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Transition to Stage B Heart Failure After Chemotherapy
Study Questions:
What percentage of patients undergoing potentially cardiotoxic chemotherapy develop left ventricular (LV) systolic dysfunction (stage B) or clinical heart failure (stages C and D)?
Methods:
This single-center study recruited 144 outpatients without known heart failure who were to receive potentially cardiotoxic chemotherapy. Patients were not limited to a specific type of malignancy or chemotherapeutic agent. Enrolled participants underwent cardiac magnetic resonance imaging (CMR) prior to initiation of chemotherapy, and at 3, 6, 12, and 24 months after treatment. Quality of life was assessed at each visit. LV dysfunction was defined as an ejection fraction (LVEF) by CMR <50% or an absolute drop of 10% down to LVEF <53%.
Results:
At 3 months post-therapy, 19% of participants had evidence of LV dysfunction, a proportion that increased to 30% at 6 months. However, at 24 months, only 22% of participants were classified as stage B heart failure. On average, the LVEF had declined from 61% at baseline to 57% at 12-24 months. Of those receiving anthracyclines alone and in combination with trastuzumab, 22% and 33%, respectively, had a decrease in LVEF by 3 months. None of the participants had progressed to clinical heart failure (stages C and D) throughout the study. Prior treatment with angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, beta-blockers, or statin was not associated with LVEF, and patients with preserved LVEF at 3 months tended to maintain their cardiac function by 24 months. With the exception of smoking, traditional risk factors were not associated with the occurrence of LV dysfunction. Quality-of-life scores did not correlate with a change in LVEF.
Conclusions:
A substantial proportion of patients undergoing potentially cardiotoxic chemotherapy develop LVEF dysfunction, albeit without clinical heart failure.
Perspective:
This study’s strength lies in the systematic use of CMR as an accurate and precise technique for assessing LVEF, and highlights the significant short-term impact chemotherapy has on LVEF. Given the small, highly heterogeneous cohort, with relatively short follow-up, it is impossible to derive other conclusions including long-term implications, as the overall decrease in LVEF was mild and none of the participants progressed to clinical HF during the study period. Further studies are needed to justify the use of CMR as a screening and monitoring modality for chemotherapy-induced cardiomyopathy.
Keywords: Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Anthracyclines, Antineoplastic Agents, Cardiomyopathies, Cardiotoxicity, Diagnostic Imaging, Heart Failure, Heart Valve Diseases, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Magnetic Resonance Imaging, Neoplasms, Quality of Life, Risk Factors, Smoking, Stroke Volume
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