Recent consensus guidelines have established criteria for the identification and surveillance of breast cancer patients at increased risk of cardiotoxicity. Dose reduction, liposomal doxorubicin, and dexrazoxane may be considered in high-risk patients receiving anthracyclines. Anthracycline-free regimens should be considered in high-risk patients with HER-2+ breast cancer, if appropriate. Data to support the routine use of concomitant neurohormonal blockade or statins to prevent anthracycline- and trastuzumab-induced cardiomyopathy is not yet available. Strategies that minimize radiation dose to the heart such as deep inspiration and intensity-modulated radiation are recommended to prevent radiation-induced cardiotoxicity. Identification of high-risk patients, aggressive management of underlying cardiovascular risk factors, consideration of cardioprotective strategies, and routine surveillance of left ventricular function before and after therapy are recommended to reduce breast cancer treatment-associated cardiotoxicities.

Aims  The prognostic importance of post-diagnosis assessment of cardiorespiratory fitness (CRF) in cancer patients is not well established. We sought to examine the association between CRF and mortality in cancer patients. Methods and results  This was a single-centre cohort analysis of 1632 patients (58% male; 64 ± 12 years) with adult-onset cancer who were clinically referred for exercise treadmill testing a median of 7 [interquartile range (IQR): 3–12] years after primary diagnosis. Cardiorespiratory fitness was defined as peak metabolic equivalents (METs) achieved during standard Bruce protocol and categorized by tertiles. The association between CRF and all-cause and cause-specific mortality was assessed using multivariable Cox proportional hazard models adjusting for important covariates. Median follow-up was 4.6 (IQR: 2.6–7.0) years; a total of 411 deaths (229, 50, and 132 all-cause, cardiovascular (CV), and cancer related, respectively) occurred during this period. Compared with low CRF (range: 1.9–7.6 METs), the adjusted hazard ratio (HR) for all-cause mortality was 0.38 [95% confidence interval (CI): 0.28–0.52] for intermediate CRF (range: 7.7–10.6 METs) and 0.17 (95% CI: 0.11–0.27) for high CRF (range: 10.7–22.0 METs). The corresponding HRs were 0.40 (95% CI: 0.19–0.86) and 0.41 (95% CI: 0.16–1.05) for CV mortality and 0.40 (95% CI: 0.26–0.60) and 0.16 (95% CI: 0.09–0.28) for cancer mortality, respectively. The adjusted risk of all-cause, CV, and cancer mortality decreased by 26%, 14%, and 25%, respectively with each one MET increment in CRF. Conclusion  Cardiorespiratory fitness is a strong, independent predictor of all-cause, CV, and cancer mortality, even after adjustment for important clinical covariates in patients with certain cancers.

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Dietary behavior can have a consequential and wide-ranging influence on human health. Intermittent fasting, which involves intermittent restriction in energy intake, has been shown to have beneficial cellular, physiological, and system-wide effects in animal and human studies. Despite the potential utility in preventing, slowing, and reversing disease processes, the clinical application of intermittent fasting remains limited. The health benefits associated with the simple implementation of a 12 to 16 h fast suggest a promising role in the treatment of chronic pain. A literature review was completed to characterize the physiologic benefits of intermittent fasting and to relate the evidence to the mechanisms underlying chronic pain. Research on different fasting regimens is outlined and an overview of research demonstrating the benefits of intermittent fasting across diverse health conditions is provided. Data on the physiologic effects of intermittent fasting are summarized. The physiology of different pain states is reviewed and the possible implications for intermittent fasting in the treatment of chronic pain through non-invasive management, prehabilitation, and rehabilitation following injury and invasive procedures are presented. Evidence indicates the potential utility of intermittent fasting in the comprehensive management of chronic pain and warrants further investigation.

Aims The minute ventilation–carbon dioxide production relationship (VE/VCO2 slope) is widely used for prognostication in heart failure (HF) with reduced left ventricular ejection fraction (LVEF). This study explored the prognostic value of VE/VCO2 slope across the spectrum of HF defined by ranges of LVEF. Methods and results In this single‐centre retrospective observational study of 1347 patients with HF referred for cardiopulmonary exercise testing, patients with HF were categorized into HF with reduced (HFrEF, LVEF < 40%, n = 598), mid‐range (HFmrEF, 40% ≤ LVEF < 50%, n = 164), and preserved (HFpEF, LVEF ≥ 50%, n = 585) LVEF. Four ventilatory efficiency categories (VC) were defined: VC‐I, VE/VCO2 slope ≤ 29; VC‐II, 29 < VE/VCO2 slope < 36; VC‐III, 36 ≤ VE/VCO2 slope < 45; and VC‐IV, VE/VCO2 slope ≥ 45. The associations of these VE/VCO2 slope categories with a composite outcome of all‐cause mortality or HF hospitalization were evaluated for each category of LVEF. Over a median follow‐up of 2.0 (interquartile range: 1.9, 2.0) years, 201 patients experienced the composite outcome. Compared with patients in VC‐I, those in VC‐II, III, and IV demonstrated three‐fold, five‐fold, and eight‐fold increased risk for the composite outcome. This incremental risk was observed across HFrEF, HFmrEF, and HFpEF cohorts. Conclusions Higher VE/VCO2 slope is associated with incremental risk of 2 year all‐cause mortality and HF hospitalization across the spectrum of HF defined by LVEF. A multilevel categorical approach to the interpretation of VE/VCO2 slope may offer more refined risk stratification than the current binary approach employed in clinical practice.