Article

Long-Term Cardiac Safety of Dose-Dense Anthracycline Therapy Cannot Be Predicted From Early Ejection Fraction Data

Department of Cardiology, The University of Texas M. D. Anderson Cancer Center, Houston, TX.
Journal of Clinical Oncology (Impact Factor: 17.88). 11/2009; 27(36):6073-5. DOI: 10.1200/JCO.2009.25.5091
Source: PubMed
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    ABSTRACT: Early recognition of cardiotoxicity from oncologic treatments is essential to set-up a strategy to prevent irreversible damage and heart failure. The left ventricular ejection fraction, regardless of the technique used for its calculation, is today recognized as inadequate to detect early cardiotoxicity and should not be used anymore as the sole index to assess left ventricular function. In the last years, a number of other parameters derived from cardiovascular imaging techniques have been proposed for cardiotoxicity recognition and many of them have shown a greater diagnostic accuracy in predicting acute and chronic cardiac damage or functional impairment caused by oncology treatments compared to the left ventricular ejection fraction. In addition, data are available that show the opportunity to evaluate also heart valves, pericardium and arterial and venous vasculature. However, because all current information on the role of cardiovascular imaging techniques in cardioncology are derived from monocenter, small, non randomized, observational studies, there is the need for large multicenter trials in this field. This is a challenge for both cardiologists and oncologists, who should work together to achieve this goal.RiassuntoRiconoscere precocemente la cardiotossicità dei trattamenti oncologici è fondamentale per impostare una strategia mirata a evitare l’instaurarsi di danni irreversibili e di scompenso cardiaco. È oggi evidente che la frazione d’eiezione del ventricolo sinistro è inadeguata, indipendentemente dalla tecnica utilizzata per il calcolo, per rilevare la cardiotossicità in fase precoce e non può più essere utilizzata come unico indice per valutare la funzione ventricolare sinistra. Negli ultimi anni numerosi altri parametri derivati da tecniche di imaging cardiovascolare sono stati proposti per il riconoscimento della cardiotossicità dovuta ai trattamenti oncologici e molti hanno mostrato di possedere una maggiore accuratezza diagnostica nel predire la comparsa di danno cardiaco e di compromissione funzionale, acuta e cronica, rispetto alla frazione di eiezione ventricolare sinistra. Inoltre, vari dati indicano l’opportunità di valutare, oltre alla funzione ventricolare, anche le valvole cardiache, il pericardio e il sistema vascolare arterioso e venoso. Tuttavia, occorre considerare che quasi tutte le informazioni attuali sul ruolo delle tecniche di imaging cardiovascolare in ambito cardioncologico sono derivate da studi monocentrici, di dimensioni in genere contenute, non randomizzati e osservazionali: vi è pertanto la necessità di trial clinici ampi e multicentrici, finalizzati a identificare il miglior approccio allo studio della cardiotossicità. Questa è oggi una grande sfida per i cardiologi e gli oncologi, i quali dovrebbero lavorare insieme per raggiungere tale obiettivo.
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    ABSTRACT: In 2015, there will be an estimated 11.3 million cancer survivors. With an increasing population of cancer survivors, it is imperative to understand the treatment options available and outcomes for chemotherapy-related cardiomyopathy. Anthracycline-based chemotherapy causes heart failure in approximately 5% of patients. Orthotopic heart transplantation (OHT) is an option for cancer survivors in complete remission who develop end-stage heart failure. We examined retrospective OHT data collected from the United Network of Organ Sharing from 1987 to 2011. The primary aim was to characterize the survival in patients with either the primary diagnosis of "dilated cardiomyopathy: Adriamycin" (DCA) versus "all other" causes of cardiomyopathy. The secondary aim was to define the differences in the primary cause of death and to describe the temporal relationship of DCA OHT. The United Network of Organ Sharing database identified 453 OHTs for the diagnosis of DCA and 51,312 OHTs for all other causes of cardiomyopathy. The DCA group was significantly younger with a greater percentage of women. After adjusting for age, gender, and history of malignancy, the 10-year survival curves showed that patients with DCA have an improved survival compared to those with all other causes of cardiomyopathy (hazard ratio 1.28, p = 0.026). No difference was found in the primary cause of death between the 2 groups. A statistically significant increasing temporal trend was seen in the number of OHTs for the diagnosis DCA. In conclusion, patients who undergo OHT for DCA have favorable 10-year survival, making OHT a good therapeutic option for end-stage heart failure due to anthracyclines. Additionally, no increased risk of cancer-related deaths was found in the DCA group, demonstrating that recurrent malignancy does not affect long-term survival. The temporal trends demonstrated that DCA remains a significant problem for cancer survivors.
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