Cardiotoxicity of Anthracyclines

Overview

Journal Front Cardiovasc Med

Specialty Cardiology & Vascular Diseases

Date 2020 Apr 8

PMID 32258060

Citations 160

Authors

Daniela Cardinale

Fabiani Iacopo

Carlo Maria Cipolla

Affiliations

Soon will be listed here.

Abstract

Cardiotoxicity is a feared side effect that may limit the clinical use of anthracyclines. It may indeed affect the quality of life and survival of patients with cancer, regardless of oncological prognosis. This paper provides an overview of anthracycline-induced cardiotoxicity in terms of definition, classification, incidence, risk factors, possible mechanisms, diagnosis, and treatment. We also report effective strategies for preventing cardiotoxicity. In addition, we discuss limiting current approaches, the need for a new classification, and early cardiotoxicity detection and treatment. Probably, anthracycline-induced cardiotoxicity is a continuous phenomenon that starts from myocardial cell injury; it is followed by left ventricular ejection fraction (LVEF) and, if not diagnosed and cured early, progressively leads to symptomatic heart failure. Anthracycline-induced cardiotoxicity can be detected at a preclinical phase. The role of biomarkers, in particular troponins, in identifying subclinical cardiotoxicity and its therapy with angiotensin-converting enzyme inhibitors (mainly enalapril) to prevent LVEF reduction is a recognized and effective strategy. If cardiac dysfunction has already occurred, partial or complete LVEF recovery may still be obtained in case of early detection of cardiotoxicity and prompt heart failure treatment.

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References

Mornos C, Petrescu L . Early detection of anthracycline-mediated cardiotoxicity: the value of considering both global longitudinal left ventricular strain and twist. Can J Physiol Pharmacol. 2013; 91(8):601-7. DOI: 10.1139/cjpp-2012-0398. View

Curigliano G, Cardinale D, Dent S, Criscitiello C, Aseyev O, Lenihan D . Cardiotoxicity of anticancer treatments: Epidemiology, detection, and management. CA Cancer J Clin. 2016; 66(4):309-25. DOI: 10.3322/caac.21341. View

Cappetta D, Rossi F, Piegari E, Quaini F, Berrino L, Urbanek K . Doxorubicin targets multiple players: A new view of an old problem. Pharmacol Res. 2017; 127:4-14. DOI: 10.1016/j.phrs.2017.03.016. View

Ky B, Putt M, Sawaya H, French B, Januzzi Jr J, Sebag I . Early increases in multiple biomarkers predict subsequent cardiotoxicity in patients with breast cancer treated with doxorubicin, taxanes, and trastuzumab. J Am Coll Cardiol. 2013; 63(8):809-16. PMC: 4286181. DOI: 10.1016/j.jacc.2013.10.061. View

Narayan H, Finkelman B, French B, Plappert T, Hyman D, Smith A . Detailed Echocardiographic Phenotyping in Breast Cancer Patients: Associations With Ejection Fraction Decline, Recovery, and Heart Failure Symptoms Over 3 Years of Follow-Up. Circulation. 2017; 135(15):1397-1412. PMC: 5388560. DOI: 10.1161/CIRCULATIONAHA.116.023463. View

Tallaj J, Franco V, Rayburn B, Pinderski L, Benza R, Pamboukian S . Response of doxorubicin-induced cardiomyopathy to the current management strategy of heart failure. J Heart Lung Transplant. 2005; 24(12):2196-201. DOI: 10.1016/j.healun.2004.12.108. View

Acar Z, Kale A, Turgut M, Demircan S, Durna K, Demir S . Efficiency of atorvastatin in the protection of anthracycline-induced cardiomyopathy. J Am Coll Cardiol. 2011; 58(9):988-9. DOI: 10.1016/j.jacc.2011.05.025. View

Tabet J, Meurin P, Ben Driss A, Berthaux X, Weber H, Renaud N . Beta-blockade intolerance in anthracycline-induced cardiomyopathy. Int J Cardiol. 2005; 106(1):132-4. DOI: 10.1016/j.ijcard.2004.12.052. View

Oliveira-Carvalho V, Ferreira L, Bocchi E . Circulating mir-208a fails as a biomarker of doxorubicin-induced cardiotoxicity in breast cancer patients. J Appl Toxicol. 2015; 35(9):1071-2. DOI: 10.1002/jat.3185. View

10.

