Abstract
Advances in oncologic therapies have led to considerable improvements in prognosis and survival. However, these improvements may ultimately be diminished by the increase of cardiovascular side effects. Typically, both conventional and new antitumoral therapies may induce asymptomatic or symptomatic left ventricular dysfunction. Its development still remains a major deterrent that may compromise clinical effectiveness of cancer treatment, independently of the oncologic prognosis, having a serious impact on the patient’s survival and quality of life. Hence, prevention of cardiotoxicity remains a crucial topic both for cardiologists and oncologists. Many strategies to mitigate the risk of cardiotoxicity have been developed, including cardiac function monitoring, limitation of chemotherapy doses, use of anthracycline analogues and cardioprotectants, and early detection of cardiotoxicity by biomarkers, followed by prophylactic intervention in selected high risk patients. We reviewed the currently available approaches which have been demonstrated to be effective in preventing or limiting cancer drug-induced cardiotoxicity.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
DeSantis C, Lin C, Mariotto A, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64:252–71.
Truong J, Yan AT, Cramarossa G, Chan KKW. Chemotherapy-induced cardiotoxicity: detection, prevention and management. Can J Cardiol. 2014;30:869–78. A complete overview on incidence, detection, prevention, management, and clinical importance of cardiotoxicity.
Lenihan D, Cardinale D. Late cardiac effects of cancer treatment. J Clin Oncol. 2012;30:3657–64.
Carver JRSC, Ng A, et al. American society of clinical oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. J Clin Oncol. 2007;25:3991–4008.
Yeh ETH, Bickford CL. Cardiovascular complications of cancer therapy. Incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol. 2009;53:2231–47.
Hahn VS, Lenihan DJ, Ky B. Cancer therapy-induced cardiotoxicity: basic mechanisms and potential cardioprotective therapies. J Am Heart Assoc. 2014;3, e000665. An excellent review focusing on basic and clinical data to support use of specific potential cardioprotective agents against cancer therapy-induced cardiotoxicity.
Ewer SM, Ewer MS. Cardiotoxicity profile of trastuzumab. Drug Saf. 2008;31:459–67.
Tocchetti CG, Ragone G, Coppola C, Rea D, Piscopo G, Scala S. Detection, monitoring, and management of trastuzumab-induced left ventricular dysfunction: an actual challenge. Eur J Heart Fail. 2012;14:130–7.
Lotrionte M, Biondi-Zoccai G, Abbate A, et al. Review and meta-analysis of incidence and clinical predictors of anthracycline cardiotoxicity. Am J Cardiol. 2013;112:1980–4.
Pinder MC, Duan Z, Goodwin JS, Hortobagyi GN, Giordano SH. Congestive heart failure in older women treated with adjuvant anthracycline chemotherapy for breast cancer. J Clin Oncol. 2007;25:3808–15.
Albini A, Pennesi G, Donatelli F, Cammarota R, De Flora S, Noonan DM. Cardiotoxicity of anticancer drugs: the need for cardio-oncology and cardio-oncological prevention. J Natl Cancer Inst. 2010;102:14–25.
Lenihan DJ, Esteva FJ. Multidisciplinary strategy for managing cardiovascular risks when treating patients with early breast cancer. Oncologist. 2008;13:1224–34.
Wouters KA, Kremer LCM, Miller TL, Herman EH, Lipshultz SE. Br J Haematol. 2005;131:561–78.
Curigliano G, Cardinale D, Suter T, et al. ESMO guidelines working group. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO clinical practice guidelines. Ann Oncol. 2012;23:vii155–66. Available from: www.annonc.oxfordjournals.org .
Vejpongsa P, Yeh ET. Prevention of anthracycline-induced cardiotoxicity: challenges and opportunities. J Am Coll Cardiol. 2014;64:938–45.
Slingerland M, Guchelaar HJ, Gelderblom H. Liposomal drug formulations in cancer therapy: 15 years along the road. Drug Discov Today. 2012;17:160–6.
Nitiss K, Nitiss J. Twisting and ironing: doxorubicin cardiotoxicity by mitochondrial DNA damage. Clin Cancer Res. 2014;20:4737–9.
Lyu YL, Kerrigan JE, Lin CP, Azarova AM, Tsai YC, Ban Y, et al. Topoisomerase IIbeta mediated DNA double-strand breaks: implications in doxorubicin cardiotoxicity and prevention by dexrazoxane. Cancer Res. 2007;67:8839–46.
Van Dalen EC, Caron HN, Dickinson HO, Kremer LC. Cardioprotective interventions for cancer patients receiving anthracyclines. Cochrane Database Syst Rev. 2011;CD003917.
FDA statement on Dexrazoxane. www.fda.gov/Drugs/DrugSafety/ucm263729.htm.
