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BACKGROUND: Anthracycline-based chemotherapy represents a cornerstone treatment for a number of common cancers, including breast cancer, lymphoma, and sarcoma. However, anthracycline-induced cardiotoxicity remains a significant concern, often presenting as a decline in cardiac function which can ultimately lead to heart failure (HF) or asymptomatic left ventricular dysfunction, in up to 10-15% of patients.Sodium-glucose transport protein 2 inhibitor (SGLT2i) therapies have been demonstrated to reduce the incidence of HF in high-risk non-cancer patients. Preliminary retrospective data suggest their role in mitigating the incidence of HF during or after anthracycline treatment METHODS: The EMPACARD-PILOT trial was a prospective caseâcontrol study involving breast cancer patients scheduled to undergo anthracycline-based chemotherapy in a 4-cycle protocol of 60 mg/m2 doxorubicin. We used the HFA/ICOS risk score to identify patients at high or very high risk of cardiotoxicity. Patients with diabetes mellitus or stable heart failure with preserved ejection fraction (HFpEF) were prescribed empagliflozin (10 mg per day), starting seven days before the administration of anthracyclines and continuing for a period of six months. Those not meeting these criteria served as controls. The primary endpoint was cancer therapy-related cardiac dysfunction (CTRCD) incidence. CTRCD was defined as either a decrease in left ventricular ejection fraction (LVEF) of at least 10% to a final value below 50% or a reduction in global longitudinal strain (GLS) of at least 15% from baseline at any point during the study. The secondary endpoints included mortality and hospitalization due to cardiovascular causes or clinical heart failure. Exploratory endpoints included increases in serum troponin and NT-proBNP levels and a decrease in the glomerular filtration rate (GFR). The safety endpoints tracked includedketoacidosis, hypoglycemia, sepsis, neutropenic fever, and urinary tract infections. RESULTS: During the enrollment period, 785 breast cancer patients were analysed. Of these, 107 met the inclusion criteria, and 76 subsequently provided informed consent. The study was conducted with comparable adherence rates of 81.5% in both the empagliflozin group (n = 38) and the control group (n = 38). The follow-up data from 62 patients revealed a significant reduction in the primary outcome within 6 months for the empagliflozin group compared with the control group (6.5% vs. 35.5%, p = 0.005), with a relative risk of 0.18 (95% CI: 0.04-0.75). Compared with the control treatment, treatment with empagliflozin also significantly preserved the ejection fraction at 6 months follow-up (56.8% ± 5.8% vs. 53.7% ± 6.7, p = 0.029). However, there were no significant differences between the groups in terms of NT-proBNP, cTnI, clinical heart failure, GFR, or mortality/hospitalization due to heart failure. CONCLUSION: Empagliflozin is associated with reduced incidence of CTRCD in high-risk patients treated with anthracyclines. These data should serve as the foundation for a clinical trial to test whether SGLT2 inhibitors can reduce the incidence of heart failure in this patient group.
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Endothelial Growth Factor Receptor (EGFR) mutations are frequently found among NSCLC patients. Second-generation Tyrosine Kinase Inhibitor (TKI) Afatinib is frequently used in this population of patients achieving better results than cytotoxic chemotherapy in terms of survival and progression. Afatinib-related cardiotoxicity has been rarely reported. Here we comment on a clinical case of a Takotsubo Cardiomyopathy Afatinib-induced in an NSCLC patient.
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Radiation therapy is a cornerstone of cancer therapy, with >50% of patients undergoing therapeutic radiation. As a result of widespread use and improved survival, there is increasing focus on the potential long-term effects of ionizing radiation, especially cardiovascular toxicity. Radiation therapy can lead to atherosclerosis of the vasculature as well as valvular, myocardial, and pericardial dysfunction. We present a consensus statement from the International Cardio-Oncology Society based on general principles of radiotherapy delivery and cardiovascular risk assessment and risk mitigation in this population. Anatomical-based recommendations for cardiovascular management and follow-up are provided, and a priority is given to the early detection of atherosclerotic vascular disease on imaging to help guide preventive therapy. Unique management considerations in radiation-induced cardiovascular disease are also discussed. Recommendations are based on the most current literature and represent a unanimous consensus by the multidisciplinary expert panel.
