analyzed. The fluctuations of the following electrocardiographic repolarization indices were evaluated in lead V5: QT, JT, T peak to T end interval (Tp-e), and activation recovery interval (ARI). These indices were corrected by heart rate with the Fridericia formula.

RESULTS

The median period from the end of chemotherapy to the diagnosis of the CTRCD group was 346 days (IQR 170-1283 days). After chemotherapy, the QT interval was significantly prolonged in both with and without CTRCD groups compared with that before chemotherapy (pre QTc vs. post QTc in CTRCD group, 386 ± 27 ms vs. 411 ± 37 ms, p = 0.03, pre QTc vs. post QTc in non-CTRCD group, 388 ± 24 ms vs. 395 ± 25 ms, p = 0.04, respectively). ARIc after chemotherapy was characteristically observed only in the CTRCD group (pre ARIc vs. post ARIc in CTRCD group, 258 ± 53 ms vs. 211 ± 28 ms, p = 0.03, pre ARIc vs. post ARIc in non-CTRCD group, 221 ± 19 ms vs. 225 ± 23 ms, NS, respectively) and had negative correlations with left ventricular ejection fraction (r = -0.56, p < 0.001). Using the receiver-operating characteristic curve, the relationship between ARIc and CTRCD morbidity was examined. The optimal cut-off point of ARIc prolongation between before and after chemotherapy was 18 ms (sensitivity 75 %, specificity 79 %, area under the curve 0.76).

CONCLUSIONS

ARIc prolongation may be useful in the early detection of developing late-onset chronic DOX-induced CTRCD and lead to early treatment for cardiac protection.

Can global longitudinal strain (GLS) with magnetic resonance prognosticate early cancer therapy-related cardiac dysfunction (CTRCD) in breast cancer patients, a prospective study?

PURPOSE

To determine if Artificial Intelligence-based computation of global longitudinal strain (GLS) from left ventricular (LV) MRI is an early prognostic factor of cancer therapy-related cardiac dysfunction (CTRCD) in breast cancer patients. The main hypothesis based on the patients receiving antineoplastic chemotherapy treatment was CTRCD risk analysis with GLS that was independent of LV ejection fraction (LVEF).

METHODS

Displacement Encoding with Stimulated Echoes (DENSE) MRI was acquired on 32 breast cancer patients at baseline and 3- and 6-month follow-ups after chemotherapy. Two DeepLabV3+ Fully Convolutional Networks (FCNs) were deployed to automate image segmentation for LV chamber quantification and phase-unwrapping for 3D strains, computed with the Radial Point Interpolation Method. CTRCD risk (cardiotoxicity and adverse cardiac events) was analyzed with Cox Proportional Hazards (PH) models with clinical and contractile prognostic factors.

RESULTS

GLS worsened from baseline to the 3- and 6-month follow-ups (-19.1 ± 2.1%, -16.0 ± 3.1%, -16.1 ± 3.0%; P < 0.001). Univariable Cox regression showed the 3-month GLS significantly associated as an agonist (hazard ratio [HR]-per-SD: 2.1; 95% CI: 1.4-3.1; P < 0.001) and LVEF as a protector (HR-per-SD: 0.8; 95% CI: 0.7-0.9; P = 0.001) for CTRCD occurrence. Bivariable regression showed the 3-month GLS (HR-per-SD: 2.0; 95% CI: 1.2-3.4; P = 0.01) as a CTRCD prognostic factor independent of other covariates, including LVEF (HR-per-SD: 1.0; 95% CI: 0.9-1.2; P = 0.9).

CONCLUSIONS

The end-point analyses proved the hypothesis that GLS is an early, independent prognosticator of incident CTRCD risk. This novel GLS-guided approach to CTRCD risk analysis could improve antineoplastic treatment with further validation in a larger clinical trial.

Diastolic heart failure is a new clinical entity of trastuzumab-induced cardiotoxicity: a case report

Background

Cancer therapy-related cardiac dysfunction (CTRCD) is defined as a decrease in the left ventricular ejection fraction (LVEF) of >10% to a value below the lower limit of normal or relative reduction in global longitudinal strain (GLS) >15% from baseline after cancer treatment. However, the possibility of the development of isolated diastolic dysfunction has never been considered in the clinical presentation of CTRCD.

Case summary

An 81-year-old woman was admitted to our institution presenting with prominent bilateral leg oedema, orthopnoea, and 8 kg of weight gain after administration of the anti-human epidermal growth factor receptor 2 (HER-2) antibody, trastuzumab, for HER-2-positive breast cancer. Transthoracic echocardiography showed a preserved LVEF of 62% without a significant reduction in GLS compared with results obtained before anti-HER-2 targeted therapy. Doppler echocardiography distinctly revealed a newly developed significant left ventricular diastolic dysfunction with evidence of elevated filling pressure. After successful achievement of volume reduction, the patient underwent cardiac catheter examination, revealing an elevated pulmonary artery wedge pressure of 18 mmHg. Subsequently, trastuzumab was discontinued and the patient was treated with diuretics, arteriodilators, and venodilators, until the signs and symptoms of heart failure completely disappeared.

