Cardiac monitoring and incidence of cardiotoxicity cardiomyopathy among breast cancer patients undergoing anthracycline regimen chemotherapy: insight from a single centre study
Anthracyclines remain a cornerstone of breast cancer therapy but carry a significant risk of cancer therapy-related cardiac dysfunction (CTRCD). This study evaluates the incidence of CTRCD in an Indonesian setting using the latest 2022 ESC Cardio-Oncology guidelines, focusing on subclinical markers such as high-sensitivity Troponin I (hs-cTnI), Global Longitudinal Strain (GLS) and Mechanical Dispersion (MD).
This retrospective analytical cohort study involved 98 breast cancer patients treated with anthracyclines at a national referral hospital in Indonesia from July 2018 to February 2020. Clinical assessments, hs-cTnI, and echocardiography (LVEF, GLS, and MD) were performed at baseline, 1, 3, and 6 months. CTRCD was defined per the 2022 ESC criteria.
CTRCD occurred in 74.5% of patients, predominantly as asymptomatic mild cases (63.26%). While symptomatic CTRCD was relatively low (7.14%), asymptomatic dysfunction was detected as early as one-month post-chemotherapy. A significant progressive decline was observed in LVEF (68.2 ± 6.2% to 61.3 ± 8.8%,
p
< 0.001) and GLS (-19.7 ± 2.9% to -17.1 ± 3.5%,
p
< 0.001). Notably, mechanical dispersion significantly increased over time (
p
= 0.029), and median hs-cTnI surged from 1.6 ng/L to 82.2 ng/L (
p
< 0.001) by month 6.
The high incidence of asymptomatic CTRCD underscores the inadequacy of relying on clinical symptoms alone. Integration of hs-cTnI, GLS, and mechanical dispersion monitoring is may be essential for early detection and enables timely cardioprotective intervention.
Cardiotoxicity associated with antineoplastic therapies remains an important clinical challenge in modern oncology. Early identification of subclinical cardiac injury may improve cardiovascular surveillance and long-term outcomes in cancer patients. This prospective observational cohort study included 90 adult patients with breast cancer, lymphoma, or lung cancer receiving potentially cardiotoxic therapy. Patients with clinically manifest heart failure, severe arrhythmias, advanced renal disease, recent acute myocardial infarction, untreated severe valvular disease, or other major cardiovascular comorbidities were excluded. High-sensitivity cardiac troponin T (hs-cTnT), NT-proBNP, and soluble ST2 (sST2) were measured at baseline, during treatment, at therapy completion, and at late follow-up. Non-parametric tests were used for repeated-measures and subgroup comparisons. Significant temporal variations were observed for all biomarkers. hs-cTnT increased from 5 [3–8] ng/L at baseline to 15 [10–25] ng/L at T2, while NT-proBNP increased from 120 [80–190] pg/mL to 210 [150–320] pg/mL. sST2 demonstrated a delayed elevation and remained increased at follow-up. Distinct biomarker patterns were observed across malignancy subgroups, with higher hs-cTnT increases in breast cancer, more prominent NT-proBNP elevation in lymphoma, and higher sST2 values in lung cancer. Serial biomarker assessment may provide complementary information on myocardial injury, ventricular stress, and fibrotic remodeling during cancer therapy. The observed biomarker trajectories are suggestive of different biological processes involved in therapy-related cardiotoxicity, but they should be interpreted in conjunction with imaging findings and clinical outcomes.
L. Kajanto, D. Stănculeanu, Anca Chisoi et al.· Cardio-Oncology· 0 citations
The results showed that MWI behaves similarly to GLS, suggesting that combining the two methods—MWI and GLS—may enhance the detection of cardiotoxicity.
R. M. Figueiredo De Sousa, V. Fonseca, C. Azevedo et al.· European Heart Journal, Supp...· 0 citations
GLS and LVEF were the most sensitive echocardiographic parameters for differentiating between groups with and without cardiotoxicity, showing consistent changes throughout the study.
R. D. De Sousa, V. Fonseca, M. Henriques et al.· European Heart Journal, Supp...· 0 citations
It is suggested that survivors treated with anthracyclines require systematic surveillance and targeted interventions to address modifiable cardiovascular risk factors and increasing awareness of prior cardiotoxic cancer treatment among survivors and health care providers may facilitate cardiovascular risk reduction.
Vigdís H Viggósdóttir, H. Helgason, Helga Jónsdóttir et al.· Journal of pediatric hematol...· 0 citations
Pembrolizumab combined with anthracycline-based chemotherapy has become standard neoadjuvant treatment for early triple-negative breast cancer (TNBC). However, concerns persist regarding potential additive cardiotoxicity. Prospective real-world data on early cardiac safety of this combination remain limited.