Cardinale D, Colombo A, Bacchiani G, Tedeschi I, Meroni C, Veglia F . Early detection of anthracycline cardiotoxicity and improvement with heart failure therapy. Circulation. 2015; 131(22):1981-8. DOI: 10.1161/CIRCULATIONAHA.114.013777. View

11.

Putt M, Hahn V, Januzzi J, Sawaya H, Sebag I, Plana J . Longitudinal Changes in Multiple Biomarkers Are Associated with Cardiotoxicity in Breast Cancer Patients Treated with Doxorubicin, Taxanes, and Trastuzumab. Clin Chem. 2015; 61(9):1164-72. PMC: 4667170. DOI: 10.1373/clinchem.2015.241232. View

12.

Tan C, Tasaka H, Yu K, Murphy M, KARNOFSKY D . Daunomycin, an antitumor antibiotic, in the treatment of neoplastic disease. Clinical evaluation with special reference to childhood leukemia. Cancer. 1967; 20(3):333-53. DOI: 10.1002/1097-0142(1967)20:3<333::aid-cncr2820200302>3.0.co;2-k. View

13.

Liu J, Banchs J, Mousavi N, Plana J, Scherrer-Crosbie M, Thavendiranathan P . Contemporary Role of Echocardiography for Clinical Decision Making in Patients During and After Cancer Therapy. JACC Cardiovasc Imaging. 2018; 11(8):1122-1131. DOI: 10.1016/j.jcmg.2018.03.025. View

14.

Asselin B, Devidas M, Chen L, Franco V, Pullen J, Borowitz M . Cardioprotection and Safety of Dexrazoxane in Patients Treated for Newly Diagnosed T-Cell Acute Lymphoblastic Leukemia or Advanced-Stage Lymphoblastic Non-Hodgkin Lymphoma: A Report of the Children's Oncology Group Randomized Trial Pediatric.... J Clin Oncol. 2015; 34(8):854-62. PMC: 4872007. DOI: 10.1200/JCO.2015.60.8851. View

15.

Kort S, Mehran R, Soman P, Dehmer G, Doherty J, Schoenhagen P . ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use.... J Am Coll Cardiol. 2019; 73(4):488-516. DOI: 10.1016/j.jacc.2018.10.038. View

16.

Jensen B, Skovsgaard T, Nielsen S . Functional monitoring of anthracycline cardiotoxicity: a prospective, blinded, long-term observational study of outcome in 120 patients. Ann Oncol. 2002; 13(5):699-709. DOI: 10.1093/annonc/mdf132. View

17.

Fazio S, Palmieri E, Ferravante B, Bone F, Biondi B, Sacca L . Doxorubicin-induced cardiomyopathy treated with carvedilol. Clin Cardiol. 1998; 21(10):777-9. PMC: 6655455. DOI: 10.1002/clc.4960211017. View

18.

Thavendiranathan P, Poulin F, Lim K, Plana J, Woo A, Marwick T . Use of myocardial strain imaging by echocardiography for the early detection of cardiotoxicity in patients during and after cancer chemotherapy: a systematic review. J Am Coll Cardiol. 2014; 63(25 Pt A):2751-68. DOI: 10.1016/j.jacc.2014.01.073. View

19.

Levis B, Binkley P, Shapiro C . Cardiotoxic effects of anthracycline-based therapy: what is the evidence and what are the potential harms?. Lancet Oncol. 2017; 18(8):e445-e456. DOI: 10.1016/S1470-2045(17)30535-1. View

20.

Vejpongsa P, Yeh E . Prevention of anthracycline-induced cardiotoxicity: challenges and opportunities. J Am Coll Cardiol. 2014; 64(9):938-45. DOI: 10.1016/j.jacc.2014.06.1167. View