Successful treatment of doxorubicin-induced cardiomyopathy with low-dose sacubitril/valsartan: a case report

Abstract

Background: Cancer therapy-related cardiac dysfunction (CTRCD) is a challenging and life-threatening complication of many chemotherapeutic regimens. CTRCD prevention, diagnosis, and therapy require both careful interdisciplinary assessment and management. For patients with CTRCD, current guidelines of the European Society of Cardiology (ESC) recommend an angiotensin-converting-enzyme inhibitor in combination with a beta-blocker. Recent studies indicate a beneficial effect of sacubitril/valsartan in this patient population.

Case summary: A 68-year-old female patient with a pleural epithelioid angiosarcoma developed heart failure with reduced ejection fraction and elevated serum biomarkers following doxorubicin treatment. After implementation of a recommended cardioprotective medical therapy including torasemide, ramipril, carvedilol, and spironolactone, the patient suffered two cardiac decompensations within 4 weeks after initiation of a paclitaxel regimen and pleural radiation therapy due to pain exacerbation. Despite a continuous application of the cardioprotective medical treatment regimen, no improvement of left-ventricular ejection fraction (LVEF) was detected in a 4-month follow up. Interestingly, after omitting ramipril and implementing low-dose sacubitril/valsartan (26/24 mg), we observed a decrease in serum biomarkers within 3 months as well as a significant improvement of LVEF within 6 months. After nearly 10 months of disease stabilization under paclitaxel, the patient suffered progressive cancer disease and deceased 1 week later after the initiation of a therapeutic attempt with pazopanib.

Discussion: This case report highlights the importance of interdisciplinary care in cancer patients as well as the promising role of (low-dose) sacubitril/valsartan in patients with CTRCD even in the setting of delayed initiation.

Keywords: Cardio-oncology; Cardiotoxicity; Cardiovascular imaging; Case report; Doxorubicin; Sacubitril/valsartan.

Figure 1

Cardiac magnetic resonance imaging demonstrating dilatation of both ventricles as well as a highly reduced left-ventricular ejection fraction of 17% left-ventricular end-diastolic volume: 187 mL, left-ventricular end-systolic volume: 156 mL. (A) Four-chamber view, diastole. (B) Four-chamber view, systole. (C) Short-axis view, diastole. (D) Short-axis view, systole.