Anthracycline-induced cardiotoxicity: A case report and review of literature

Table 1 Strategies to mitigate selected modifiable risk factors associated with anthracycline-induced cardiotoxicity

Risk factor	Risk-reduction strategy
Hypertension	Lifestyle modification and pharmacologic control
Diabetes	Lifestyle modification and pharmacologic control
Dyslipidemia	Lifestyle modification and pharmacologic control
Smoking	Smoking cessation
Coronary artery disease	Lifestyle modification and pharmacologic control
Obesity	Lifestyle modification and weight management

Table 2 Monitoring and prevention strategies for anthracycline-induced cardiotoxicity

Method	Description
Biomarkers	Serial measurement of troponin and brain natriuretic peptide
Imaging studies	Regular monitoring of left ventricular function with echocardiogram or cardiac MRI
Pharmacologic agents	Concurrent use of dexrazoxane (for patients receiving doxorubicin ≥ 250 mg/m2 or epirubicin ≥ 600 mg/m2)
Administration strategies	Limiting total dose of anthracycline therapy
	Continuous infusion
	Divided doses
	Liposomal formulation

MRI: Magnetic resonance imaging.

Table 3 Selected ongoing randomized adult clinical trials on the pharmacological prevention of anthracycline-induced cardiotoxicity

Trial No./phase/name	Patient (n) and selection	Randomization schema	Primary endpoint
NCT02236806/Phase III/Cardiotoxicity prevention in breast cancer patients treated with anthracyclines and/or trastuzumab (SAFE)	480 non-metastatic breast cancer receiving anthracycline-based regimens with or without trastuzumab	2 × 2 factorial design. Arm 1: Bisoprolol plus ramipril; Arm 2: Bisoprolol plus placebo; Arm 3: Ramipril plus placebo; and Arm 4: Placebo	Maximum change in left ventricular ejection fraction at months 6, 9, 12 and 24, compared to baseline
NCT03265574/Phase III/Can we prevent chemotherapy-related heart damage in patients with breast cancer? (PROACT)	170 breast cancer receiving epirubicin-based adjuvant chemotherapy	Open-label comparing enalapril versus standard care	Cardiac troponin T release during epirubicin treatment
NCT03760588/Phase II/Prevention of cardiac dysfunction during breast cancer therapy (PRADAII)	300 breast cancer receiving anthracycline-based adjuvant chemotherapy	Double-blinded comparing LCZ696 (neprilysin inhibitor plus angiotensin receptor blocker) versus placebo	Left ventricular ejection fraction at 18 mo
ISRCTN24439460/Phase II/Can heart muscle injury related to chemotherapy be prevented? (cardiac CARE)	168 breast cancer or non-Hodgkin’s lymphoma with elevated troponin I level during anthracycline-based chemotherapy	Open-label comparing carvedilol plus candesartan versus standard care	Left ventricular ejection fraction at 6 mo
NCT02943590/Phase II/Statins to prevent the cardiotoxicity from anthracyclines (STOP-CA)	300 newly diagnosed non-Hodgkin’s lymphoma receiving doxorubicin-based regimens	Double-blinded comparing atorvastatin versus placebo	Left ventricular ejection fraction at 12 mo
NCT01988571/Phase II/Preventing anthracycline cardiovascular toxicity with statins (PREVENT)	279 breast cancer receiving anthracycline-based adjuvant chemotherapy	Double-blinded comparing atorvastatin versus placebo	Left ventricular ejection fraction at 24 mo