To prospectively evaluate early cancer therapy–related cardiac dysfunction (CTRCD) in patients with early TNBC treated according to the KEYNOTE-522 protocol, using the 2022 ESC cardio-oncology definitions.
Consecutive patients with early TNBC receiving neoadjuvant pembrolizumab combined with taxane–carboplatin followed by anthracycline-based chemotherapy were prospectively enrolled. Cardiac monitoring included serial transthoracic echocardiography with left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), electrocardiogram (ECG), and serial measurements of high-sensitivity cardiac troponin I (hs-cTnI) and NT-proBNP prior to the start of anthracyclines administration, at the completion of NACT and at 3 months and 12 months after the end of anthracycline therapy. CTRCD was defined according to ESC criteria.
Fifty-eight patients were included (mean age 54 years). One patient died from cancer progression and was censored from follow-up. Overall, 32 of 57 patients (56.1%) fulfilled the primary endpoint, predominantly driven by biomarker-defined cardiotoxicity. Two patients (3.5%) experienced symptomatic heart failure during the initial phase of treatment with paclitaxel, carboplatin, and pembrolizumab and therefore did not receive anthracyclines. Moderate asymptomatic CTRCD occurred in 2 patients (3.5%) with concomitant LVEF and GLS decline, while 4 patients (7.0%) developed mild CTRCD with isolated GLS reduction. No patient developed symptomatic heart failure during or after anthracycline therapy. Significant hs-cTnI elevation was observed in 17.5% of patients, with 80% occurring during anthracycline administration. NT-proBNP elevations were frequent, resulting in a 49.1% incidence of mild cardiotoxicity according to HFA-ICOS criteria. No cases of myocarditis, acute coronary syndrome, arrhythmia, or atrioventricular block were identified.
In this prospective real-world cohort, with near-complete echocardiographic follow-up (97.8% of planned echocardiographic assessments in patients treated with anthracyclines), the addition of pembrolizumab to anthracycline-based neoadjuvant chemotherapy was not associated with increased early cardiotoxicity. Biomarker elevations were common but rarely translated into functional cardiac impairment, supporting the short-term cardiac safety of pembrolizumab when managed within a structured cardio-oncology surveillance program.
A. Besnard, A. Patsouris, L. Bière et al.· European Heart Journal, Supp...· 0 citations
Anthracycline and Human Epidermal Growth Factor Receptor 2 (HER2) targeted therapy may induce cancer therapy-related cardiac dysfunction (CTRCD). Current guidelines recommend risk stratification using the Heart Failure Association–International Cardio-Oncology Society (HFA-ICOS) risk assessment tool. However, data on the incidence of CTRCD in contemporary breast cancer populations treated according to current standard-of-care regimens remain limited. Moreover, the actual cardiovascular risk associated with the HFA-ICOS risk categories in breast cancer treatment remains uncertain. Real-world evaluation of whether this consensus-based stratification appropriately separates patients according to subsequent CTRCD risk has been highlighted as a key research priority.
Overall, the study aims to determine the incidence of CTRCD and to evaluate cardiovascular risk stratification using the HFA-ICOS tool and its association with subsequent CTRCD.
CARE is a prospective observational study including women scheduled for (neo)adjuvant anthracycline therapy and/or HER2-targeted therapy. Echocardiography, using standard and novel echocardiographic parameters, and circulating cardiac biomarkers were assessed at baseline (visit 1), after completion of scheduled therapy (visit 2), and 12 months after completion of scheduled therapy (visit 3). Participants were categorized into three treatment regimen groups: 1) Anthracycline therapy only, 2) HER2-targeted therapy only, and 3) HER2-targeted therapy sequentially to anthracyclines (Figure 1). The primary outcome is incidence of CTRCD. Secondary outcomes include HFA-ICOS risk stratification in relation to subsequent CTRCD.
In total, 515 women (median age (Q1,Q3): 53 (45,64) years) were included. Overall, 335 (63%) participants received anthracycline therapy only, 100 (15%) received HER2-targeted therapy only, and 80 (19%) received anthracycline therapy followed by HER2-targeted therapy. Baseline cardiovascular risk factors included hypertension in 20%, current smoking in 13%, diabetes in 7%, and a history of heart disease in 7.6%, while 3.5% had received previous anti-cancer treatment (Table 1).
The CARE study is a large prospective observational cardio-oncology study evaluating the incidence of CTRCD after contemporary breast cancer therapy regimens. With systematic echocardiographic and biomarker assessment, the study will provide important insights into the incidence of CTRCD, the performance of the HFA-ICOS risk stratification tool and follow-up strategies in routine cardio-oncology care.Table 1Baseline Characteristics CARE Figure 1Consort Diagram
V. Vinje, E. Orstad, G. Gulati et al.· European Heart Journal, Supp...· 0 citations