Utility of routine pretreatment evaluation of left ventricular ejection fraction in breast cancer patients receiving anthracyclines

Abstract

Anthracycline‐based chemotherapy is widely used in the management of breast cancer. Despite the lack of clinical evidence, obtaining prechemotherapy left ventricular ejection fraction (LVEF) by echocardiogram or multigated acquisition scan is a widely adopted practice throughout the world. We present here the results of a retrospective analysis of breast cancer patients who had LVEF measurements in anticipation of an anthracycline chemotherapy to determine whether predefined cardiac risk factors predicted for poor cardiac function. Retrospective data were analyzed from 482 female breast cancer patients in whom LVEF was measured before starting anthracycline‐based chemotherapy. Baseline demographics and multiple risk factors associated with congestive heart failure were collected. Twenty‐six possible risk factors for CHF were defined, and the frequency of finding an abnormal LVEF as a function of total risk factors was assessed. Statistical tests include chi‐squared and logistic regression analysis. The median age of the study population was 52 years. The original chemotherapy plan was changed in 7 patients (1.45%) based on LVEF findings, all of which had asymptomatic LV dysfunction (LVEF ranging 40%‐50%). In 32 patients, despite normal LVEF results, anthracyclines were omitted secondary to prior cardiac issues. In 17 patients where LVEF was reported normal, anthracyclines were skipped based on patient's preference, tumor characteristics, or upstaging of the cancer based on imaging studies. No patient with ≤2 risk factors had an abnormal LVEF (N = 350). The probability of finding an abnormal LVEF in patients without any cardiac risk factors is extremely rare. Skipping baseline LVEF assessment may be an option in some patients with no cardiac risk factors undergoing anthracycline‐based chemotherapy.

Arrhythmias caused by chemotherapy agents used on the treatment of triple- negative Breast cancer: A mini review of literature

“…However, 90% of the patients re-exposed can have reappearance of these arrhythmias, which corroborates with the cardiotoxic effect of these chemotherapy agents [4]. In addition, SCD was observed with the use of 5-FU and doxorubicin [1][2][3][4][5][6][7][8][9][10][11]. Therefore, with the broad spectrum of arrhythmias caused by chemotherapy treatment, it is essencial to monitor these patients before, during and after the use of these drugs.…”

“…Cardiotoxicity chemotherapy-induced is defined by declining LVEF and symptoms of HF and it is commonly discussed in terms of cardiac dysfunction. Only recently cancer-treatment inducing arrhythmia (CTIA), and changes in ventricular repolarization have been brought to attention [1,[3][4][5]. With the aging of the population, both cardiac diseases and cancer have turned into more prevalent diseases, therefore, cardiotoxicity is likely to occur in many patients undergoing cancer treatment.…”

“…With the aging of the population, both cardiac diseases and cancer have turned into more prevalent diseases, therefore, cardiotoxicity is likely to occur in many patients undergoing cancer treatment. Contrary to initial guesses, the risk for cardiotoxicity still happens with the new target therapy agents, which act by inhibiting specific signals, such as monoclonal antibodies (trastuzumabe and pertuzmabe) [3][4][5][6] Therefore, CTIA can be divided into primary and secondary. Primary CTIA occurs when a drug has an effect interfering in a molecular pathway that causes an specific arrhythmia.…”

“…Furthermore, it is difficult to determine the exact chemotherapy agent that developed the arrhythmia because cancer and cardiac diseases have many risk factors in common, for example, obesity and alcohol use [3] Risk factors associated with cardiotoxicity of chemotherapeutic agents are broad, which included history of coronary artery disease (CAD), diabetes mellitus (DM), hypertension (HTN), arrhythmias, history of congestive heart failure (CHF), congenital heart disease, chest radiation, exposure to cardiotoxic chemotherapy, drug abuse, pulmonary hypertension (PHTN), pulmonary changes such as asthma, sleep apnea, sarcoidosis, thyroid dysfunction, chronic kidney disease and miscellaneous causes that included any other rare disease processes that could potentially cause CHF. Common factors found in breast cancer patients, according to age group [5,8]. In this context, anthracyclines (doxorubicin and epirubicin) present risk of adverse events is significantly elevated in the cumulative dose.…”

“…The number of cardiomyocytes decreases causing remodeling and leading overt symptoms. Resulting in transient electrocardiographic changes, LV dysfunction, myocarditis and supraventricular arrhythmias[5,[9][10]. There are many mechanisms proposed to explain the cardiotoxic effects of the anthracyclines[1,4,6].…”