Arrhythmia and Electrophysiological Effects of Chemotherapy: A Review

Abstract

Importance: Cardiotoxicity is an important limiting factor in the use of antineoplastic agents. The risk of arrhythmia and the electrophysiological effects of these agents are poorly characterized though increasing evidence suggests a high prevalence of complications. Observations: Patients with substantial cardiovascular risk factors are often excluded from clinical trials, while the aging population of patients actually receiving therapies may have an underlying arrhythmogenic substrate due to comorbidities. Risk stratification of patients before the selection of a therapeutic regimen is essential. Given the regular use of combination therapies, the potential for arrhythmia of each agent must be fully understood. Despite limited data and understanding in clinical practice, decisions on whether to initiate specific therapies in high-risk patients and how to manage the associated complications are made regularly. Conclusions and Relevance: This review describes the observed arrhythmias and proposed mechanisms for several major classes of antineoplastic agents. It also provides recommendations for risk stratification, monitoring, prophylaxis, and therapy, emphasizing the need for a collaborative relationship between oncologists and cardiologists and areas for future research.

Diagnosis, Treatment, and Prevention of Cardiovascular Toxicity Related to Anti-Cancer Treatment in Clinical Practice: An Opinion Paper from the Working Group on Cardio-Oncology of the Korean Society of Echocardiography

“…Atrial fibrillation is frequently observed during treatment with alkylating agents (up to 30%), anthracyclines, and antimetabolites. 43) The suggested mechanism of arrhythmia induced by alkylating agents is thought to involve direct irritation of the myocardium. 44) …”

Electrophysiological effects of anthracyclines in adult survivors of pediatric malignancy

“…The use of anthracyclines has improved the success of therapy for breast cancer, sarcomas, and a variety of pediatric malignancies, although there is significant cardiovascular toxicity with limited knowledge of electrophysiological effects . The most studied cardiotoxicity is left ventricular (LV) dysfunction, which has limited the cumulative dose and ultimate therapeutic benefit of these agents and can occur acutely during therapy, within 1 year of completion, or during long‐term follow‐up .…”

“…The use of anthracyclines has improved the success of therapy for breast cancer, sarcomas, and a variety of pediatric malignancies, although there is significant cardiovascular toxicity with limited knowledge of electrophysiological effects. [1][2][3] The most studied cardiotoxicity is left ventricular (LV) dysfunction, which has limited the cumulative dose and ultimate therapeutic benefit of these agents and can occur acutely during therapy, within 1 year of completion, or during long-Abbreviations: ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker; ECG, electrocardiogram; GEE, generalized estimating equation; LV, left ventricular; QTc, corrected QT term follow-up. [4][5][6] In pediatric patients, large cumulative doses are used with curative intent and up to 57% of survivors develop cardiovascular complications.…”

Cardio-Oncology: mechanisms of cardiovascular toxicity

“…The rate of dangerous ventricular arrhythmias may increase by 10-fold in patients with cancer, and chemotherapy-induced cardiomyopathy has been reported in 1–5% of cancer survivors and is substantially higher in certain populations 5 – 7 . These toxicities represent a limiting factor in the therapy of several otherwise-treatable neoplasms, and an aging population with impaired cardiac reserve may be even more susceptible to these effects 8 , 9 . In this review, we explore both established and theoretical mechanisms of cardiac toxicity contributing to cardiovascular disease from several important classes of antineoplastic therapy.…”