Discussion

In the management of CTRCD, including pretreatment screening, cardiotoxicity monitoring, follow-up after anti-cancer agents, and evaluation of the effectiveness of the therapy, too much emphasis has been paid exclusively to the development of systolic dysfunction; however, perspectives for diastolic dysfunction may be needed. A comprehensive multidisciplinary team approach composed of breast surgeons, oncologists, onco-cardiologists, and echocardiography specialists is required.

Echocardiography image quality of global longitudinal strain in cardio-oncology: a prospective real-world investigation

BACKGROUND

Left-ventricular (LV) global longitudinal strain (GLS) has been reported to be a robust and sensitive marker of chemotherapy-induced cardiac damage. Image quality is paramount for accurate GLS measurements. In real-world cardio-oncology settings, the incidence of suboptimal echocardiography quality and its significance in clinical decision-making have not been well investigated. This prospective study examined the incidence and impact of suboptimal echocardiographic image quality on detecting subtle myocardial damage by chemotherapy.

METHODS

Seventy-seven consecutive patients with breast cancer (age, 52 ± 12 years, 76 women, 33 with left-sided breast cancer) were included in this study. Echocardiography was performed at 3-month intervals 1 year before and after chemotherapy initiation. We classified the image quality of each echocardiographic acquisition into three groups: optimal, suboptimal, or inadequate for speckle tracking.

RESULTS

Among the 376 examinations obtained during the cardiac monitoring, the image quality in 194 (52%) was optimal, suboptimal in 159 (42%), and inadequate in 23 (6%). The interobserver reproducibility was 0.91 in the optimal and 0.21 in the suboptimal group. In contrast, the optimal group showed progressive impairment in both GLS (p = 0.001) and LV ejection fraction (LVEF) (p < 0.001) during follow-up, and the suboptimal group showed a progressive decrease in LVEF (p = 0.006), but not in GLS (p = 0.13). Left-sided mammotomy and/or reconstruction surgery and high body mass index were significant determinants of suboptimal image quality.

CONCLUSIONS

Even in cases of minor image quality impairment, the physician should assess GLS carefully to avoid errors in crucial clinical decision-making.

The roles of global longitudinal strain imaging in contemporary clinical cardiology

Myocardial deformation imaging is now readily available during routine echocardiography and plays an important role in the advanced care of cardiovascular diseases. Its clinical value in detecting subtle myocardial dysfunction, by helping diagnose disease and allowing prediction of disease progression and earlier pharmacological intervention, has been demonstrated. Strain imaging has been the most studied and clinically used technique in the field of cardio-oncology. A relative percent reduction in left ventricular (LV) global longitudinal strain > 15% from baseline is considered a marker of early subclinical LV dysfunction and may have the potential to guide early initiation of cardioprotective therapy. The role of strain imaging is expanding to other fields, such as cardiac amyloidosis, other cardiomyopathies, valvular heart diseases, pulmonary hypertension, and heart failure with preserved ejection fraction. It is also used for the evaluation of the right ventricle and atria. This review aims to provide a current understanding of the roles of strain imaging in the evaluation and management of patients with cardiovascular diseases in clinical practice.

Time to switch angiotensin-converting enzyme inhibitors/angiotensin receptor blockers to sacubitril/valsartan in patients with cancer therapy-related cardiac dysfunction

Advances in cancer therapy have resulted in more cancer therapy-related cardiac dysfunction (CTRCD), which is the main cause of death in older female survivors of breast cancer. Traditionally, guideline-recommended medications for heart failure, such as beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), are commonly used to prevent or attenuate CTRCD. However, sometimes their effectiveness is not satisfactory. Recently, the drug combination of sacubitril plus valsartan has been proven to be more beneficial for heart failure with reduced ejection fraction in the long term compared with an ACEI/ARB alone. However, there is a lack of evidence of the efficacy and safety of this drug combination in CTRCD. We report a case of worsening CTRCD, despite treatment with traditional medications, in which the patient improved after changing perindopril to sacubitril/valsartan. The patient's heart function greatly improved after changing this ACEI to sacubitril/valsartan. Changing an ACEI/ARB to sacubitril/valsartan in patients with worsening chemotherapy-induced heart failure is appropriate. Further studies with a high level of evidence are required to assess the efficacy and safety of sacubitril/valsartan for CTRCD.

