Treating the oncology patient with cardiotoxicity is becoming an increasing issue for clinicians. Therapies are needed for both primary and secondary prevention. In this video, Aarti Asnani, MD, a cardiologist from Beth Israel Deaconess hospital in Boston, discusses some of the treatments and evidence for therapy in these patients.
The following is a transcript of her remarks:
Targeting Mechanisms
For primary prevention, thinking about a patient who's at high risk for cardiac toxicity, it's still not clear that we have strategies that target the mechanisms of cardiac toxicity that we can use to help prevent cardiotoxicity. Much of the work has focused so far on the use of beta blockers and ACE [angiotensin-converting enzyme] inhibitors or ARBs [angiotensin II receptor blockers], and these tend to be the ones we reach for currently for primary prevention in a high-risk patient. However, we still need the large randomized controlled trials to show that these agents are effective for primary prevention in this population.
Proven Therapies
For patients at high risk for cardiotoxicity, much of what we have at our disposal comes from the medications that have been proven to be effective in other types of heart failure - - for instance, heart failure with reduced ejection fraction such as beta blockers, ACE inhibitors. Many of these therapies also have some preclinical data to support their use in, for instance, anthracycline cardiotoxicity.
Evidence Lacking
We're still lacking the large randomized controlled clinical trials to assess the efficacy of these agents in large populations, and there have been smaller trials looking at high-risk patients - - for instance, patients with aggressive lymphoma - - that have suggested some benefit from the use of these strategies. At this point, it still comes down to a detailed conversation with the patient and the cancer treatment team, and really the importance of having a cardiology evaluation proactively before cancer treatment for patients who are at particularly high risk of cardiotoxicity.
Anthracyclines and Trastuzumab
For patients undergoing treatment with anthracyclines and trastuzumab, at present, we still don't have the data to support the use of cardioprotection, and this typically includes beta blockers and ACE inhibitors. We still don't have the data to support their use in all comers. One of the active areas of research in this field is to identify patients who are at high risk. They're seeing increasing attention paid to the use of "omics" technologies and new biomarkers of early cardiotoxicity and predilection of cardiotoxicity that will help inform our future strategies to incorporate primary prevention and cardioprotective strategies in this population.
Neurohormonal Agents
For patients who develop cancer therapy-induced cardiotoxicity, we tend to reach for the neurohormonal agents that we use in other types of LV [left ventricular] systolic dysfunction , beta blockers, ACE inhibitors. There have been small studies looking at these patient populations showing that early initiation of these medications is beneficial. These studies suggest that the earlier they're started upon the development of cardiac toxicity, the more likely patients are to recover their LV function.
As with many areas in cardio-oncology, we need larger randomized control trials to really address this question, but most cardio-oncologists tend to incorporate beta blockers, ACE inhibitors, ARBs early on when there's a sign of cardiac toxicity.