Journal Wrap

The hottest research from various peer-reviewed journals – handpicked weekly by the ACC.org Editorial Board led by Kim A. Eagle, MD, MACC.

CARDIOTOX Registry Finds Further Research Needed to Guide Anticancer Therapy-Induced Cardiotoxicity

Due to the lack of uniform diagnostic criteria to guide clinical practices in cardiotoxicity and cancer therapies, comprehensive cardiovascular monitoring may be critical to identify and treat heart failure risk factors and preclinical left ventricular dysfunction when needed, according to a study published in the European Heart Journal.

José López-Sendón, MD, et al., used data from the CARDIOTOX registry to determine the prevalence of common clinical, biochemical and echocardiographic parameters currently accepted as indicative of cardiotoxicity and identified after initiation of cancer therapies, as well as their relationship with heart failure criteria and treatment recommendations in current guidelines.

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The researchers studied 865 patients scheduled for anticancer therapy related to moderate or high risk of cardiotoxicity. Cardiotoxicity was defined as new or worsening of myocardial damage or ventricular function from baseline during a median of 24 months follow-up.

Results showed that cardiotoxicity was identified in 37.5% patients during follow-up – 31.6% with mild, 2.8% moderate and 3.1% with severe myocardial damage or dysfunction. Results also showed the mortality rate in the severe cardiotoxicity group was 22.9 deaths per 100 patient-years vs. 2.3 deaths per 100 patient-years in the mild and moderate groups.

The researchers point out that while a significant number of patients receiving high-risk cancer therapies present objective data of myocardial injury or left ventricular dysfunction, the number of patients with severe cardiotoxicity is comparatively very low but still strongly related with all-cause mortality.

"We propose a classification of cardiotoxicity that could be used in protocols defining strategies for early identification, prevention and treatment in patients receiving potentially cardiotoxic cancer therapies," the researchers write.

In an accompanying editorial comment, Ana Pardo Sanz, MD, and Jose´ Luis Zamorano, MD, note that "the next goal is to establish the relationship of different grades of cardiotoxicity and the clinical outcomes."

They add, "The elaboration of a clinical score to determine the risk of severe cardiotoxicity and, according to this, refine the follow-up and treatment of these patients, will be the key of the cardio-oncology field for the present and near future."


López-Sendón J, Álvarez-Ortega C, Auñon PZ, et al. Eur Heart J 2020;41:1720-9.

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Use of PTXD in PAD Patients Associated With Increased Mortality

In patients with symptomatic femoropopliteal peripheral artery disease (PAD), there is an absolute 4.6% increased morality risk associated with the use of paclitaxel-containing device (PTXD) use compared with balloon angioplasty at a median four-year follow-up, according to a study published in Circulation.

Krishna J. Rocha-Singh, MD, et al., performed an individual patient data (IPD) meta-analysis to evaluate mortality in PAD patients treated with PTXD. The authors sought to conduct an IPD meta-analysis after a recent aggregate-data meta-analysis reported increased late mortality in patients treated with PTXD. The study used de-identified IPD from manufacturers of U.S. Food and Drug Administration-approved and commercially available devices in the U.S.

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The authors of the study identified 2,185 patients of whom 1,382 were assigned to PTXD and 803 to control. There were 386 deaths from eight PTXD trials with a four-year median follow-up. The primary analysis showed a 38% relative increase in mortality for PTXD relative to control, corresponding to a 4.6% absolute increase at five years associated with PTXD.

With inclusion of recovered vital status data, the excess relative mortality risk was 27%. Exploratory analyses identified no paclitaxel drug dose-mortality relationship. The analysis did not identify a specific cause of death as being particularly responsible for the overall increase in mortality.

"Despite [the] contrary data from large population studies, safety in coronary trials, and established drug safety for systemic use [of PTXD], the issue of risk versus benefit must be considered given the increased mortality we are reporting," write the authors.

"Nevertheless, some patients may prefer gains in quality of life and reduced revascularization procedures even at the expense of potentially increased mortality risk."


Rocha-Singh KJ, Duval S, Jaff, MR, et al. Circulation 2020;May 6:[Epub ahead of print].

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LEADERS FREE: Sex-based Analysis of High Bleeding Risk, Post PCI Long-Term Outcomes

Women with high bleeding risk should not be denied the benefits of PCI when indicated and bleeding avoidance strategies should be uniformly adopted for all patients, especially in women, according to a study publish in JAMA Cardiology.

Using data from the LEADERS FREE trial, Roxana Mehran, MD, FACC, et al., sought to assess the two-year outcomes by sex in patients with high bleeding risk. This cohort study was conducted at 68 sites in 20 countries, and included 2,432 patients with high bleeding risk and a mean age of 75 years.

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Results showed that women and men had similar incidence of the two-year primary and efficacy endpoints. The drug-coated stent was found to be superior to the bare-metal stent in both sexes, with lower target lesion revascularization (women, 6.3% vs. 12.1%; men, 7.0% vs. 12.0%) and similar rates of the primary safety endpoint (women, 12.4% vs. 17.0%; men, 12.6% vs. 14.5%).

Furthermore, the researchers found that two-year major bleeding was not statistically different between the sexes, but women experienced greater major bleeding within the first 30 days and greater vascular access site major bleeding than men.

In both sexes, the researchers discovered that vascular and nonvascular major bleeding were associated with greater two-year mortality.

"We used a broad definition of high bleeding risk, but this analysis was the first sex-based subanalysis in patients with a high bleeding risk enrolled in a randomized clinical trial," the authors write.

"Thus, it provides detailed sex-based descriptions of baseline demographic characteristics and long-term outcomes up to two years with a drug-coated stents or bare-metal stent PCI and one month of DAPT."


Mehran R, Chandrasekhar J, Urban P, et al. JAMA Cardiol 2020;May 20:[Epub ahead of print].

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Keywords: ACC Publications, Cardiology Magazine, Paclitaxel, Cardiotoxicity, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Cohort Studies, Prevalence, Follow-Up Studies, Risk Factors, United States Food and Drug Administration, Neoplasms, Angioplasty, Balloon, Coronary, Angioplasty, Balloon, Echocardiography, Ventricular Dysfunction, Left, Registries


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