Cardioprotective Strategies from Cardiotoxicity in Cancer Patients: A Comprehensive Review

Abstract

Cardiotoxicity is a significant complication of chemotherapeutic agents in cancer patients. Cardiovascular incidents including LV dysfunction, heart failure (HF), severe arrhythmias, arterial hypertension, and death are associated with high morbidity and mortality. Risk stratification of cancer patients prior to initiation of chemotherapy is crucial, especially in high-risk patients for cardiotoxicity. The early identification and management of potential risk factors for cardiovascular side effects seems to contribute to the prevention or minimization of cardiotoxicity. Screening of cancer patients includes biomarkers such as cTnI and natriuretic peptide and imaging measurements such as LV function, global longitudinal strain, and cardiac MRI. Cardioprotective strategies have been investigated over the last two decades. These strategies for either primary or secondary prevention include medical therapy such as ACE inhibitors, ARBs, b-blockers, aldosterone antagonists, statins and dexrazoxane, physical therapy, and reduction of chemotherapeutic dosages. However, data regarding dosages, duration of medical therapy, and potential interactions with chemotherapeutic agents are still limited. Collaboration among oncologists, cardiologists, and cardio-oncologists could establish management cardioprotective strategies and approved follow-up protocols in patients with cancer receiving chemotherapy.

Comment on: AGS And NIA bench‐to bedside conference summary: Cancer and cardiovascular disease

“…11 A recent comprehensive review has been published on cardioprotective strategies for chemotherapy-induced cardiotoxicity. 12 This conference summary opens the door to an extremely important area for discussion. Let us hope that the dialogue continues.…”

Established and Emerging Cancer Therapies and Cardiovascular System: Focus on Hypertension—Mechanisms and Mitigation

“…Furthermore, limited sample sizes, cardiovascular event rates, lack of accurately captured cardiovascular data, vast heterogeneity among cancer therapy trial populations, and short trial follow-up durations make risk assessment tools and cardioprotective strategies difficult to accurately assess and validate. 214 Efforts have been made by the European Society of Cardiology (ESC) in collaboration with the International Cardio Oncology Society to develop risk assessment tools to guide screening and decision-making for patients with cancer in clinical practice, 215 but these have not yet achieved widespread use.…”

“…227 Further investigation to compliment Hypertensive and CVD screening within the cardio-oncology setting may also encompass a multimarker approach to assess for cardiac dysfunction and improve initiation of cardioprotective measures. 214,216,231 This may include the use of transthoracic echocardiography with Global Longitudinal Strain, 3-dimensional left ventricular ejection fraction assessment, and cardiac magnetic resonance imaging. 214,232,233 The use of troponin, natriuretic peptide, and D-dimer biomarkers have an established role in cardio-oncological workup for cardioprotective screening 234 particularly in the setting of cancer therapies known to cause cardiac dysfunction; however, their use as a marker for hypertensive heart disease has not been described in the literature.…”

“…Furthermore, limited sample sizes, cardiovascular event rates, lack of accurately captured cardiovascular data, vast heterogeneity among cancer therapy trial populations, and short trial follow-up durations make risk assessment tools and cardioprotective strategies difficult to accurately assess and validate. 214…”

Myocardial Cell Preservation from Potential Cardiotoxic Drugs: The Role of Nanotechnologies

“…Several cardiovascular event-preventing drugs have been considered [ 126 ], including ACE inhibitors, angiotensin receptor blockers, and beta-blockers. In particular, carvedilol, a non-selective beta and alpha-1 adrenergic receptor blocker with several indications (e.g., hypertension, arrhythmias, and heart failure) [ 127 ], demonstrated effective prevention of doxorubicin-induced cardiovascular complications, as assessed by echocardiographic strain parameters [ 128 ]. Sacubitril/valsartan, a combination therapy of angiotensin receptor/neprilysin inhibitors improving the prognosis of patients suffering from heart failure with reduced ejection fraction [ 129 , 130 ], is currently under investigation as a preventive agent during cardiotoxic therapies, although data from large clinical trials are missing.…”