Kalay N, Basar E, Ozdogru I, et al. Protective effects of carvedilol against anthracycline-induced cardiomyopathy. J Am Coll Cardiol. 2006;48:2258–62.
Nohria A. Beta-adrenergic blockade for anthracycline- and trastuzumab-induced cardiotoxicity. Is prevention better than cure? Circ Heart Fail. 2013;6:358–61.
Kaya MG, Ozkan M, Gunebakmaz O, et al. Protective effects of nebivolol against anthracycline-induced cardiomyopathy: a randomized control study. Int J Cardiol. 2013;167:2306–10.
Seicean S, Seicean A, Alan N, Plana JC, Budd GT, Marwick TH. Cardioprotective effect of β-adrenoceptor blockade in patients with breast cancer undergoing chemotherapy: follow-up study of heart failure. Circ Heart Fail. 2013;6:420–6.
Choe JY, Combs AB, Folkers K. Potentiation of the toxicity of adriamycin by propranolol. Research communications in chemical pathology and pharmacology. Res Commun Chem Pathol Pharmacol. 1978;21:577–80.
Georgakopoulos P, Matsakas E, Karavidas A, et al. Cardioprotective effect of metoprolol and enalapril in doxorubicin-treated lymphoma patients: a prospective, parallel-group, randomized, controlled study with 36-month follow-up. Am J Hematol. 2010;85:894–6.
Cardinale D, Colombo A, Sandri MT, et al. Prevention of high-dose chemotherapy-induced cardiotoxicity in high-risk patients by angiotensin-converting enzyme inhibition. Circulation. 2006;114:2474–81.
Okumura K, Jin D, Takai S, Miyazaki M. Beneficial effects of angiotensin-converting enzyme inhibition in adriamycin-induced cardiomyopathy in hamsters. Jpn J Pharmacol. 2002;88:183–8.
Vaynblat M, Shah HR, Bhaskaran D, et al. Simultaneous angiotensin converting enzyme inhibition moderates ventricular dysfunction caused by doxorubicin. Eur J Heart Fail. 2002;4:583–6.
Abd El-Aziz MA, Othman AI, Amer M, El-Missiry MA. Potential protective role of angiotensin-converting enzyme inhibitors captopril and enalapril against adriamycin-induced acute cardiac and hepatic toxicity in rats. J Appl Toxicol. 2001;21:469–73.
Nakamae H, Tsumura K, Terada Y, et al. Notable effects of angiotensin II receptor blocker, valsartan, on acute cardiotoxic changes after standard chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone. Cancer. 2005;104:2492–8.
Cadeddu C, Piras A, Mantovani G, et al. Protective effects of the angiotensin II receptor blocker telmisartan on epirubicin-induced inflammation, oxidative stress, and early ventricular impairment. Am Heart J. 2010;160:4871.e1–7.
Gulati G, Heck SL, Ree AH, et al. Prevention of cardiac dysfunction during adjuvant breast cancer therapy (PRADA): primary results of a randomized, 2 × 2 factorial, placebo-controlled, double blind clinical trial. AHA 2015; abstract 2015-LBCT-20236-AHA.
Pituskin E, Mackey JR, Koshman S, et al. Prophylactic beta blockade preserves left ventricular ejection fraction in HER2-overexpressing breast cancer patients receiving trastuzumab: Primary results of the MANTICORE randomized controlled trial. SABCS 2015; abstract S1-05.
Akpek M, Ozdogru I, Sahin O, et al. Protective effects of spironolactone against anthracycline-induced cardiomyopathy. Eur J Heart Fail. 2015;17:81–9.
Bosch X, Rovira M, Sitges M, et al. Enalapril and carvedilol for preventing chemotherapy-induced left ventricular systolic dysfunction in patients with malignant hemopathies: the OVERCOME trial (preventiOn of left Ventricular dysfunction with Enalapril and caRvedilol in patients submitted to intensive ChemOtherapy for the treatment of Malignant hEmopathies). J Am Coll Cardiol. 2013;61:2355–62.
Riad A, Bien S, Westermann D, et al. Pretreatment with statin attenuates the cardiotoxicity of doxorubicin in mice. Cancer Res. 2009;69:695–9.
Henninger C, Huelsenbeck S, Wenzel P, et al. Chronic heart damage following doxorubicin treatment is alleviated by lovastatin. Pharmacol Res. 2015;91:47–56.
Acar Z, Kale A, Turgut M, et al. Efficiency of atorvastatin in the protection of anthracycline-induced cardiomyopathy. J Am Coll Cardiol. 2011;58:988–9.
Seicean S, Seicean A, Plana JC, Budd GT, Marwick TH. Effect of statin therapy on the risk for incident heart failure in patients with breast cancer receiving anthracycline chemotherapy: an observational clinical cohort study. J Am Coll Cardiol. 2012;60:2384–90.
