Chemotherapy-Associated Cardiotoxicity: A Silent Threat Evidenced in a Retrospective Cohort Study

Abstract

Introduction: At present, cancer represents one of the main causes of mortality both globally and in Colombia, with a growing trend that could position it as the leading cause of death shortly, surpassing other diseases of great health impact. Cardiotoxicity associated with antineoplastic treatments can manifest itself at different times, either during the administration of chemotherapy or sometime after its completion, becoming evident only when clinical complications such as heart failure have developed. Therefore, it is essential to use diagnostic tools to identify patients at greater risk of developing cardiotoxicity associated with administering chemotherapeutic agents.

Methods: We conducted a descriptive observational cohort study, which included patients over 18 years of age with an active diagnosis of cancer, both of hematological or nonhematological origin, who were treated in a university hospital in Colombia between 2016 and 2019.

Results: One hundred ninety-seven patients were included, with a mean age of 53. During follow-up, 20 patients (10%) developed cardiotoxicity, with an incidence density of 3.64% person-months. Dyslipidemia was the most prevalent comorbidity (45%), followed by arterial hypertension (28.7%). Non-Hodgkin's lymphoma was the most frequent oncologic diagnosis (40.3%), with an incidence of cardiotoxicity of 13%. Patients exposed to anthracyclines had a higher incidence of cardiotoxicity (11.8%) compared to those not exposed (5.7%), with a relative risk of 2.074 (95% confidence interval = 1.91-2.24). The left ventricular ejection fraction was significantly lower in patients with cardiotoxicity (55.3%) compared to those without cardiotoxicity (62.1%) (p = 0.029).

Conclusions: Taking into account the usefulness of echocardiography and the use of biomarkers found in this study and referred to in the literature, we can determine that these studies, far from being routine, are one of the main strategies that the clinician has to favor the early and timely identification of those patients who are developing a cardiotoxic effect; therefore, it is essential to include these tools in the algorithms of care as a model of serial monitoring. This is not only to reduce the incidence of cardiotoxicity but also as part of an integral management of the oncologic patient to increase the efficiency of pharmacological treatment and improve the quality of life of the patients treated in the short, medium, and long term.

Keywords: cardio-oncology; cardiotoxicity; chemotherapy; heart failure; left ventricular dysfunction; myocardial injury.

Figure 1. Incidence of cardiotoxicity

Data are presented as a percentage Total number of patients: n = 197. Yes: 20 patients (10%). No: 177 patients (90%)

Figure 2. Distribution by gender and type of oncologic diagnosis

n represents the number of nonmissing values

Figure 3. Relationship between ages/cardiotoxicity and oncologic diagnosis

Data are presented as a percentage. n is the number of nonmissing values

Figure 4. Oncologic diagnoses and cardiotoxicity

The numbers below each bar represent the absolute frequency (n) of patients without (left) and with (right) cardiotoxicity for each diagnosis category

Figure 5. Cumulative incidence and incidence density in anthracycline cardiotoxicity

Figure 6. Oncospecific therapy and cardiotoxicity

The numbers below each bar represent the absolute frequency (n) of patients without (left) and with (right) cardiotoxicity for each treatment category

Figure 7. Scatterplot smoothing LVEF/cardiotoxicity

LVEF: left ventricular ejection fraction