Usefulness of Cardiac Computed Tomography in the Diagnosis of Anti-Cancer Therapy-Related Cardiac Dysfunction - Consistency With Magnetic Resonance Imaging

BACKGROUND

Cardiac magnetic resonance (CMR) imaging is the golden standard used for the diagnosis of cancer therapy-related cardiac dysfunction (CTRCD). The consistency of cardiac computed tomography (CCT) in CTRCD cases using CMR imaging is investigated in this study.Methods and Results:In 7 clinically confirmed CTRCD patients, focal late enhancement was confirmed on both CCT and CMR for 4 patients. Myocardial extracellular volume (ECV) values measured by CCT and CMR were elevated in all patients, suggesting the presence of diffuse myocardial damage.

CONCLUSIONS

The study findings indicated that CCT could provide adequate information about late myocardial enhancement and ECV quantification, indicating the effective evaluation of CTRCD by CCT.

Global Longitudinal Strain: Is It Time to Change the Preoperative Cardiac Assessment of Oncology Patients?

The introduction of new anticancer treatment modalities has improved survival rates, transforming cancer into a chronic disease in many instances. One of the most devastating complications of cancer treatment is cancer therapy-related cardiac dysfunction. Adequate preoperative assessment of any significant cancer therapy-related cardiac impairment is critical, and may be missed with conventional measures. The assessment of global longitudinal strain by speckle-tracking echocardiography is more sensitive for the early detection of cardiac contractility before a decline in ejection fraction can be discovered. Global longitudinal strain can also predict postoperative cardiac dysfunction, which makes it a good alternative for preoperative cardiac assessment in the oncology population when cancer therapies have been administered that can alter normal performance.

Layer-specific distribution of myocardial deformation from anthracycline-induced cardiotoxicity in patients with breast cancer-From bedside to bench

BACKGROUND

Anthracycline anticancer drugs such as epirubicin and doxorubicin may induce myocardial dysfunction, leading to poor prognosis. Early detection of minor left ventricular (LV) myocardial dysfunction is important for the prevention of anthracylcine-induced cardiotoxicity. Using layer-specific speckle tracking echocardiography (STE), we investigated the progressive distribution of myocardial dysfunction in both breast cancer patients and an animal toxicity model.

METHODS

Patients with preserved LV ejection fraction (LVEF) preparing for epirubicin chemotherapy (N = 125) were prospectively enrolled. Layer-specific STE, including LV longitudinal and circumferential strains on subepicardium and subendocardium, were evaluated at baseline and after the first cycle, third cycle and six months of epirubicin therapy. A decline of LVEF above 10% to <55% at six months was defined as cardiotoxicity. These same strain measures were obtained in doxorubicin-treated rats and the distribution of myocardial fibrosis evaluated.

RESULTS

In patients developing cardiotoxicity, LV longitudinal strain on subendocardium (LVLSendo) was significantly reduced after three cycles of therapy despite no significant changes in conventional LV systolic, diastolic parameters as well as LV circumferential strains at that moment. Compared to conventional echocardiographic parameters, LVLSendo was significantly predictive of cardiotoxicity. Declines in LVLSendo were also observed in doxorubicin-treated rats at an early stage. These reductions also predicted significant fibrosis in the subendocardial layer.

CONCLUSION

LVLSendo is useful for the early detection of minor cardiac dysfunction during chemotherapy, thereby implicating endocardial involvement in the development of cardiotoxicity.

Echocardiography and Cardio-Oncology

Owing to the ongoing increase in cancer survivors because of the remarkable and continuous progress in cancer management, a paradigm shift is occurring from cancer as a 'terminal illness' to a 'chronic condition' with cardiovascular risks. This also affects cardiology practice with increased cardiovascular morbidity and mortality rates among patients with cancer due to direct and/or indirect side effects of anticancer treatment. Thus, cardio-oncology has emerged as a new cardiology subspecialty, which focusses on risk stratification, prevention, diagnosis, treatment, and follow-up of cardiovascular disease related to cancer treatment. This review summarises echocardiographic evaluation of cardiac dysfunction and heart failure as they are the most concerning cardiovascular complications of cancer therapy and worsen its morbidity and mortality. This review covers cardiac function assessment and proposed cut-off values before/during/after cancer chemotherapy. The goal of this review is to aid clinicians to manage the patients with cancer sufficiently by connecting the existing knowledge in clinical cardiology with novel information from current advances in cardio-oncology.

Echocardiographic evaluation of cardiac function after cancer chemotherapy

Progress in cancer therapy has led to improved prognosis of patients with cancer and thus to a continuous rise of cancer survivors. However, it has simultaneously increased cardiovascular morbidity and mortality rates due to direct and/or indirect side effects of anticancer treatment. Similar to the rapid rise of patients with adult congenital disease, the number of patients suffering or at risk of cardiotoxicity has been steeply increasing and getting an emerging issue. Among the many facets of chemotherapy-induced cardiovascular toxicity, this review attempts to summarize echocardiographic evaluation of cardiac function after cancer chemotherapy by reviewing the definition, risk factors, brief history, limitation of left ventricular ejection fraction and myocardial strain imaging, as well as the limitations of this technique.