Current and emerging modalities for detection of cardiotoxicity in cardio-oncology

Abstract

Advancements in diagnostic tools and curative-intent therapies have improved cancer-specific survival. With prolonged survival, patients are now subject to increased aging and development of cardiovascular risk factors such that further improvements in cancer-specific mortality are at risk of being offset by increased cardiovascular mortality. Moreover, established and novel adjuvant therapies used in cancer treatment are associated with unique and varying degrees of direct as well as indirect myocardial and cardiovascular injury (i.e., cardiotoxicity). Current approaches for evaluating anticancer therapy-induced injury have limitations, particularly lack of sensitivity for early detection of subclinical cardiac and cardiovascular dysfunction. With emerging evidence suggesting early prevention and treatment can mitigate the degree of cardiotoxicity and limit interruption of life-saving cancer therapy, the importance of early detection is increasingly paramount. Newer imaging modalities, functional capacity testing and blood biomarkers have the potential to improve early detection of cardiotoxicity and reduce cardiovascular morbidity and mortality.

Keywords: anthracyclines; biomarkers; cardiotoxicity; chemotherapy; echocardiography; imaging; stress testing; trastuzumab.

Figure 1.. Cardiovascular disease and detection of cardiotoxicity in cancer.

A schematic representation describing the continuum of cancer treatment, subclinical cardiotoxicity and eventual development of overt cardiovascular disease, in particular, heart failure. Cancer occurs in the setting of the patient's baseline health and risk factors profile. With the administration of potentially cardiotoxic therapies, various surveillance diagnostic strategies may be adopted. Traditional and novel imaging, functional capacity testing and blood-based biomarker strategies have been assessed to detect cardiotoxicity. Once there is evidence of overt cardiac dysfunction (i.e., ACC/AHA stage B heart failure), imaging and blood-based biomarkers may also help to guide treatment. ↓: Decline; ACC/AHA: American College of Cardiology/American Heart Association; CV: Cardiovascular; LVEF: Left ventricular ejection fraction. Adapted with permission from [36].