Cardiovascular Disease After Aromatase Inhibitor Use

Haque, Reina; Shi, Jiaxiao; Schottinger, Joanne E.; Chung, Joanie; Avila, Chantal; Amundsen, Britta; Xu, Xiaoqing; Barac, Ana; Chlebowski, Rowan T.

doi:10.1001/jamaoncol.2016.0429

Cited by 82 publications

(78 citation statements)

References 28 publications

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“…Many anticancer drugs used to treat patients with advanced/metastatic breast cancer have been associated with early or delayed cardiac side effects, from left ventricular (LV) dysfunction to overt heart failure, arrhythmias, myocardial ischemia, valvular disease, thromboembolic disease, pulmonary hypertension, arterial hypertension, and pericarditis . Here, we explore the cardiac effects observed with radiotherapy, chemotherapy, endocrine therapy, and other approved targeted therapies for metastatic breast cancer.…”

Section: Resultsmentioning

confidence: 99%

Prevention, Monitoring, and Management of Cardiac Dysfunction in Patients with Metastatic Breast Cancer

et al. 2019

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Cardiac monitoring is becoming an important part of breast cancer care. Breast cancer and cardiovascular disease (CVD) share many common risk factors, and it is estimated that by the median age of diagnosis, many patients with breast cancer will have established or subclinical CVD. In addition, a number of treatments for metastatic breast cancer are known to have cardiac effects. As such, there is a clear need to prevent, identify, and effectively manage cardiovascular events in patients with breast cancer. Current clinical practice for patients with metastatic breast cancer involves a comprehensive set of assessments to ensure efficacy and safety of treatment. Adding cardiac monitoring to the assessments already required for patients with breast cancer may improve survival and quality of life. Currently, cardiac monitoring is recommended for several breast cancer treatments, and guidelines related to cardiac monitoring are available. Here, we review the risk of CVD in patients with breast cancer, providing an overview of the cardiac events associated with standard therapies for metastatic breast cancer. We also assess the current clinical recommendations relating to cardiac monitoring, and practical management strategies for oncologists. Cardio‐oncology is a growing medical subspecialty that promotes the need for effective cancer therapy while minimizing cardiac effects. Integrating cardiac monitoring into routine clinical practice may safeguard patients with metastatic breast cancer against adverse cardiac effects. Implications for Practice This review details the common risk factors associated with cardiovascular disease that are frequently observed in patients with metastatic breast cancer, as well as the adverse cardiac effects of many therapies that are commonly prescribed. The review also provides a rationale for routine and comprehensive cardiovascular assessment of all patients at baseline, and during and after therapy depending on the treatment and presence of risk factors for cardiovascular disease. The medical discipline of cardio‐oncology is increasingly being recognized as an important part of clinical practice to ensure effective cancer therapy while maintaining cardiac health.

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Section: Resultsmentioning

confidence: 99%

Prevention, Monitoring, and Management of Cardiac Dysfunction in Patients with Metastatic Breast Cancer

et al. 2019

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“…However, there was no evidence that menopausal status was a confounder of the relationship between aromatase inhibitors and HF (data not shown). A number of studies have suggested that aromatase inhibitors may increase the HF risk . Haque et al .…”

Section: Discussionmentioning

confidence: 99%

“…A number of studies have suggested that aromatase inhibitors may increase the HF risk . Haque et al . studied CVD outcomes in over 13 000 post‐menopausal BC patients and found a higher HF risk in patients treated with aromatase inhibitors compared to patients treated with tamoxifen only (hazard ratios 1.1–1.3).…”

