Article

Journal of Nuclear Cardiology

, 10:132

First online:

Doxorubicin cardiotoxicity: Prevention of congestive heart failure with serial cardiac function monitoring with equilibrium radionuclide angiocardiography in the current era

  • Isao MitaniAffiliated withSection of Cardiovascular Medicine, Cardiovascular Nuclear Imaging Laboratory, and Section of Medical Oncology, Department of Medicine, Yale University School of Medicine
  • , Diwakar JainAffiliated withSection of Cardiovascular Medicine, Cardiovascular Nuclear Imaging Laboratory, and Section of Medical Oncology, Department of Medicine, Yale University School of Medicine Email author 
  • , Tammy M. JoskaAffiliated withSection of Cardiovascular Medicine, Cardiovascular Nuclear Imaging Laboratory, and Section of Medical Oncology, Department of Medicine, Yale University School of Medicine
  • , Barbara BurtnessAffiliated withSection of Cardiovascular Medicine, Cardiovascular Nuclear Imaging Laboratory, and Section of Medical Oncology, Department of Medicine, Yale University School of Medicine
  • , Barry L. ZaretAffiliated withSection of Cardiovascular Medicine, Cardiovascular Nuclear Imaging Laboratory, and Section of Medical Oncology, Department of Medicine, Yale University School of Medicine

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Abstract

Background

Congestive heart failure (CHF) is among the most serious toxicities of doxorubicin, a potent cancer chemotherapeutic agent. Serial left ventricular ejection fraction (LVEF) monitoring during doxorubicin therapy for preventing CHF was proposed over 20 years ago. The current utility and cost-effectiveness of this approach in the present era are not known.

Methods and Results

Clinical and follow-up data of 265 patients with cancer (age, 53 ± 14 years; 76% women) undergoing doxorubicin chemotherapy with serial equilibrium radionuclide angiocardiography (ERNA) monitoring (≥2 studies) were analyzed retrospectively. Patients with a normal baseline LVEF (≥50%) and a 10% or greater point fall in LVEF to a final value of less than 50% during doxorubicin therapy were considered “at risk” for CHF (n = 41). Over 679 ± 426 days of follow-up, 7 patients (2.6%) had CHF develop and 90 (34%) died (all cancer-related deaths, with none due to CHF). A comparison of “at-risk” (n = 41 [15%]) and “low-risk” (n = 224 [85%]) groups showed a higher incidence of CHF (12% vs 0.9%, P < .0001), lower baseline LVEF (58% ± 8% vs 64% ± 8%, P < .0001), lower value for the lowest LVEF (42% ± 8% vs 57% ± 7%, P < .0001), and higher rate of cancer-related deaths (59% vs 29%, P = .0003) in the former despite similar cumulative doxorubicin dose (304 ± 124 mg/m2 vs 284 ± 110 mg/m2, P not significant). There were no differences in age, gender, cancer type, and co-morbidity. Cost analysis showed the overall cost of ERNA studies to be lower than the 1-year cost of caring for additional cases of CHF that would potentially be prevented by routine LVEF monitoring.

Conclusions

An incipient fall in LVEF detected on serial ERNA during doxorubicin therapy provides an appropriate and cost-effective approach for predicting and preventing impending CHF. Use of this approach was associated with a low incidence of CHF (2.6%) and no CHF-related mortality in this study. (J Nucl Cardiol 2003;10:132-9.)

Key Words

Doxorubicin cardiotoxicity equilibrium radionuclide angiocardiography left ventricular ejection fraction