Cardio-oncology Part II: the monitoring, prevention, detection and treatment of chemotherapeutic cardiac toxicity

Abstract

Cancer treatment has advanced in recent years with new drugs, complex regimes and multiple modalities of treatment; which has improved survival of cancer patients. Cardiotoxicity from chemotherapy is an emerging, important issue. Currently, echocardiographic evaluation of ejection fraction is the most commonly employed diagnostic tool for detecting chemotherapy-induced cardiotoxicity. However, novel echocardiographic techniques assessing myocardial mechanics using strain imaging can detect earlier changes. New imaging techniques and biomarkers can risk stratify patients to identify those requiring closer monitoring. Cardiologists collaborating with oncologists can detect and treat cardiovascular chemotherapeutic complications earlier, reducing morbidity and mortality. While cardiac MRI and multigated acquisition nuclear scanning are alternatives, echocardiography has become the mainstream for assessing cardiac function due to its portability, efficiency and low cost. Current recommendations regarding cardiac monitoring of cancer patients are based on expert consensus opinion. There is a need for prospective controlled trials to support specific guidelines.

Keywords:

• biomarkers
• chemotherapy-induced cardiotoxicity
• early detection
• hypertension
• strain
• systolic dysfunction

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

Key issues

• With increasing cancer survivorship, the long-term cardiovascular morbidity associated with many chemotherapeutic regimes is becoming a significant issue.

• Decreased systolic function is the most commonly encountered form of cardiotoxicity, and has traditionally been detected by declining left ventricular ejection fraction (LVEF) on serial echocardiogram.

• Other established options for evaluation of LVEF include multigated acquisition scintigraphy, cardiac MRI and equilibrium radionuclide angiocardiography.

• Earlier detection of cardiotoxicity allows for risk stratification. New techniques aim to detect cardiotoxicity before the onset of a measurable decrease in LVEF or symptoms. These methods include echocardiographic assessment for strain using speckle-tracking imaging, as well as testing for elevations in cardiac biomarkers including troponin.

• Primary preventative measures such as dose adjustment of anthracycline chemotherapy or use of cardioprotective therapies can be applied to all patients.

• Alternatively, there is growing evidence to support therapeutic intervention in at-risk patients prior to the onset of a measurable decrease in LVEF.

Notes