J Cardiovasc Ultrasound.  2018 Mar;26(1):1-25. 10.4250/jcu.2018.26.1.1.

Diagnosis, Treatment, and Prevention of Cardiovascular Toxicity Related to Anti-Cancer Treatment in Clinical Practice: An Opinion Paper from the Working Group on Cardio-Oncology of the Korean Society of Echocardiography

• Kim H
• Chung WB
• Cho KI
• Kim BJ
• Seo JS
• Park SM
• Kim HJ
• Lee JH
• Kim EK
• Youn HJ

• KMID: 2407677
• DOI: http://doi.org/10.4250/jcu.2018.26.1.1

Abstract

Cardiovascular (CV) toxicity associated with anti-cancer treatment is commonly encountered and raises critical problems that often result in serious morbidity or mortality. Most cardiac toxicities are related to the cumulative dose of chemotherapy; however, the type of chemotherapy, concomitant agents, and/or conventional CV risk factors have been frequently implicated in CV toxicity. Approximately half of the patients exhibiting CV toxicity receive an anthracycline-based regimen. Therefore, serologic biomarkers or cardiac imagings are important during anti-cancer treatment for early detection and the decision of appropriate management of cardiotoxicity. However, given the difficulty in determining a causal relationship, a multidisciplinary collaborative approach between cardiologists and oncologists is required. In this review, we summarize the CV toxicity and focus on the role of cardiac imaging in management strategies for cardiotoxicity associated with anti-cancer treatment.

Keyword

Cardiovascular toxicity; Cardio-oncology; Anti-cancer treatment; Echocardiography

MeSH Terms

Biomarkers
Cardiotoxicity
Diagnosis*
Drug Therapy
Echocardiography*
Humans
Mortality
Risk Factors
Biomarkers

Figure

• 

  Fig. 1 Flow chart of surveillance and diagnosis of cardiac toxicity in breast cancer treatment. For pretreatment evaluation of breast cancer, conventional and CV risk factors should be assessed. In case of absence of risk factors, anti-cancer treatment could be proceeded. For surveillance of cardiac toxicity, cardiac biomarkers such as NT-proBNP or Tn-I may be useful at each chemotherapeutic cycle, and echocardiography is also required regularly according to the drugs. However, if risk factor is present, echocardiography (or CMR imaging) would be necessary for cardiac function. Overall, LV dysfunction or myocardial injury with elevated Tn-I can be managed with BB, ACEIs/ARBs, or statin. CV: cardiovascular, NT-proBNP: N-terminal pro-B-type natriuretic peptide, Tn-I: troponin-I, LV: left ventricle, CMR: cardiac magnetic resonance, BB: beta-blocker, ACEIs: angiotensin converting enzyme inhibitors, ARBs: angiotensin receptor blockers.

• 

  Fig. 2 Approach of LV dysfunction in diagnostic or therapeutic modalities. Baseline cardiac imaging for LV function can be performed using 2D-echocardiography (or contrast-/3D-echocardigraphy) or strain. In case of LV dysfunction, cardio-oncologic consultation is required, and the etiologies of LV dysfunction should be evaluated using appropriate imaging modalities, including CMR, CAG, SPECT, and cardiac CT. ECG: electrocardiography, BNP: B-type natriuretic peptide, NT-proBNP: N-terminal pro-B-type natriuretic peptide, Tn-I: troponin-I, 2D: two-dimensional, 3D: three-dimensional, CMR: cardiac magnetic resonance, LV: left ventricle, CT: computed tomography, CAG: coronary angiography, SPECT: singlephoton emission computed tomography.

• 

  Fig. 3 Flow chart of approach for cardiac dysfunction during breast cancer treatment. Treatment with BB, ACEIs/ARBs, or statin is required for LV dysfunction. According to the strain and LVEF using echocardiography, the risk-and-benefit for breast cancer treatment should be evaluated. If necessary, cancer treatment could be stopped for 4 weeks and re-evaluation of LV function is required using repeated echocardiography. Tn-I: troponin-I, BB: beta-blocker, ACEIs: angiotensin converting enzyme inhibitor, ARBs: angiotensin receptor blockers, LV: left ventricle, EF: ejection fraction, GLS: global longitudinal strain.

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