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BACKGROUND: Cancer therapy-related cardiac dysfunction (CTRCD) is a critical problem with an impact on both oncological and cardiovascular prognosis, especially when it prevents patients from receiving cancer treatment. Standard therapy for heart failure (HF) is recommended for CTRCD, but there is no well-established evidence on how sacubitril/valsartan may help cancer patients with cardiotoxicity. OBJECTIVES: The aim of this trial was to study the effectiveness of sacubitril-valsartan in patients with CTRCD treated in cardio-oncology units. METHODS: We enrolled 635 patients with breast cancer and followed them with echocardiography and NT- proBNP. Patients who developed left ventricular dysfunction and heart failure were treated with angiotensin-converting enzyme inhibitors (ACEI) (enalapril) or angiotensin receptor blockers (ARB) (valsartan), aldosterone antagonists (eplerenone), digitalis and diuretics (furosemide), as needed. When patients remained symptomatic and met the PARADIGM-HF inclusion criteria, sacubitril/valsartan was started instead of enalapril or valsartan. We analyzed clinical, laboratory and echocardiographic variables to determine the beneficial effects of sacubitril/valsartan on left ventricular remodeling (improvement of left ventricular ejection fraction (LVEF), left ventricle internal diameter in diastole), diastolic dysfunction (E/e' ratio), reduction in NT-proBNP levels, New York Heart Association (NHYA) class and improvement in the 6-min walk test. Also, we analyzed serum creatinine and potassium levels to determine treatmentsafety in this population. Median follow-up was 20 months. RESULTS: Twenty-eight patients developed cardiotoxicity and were treated with sacubitril/valsartan. The sacubitril/valsartan dose was 100 mg (sacubitril 49 mg/valsartan 51 mg) in 12 patients (42.85%) and 200 mg (sacubitril 97 mg/valsartan 103 mg) in 16 patients (57.15%). No deaths were reported, and one patient underwent heart transplantation. Baseline median NT-proBNP was 997.5 pg/ml (IQR 663.8 - 2380.8), which decreased to a median of 416.5 pg/ml (IQR 192.0-798.2) on follow-up with p < 0.001. Baseline NYHA functional class was III (78.6%) or IV (21.4%), and it improved to I (57.1%) or II (42.9%) on follow-up. LVEF increased with treatment from 26.7 ± 5.4% to 32.3 ± 5.5% (p < 0.001). There were also significant improvements in left ventricle internal diameter in diastole (LVIDD), diastolic function, 6-min walk test, and mitral valve regurgitation. There were no differences between basal and follow-up levels of serum creatinine or potassium. CONCLUSION: Sacubitril/valsartan might be a promising treatment option in patients with refractory CTRCD.
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La infección por SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) puede presentar manifestaciones propias, pero también, puede exacerbar las de enfermedades preexistentes o provocar manifestaciones que simulen dichas patologías. Las enfermedades cardiovasculares, neoplásicas o reumatológicas son ejemplos de ello. Este tipo de patologías comparten factores de riesgo de mal pronóstico y de muerte por la infección, la posibilidad de desarrollar complicaciones a largo plazo, e implican un desafío al momento de instaurar medidas de seguimiento y tratamiento con requerimiento de valoración multidisciplinaria. Por ello, nuestro objetivo fue plantear las dificultades en el seguimiento a corto y largo plazo de este tipo de pacientes y evaluar cómo la pandemia afecta su tratamiento. La pandemia ha cambiado la práctica médica habitual, promoviendo nuevas formas de seguimiento de los pacientes, como la telemedicina, imponiendo jerarquizar la necesidad de atención y procedimientos presenciales, obligando a reasignar las partidas presupuestarias para poder hacer frente a la misma, con consecuencias que probablemente habrá que analizar a largo plazo.
SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection clinical course can present its own manifestations, but it can also exacerbate those of pre-existing diseases or cause manifestations that simulate said pathologies. Cardiovascular, cancer or rheumatological diseases are examples of this. These types of pathologies share risk factors for poor prognosis and death due to infection, the possibility of developing long-term complications, and they imply a challenge when establishing follow-up and treatment measures requiring multidisciplinary assessment. Therefore, our objective was to raise the difficulties in the short and long-term follow-up of this type of patients and to evaluate how the pandemic affects their treatment. The pandemic has changed the usual medical practice, promoting new forms of patient follow-up, such as telemedicine, imposing a hierarchy of the need for face-to-face care and procedures, forcing budget items to be reallocated to be able to deal with it, with consequences that are likely to it will have to be analyzed in the long term.
A infecção por SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pode apresentar manifestações próprias, mas também pode exacerbar aquelas de doenças pré-existentes ou causar manifestações que simulam essas patologias. Doenças cardiovasculares, neoplásicas ou reumatológicas são exemplos disso. Esses tipos de patologias compartilham fatores de risco para mau prognóstico e óbito por infecção, possibilidade de desenvolvimento de complicações em longo prazo, e representam um desafio no estabelecimento de medidas de acompanhamento e tratamento que requerem avaliação multidisciplinar. Portanto, nosso objetivo foi levantar as dificuldades no acompanhamento a curto e longo prazo desse tipo de paciente e avaliar como a pandemia afeta seu tratamento. A pandemia alterou a prática médica usual, promovendo novas formas de acompanhamento do paciente, como a telemedicina, impondo uma hierarquia da necessidade de atendimento e procedimentos presenciais, obrigando a realocação de itens orçamentários para poderem lidar com ela, com consequências que provavelmente terá que ser analisado a longo prazo.