Chotenimitkhun R, D’Agostino Jr R, Lawrence JA, et al. Chronic statin administration may attenuate early anthracycline-associated declines in left ventricular ejection function. Can J Cardiol. 2015;31:302e–7a.
Cardinale D, Salvatici M, Sandri MT. Role of biomarkers in cardioncology. Clin Chem Lab Med. 2011;49:1937–48.
Christenson ES, James T, Agrawal V, Park BH. Use of biomarkers for the assessment of chemotherapy-induced cardiac toxicity. Clin Biochem. 2015;48:223–35. Excellent review on strength and weakness points for the use of various biomarkers in the detection of chemotherapy-induced cardiotoxicity.
Thavendiranathan P, Poulin F, Lim KD, Plana JC, Woo A, Marwick TH. Use of myocardial strain imaging by echocardiography for the early detection of cardiotoxicity in patients during and after cancer chemotherapy: a systematic review. J Am Coll Cardiol. 2014;63:2751–68.
Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG. Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53:e1–90.
Eschenhagen T, Force T, Ewer MS, De Keulenaer GW, Suter TM, Anker SD. Cardiovascular side effects of cancer therapies: a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2011;13:1–10.
Cardinale D, Bacchiani G, Beggiato M, Colombo A, Cipolla CM. Strategies to prevent and treat cardiovascular risk in cancer patients. Semin Oncol. 2013;40:186–98.
Lenihan DJ, Oliva S, Chow EJ, Cardinale D. Cardiac toxicity in cancer survivors. Cancer. 2013;119:2131–42.
Cardinale D, Colombo A, Bacchiani G, et al. Early detection of anthracycline cardiotoxicity and improvement with heart failure therapy. Circulation. 2015;131:1981–8.
Sengupta PP, Northfelt DW, Gentile F, Zamorano JL, Khandheria BK. Trastuzumab-induced cardiotoxicity: heart failure at the crossroads. Mayo Clin Proc. 2008;83:197–203.
Martin M, Esteva FJ, Alba E, Khandheria B, Pérez-Isla L, Garcìa-Sàenz JA. Minimizing cardiotoxicity while optimizing treatment efficacy with trastuzumab: review and expert recommendations. Oncologist. 2009;14:1–11.
Telli ML, Hunt SA, Carlson RW, Guardino AE. Trastuzumab-related cardiotoxicity: calling into question the concept of reversibility. J Clin Oncol. 2007;25:3525–33.
De Angelis A, Piegari E, Cappetta D, et al. Anthracycline cardiomyopathy is mediated by depletion of the cardiac stem cell pool and is rescued by restoration of progenitor cell function. Circulation. 2010;121:276–92.
Sharp III TE, George JC. Stem cell therapy and breast cancer treatment: review of stem cell research a potential therapeutic impact against cardiotoxicities due to breast cancer treatment. Front Oncol. 2014;4:299.
Oliveira MS, Carvalho JL, De Angelis Campo AC, et al. Doxorubicin has in vivo toxicological effects on ex vivo cultured mesenchymal stem cells. Toxicol Lett. 2014;224:380–6.
De Angelis A, Piegari E, Cappetta D, et al. SIRT1 activation rescues doxorubicin-induced loss of functional competence of human cardiac progenitor cells. Int J Cardiol. 2015;189:30–44.
Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev. 2012;8, CD008465. doi:10.1002/14651858.
Ascensão A, Oliveira PJ, Magalhães J. Exercise as a beneficial adjunct therapy during doxorubicin treatment. Role of mitochondria in cardioprotection. Int J Cardiol. 2012;156:4–10.
Marques-Aleixo I, Santos-Alves E, Mariani D, et al. Physical exercise prior and during treatment reduces sub-chronic doxirubicin-induced mitochondrial toxicity and oxidative stress. Mitochondrion. 2015;20:22–33.
Scott JM, Khakoo A, Mackey JR, Haykowsky MJ, Douglas PS, Jones LW. Modulation of anthracycline-induced cardiotoxicity by aerobic exercise in breast cancer: current evidence and underlying mechanisms. Circulation. 2011;124:642–50.
Jones L, Dolinsky VW, Haykowsky MJ, et al. Effects of aerobic training to improve cardiovascular function and prevent cardiac remodeling after cytotoxic therapy in early breast cancer. AACR 2011; abstract 5024.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Daniela Cardinale, Gina Biasillo, and Carlo Maria Cipolla declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Cardio-Oncology
Rights and permissions
About this article
Cite this article
Cardinale, D., Biasillo, G. & Cipolla, C.M. Curing Cancer, Saving the Heart: A Challenge That Cardioncology Should Not Miss. Curr Cardiol Rep 18, 51 (2016). https://doi.org/10.1007/s11886-016-0731-z
Published:
DOI: https://doi.org/10.1007/s11886-016-0731-z