Section: Discussionmentioning

confidence: 99%

Heart failure after treatment for breast cancer

Boekel

Duane

Jacobse

et al. 2019

European J of Heart Fail

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Background We aimed to develop dose–response relationships for heart failure (HF) following radiation and anthracyclines in breast cancer treatment, and to assess HF associations with trastuzumab and endocrine therapies. Methods and results A case–control study was performed within a cohort of breast cancer survivors treated during 1980–2009. Cases (n = 102) had HF as first cardiovascular diagnosis and were matched 1:3 on age and date of diagnosis. Individual cardiac radiation doses were estimated, and anthracycline doses and use of trastuzumab and endocrine therapy were abstracted from oncology notes. For HF cases who received radiotherapy, the estimated median mean heart dose (MHD) was 6.8 Gy [interquartile range (IQR) 0.9–13.7]. MHD was not associated with HF risk overall [excess rate ratio (ERR) = 1%/Gy, 95% confidence interval (CI) −2 to 10]. In patients treated with anthracyclines, exposure of ≥20% of the heart to ≥20 Gy was associated with a rate ratio of 5.7 (95% CI 1.7–21.7) compared to <10% exposed to ≥20 Gy. For cases who received radiotherapy, median cumulative anthracycline dose was 247 mg/m2 (IQR 240–319). A dose‐dependent increase was observed after anthracycline without trastuzumab (ERR = 1.5% per mg/m2, 95% CI 0.5–4.1). After anthracycline and trastuzumab, the rate ratio was 34.9 (95% CI 11.1–110.1) compared to no chemotherapy. Conclusions In absence of anthracyclines, breast cancer radiotherapy was not associated with increased HF risk. Strongly elevated HF risks were observed after treatment with anthracyclines and also after treatment with trastuzumab. The benefits of these systemic treatments usually exceed the risks of HF, but our results emphasize the need to support ongoing efforts to evaluate preventative strategies.

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“…The largest datasets come from pediatric cancer survivors who are well followed after their cancer diagnoses and who seem to have increased rates of coronary artery disease. Also, the breast and prostate cancer patients, who are treated with hormone deprivation therapies for many years, appear to have slightly higher rates of coronary artery disease than the general population [6][7][8]. Finally, patients treated with other cancer therapies may experience increased rates of late coronary artery disease due to other factors such as increased systemic inflammation either due to the underlying disease, the treatments, the stress of treatment, or perhaps even due to changes in the microbiome that accompany a cancer diagnosis and treatment.…”

Section: Mechanisms and Types Of Cardiac Toxicitiesmentioning

confidence: 99%

Cancer treatment-related cardiac toxicity: prevention, assessment and management

Fanous

Dillon

2016

Med Oncol

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Cancer therapies, especially anthracyclines and monoclonal antibodies, have been linked with increased rates of cardiotoxicity. The development of some cardiac side effects happens over several months, and changes in ejection fraction can be detected long before permanent damage or disability occurs. Advanced heart failure could be averted with better and earlier detection. Methodologies for early detection of cardiac changes include stress echocardiograms, cardiac velocity measurements, radionuclide imaging, cardiac MRI and several potential biomarkers. Many agents have been described for prophylaxis of cardiac events precipitated by cancer therapy. Prophylactic use of beta-blockers and ACE inhibitors may be considered for use with trastuzumab in breast cancer as tolerated. Recovery of cardiac function is possible early after the injury from a cancer therapy. Late complications for coronary artery disease, hypertension and arrhythmia are underappreciated. Treatments for severe cancer therapy-related cardiac complications follow the existing paradigms for congestive heart failure and coronary artery disease, although outcomes for cancer patients differ from outcomes for non-cancer patients.

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Cardiovascular Disease After Aromatase Inhibitor Use

Abstract: The risk of the most serious cardiovascular events (cardiac ischemia or stroke) was not elevated in AI-only users compared with tamoxifen users. The finding that other CVD events combined were greater in AI users requires further study.

Cited by 82 publications

References 28 publications

Prevention, Monitoring, and Management of Cardiac Dysfunction in Patients with Metastatic Breast Cancer

Prevention, Monitoring, and Management of Cardiac Dysfunction in Patients with Metastatic Breast Cancer

Heart failure after treatment for breast cancer

Cancer treatment-related cardiac toxicity: prevention, assessment and management

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