Prevention and management of anthracycline cardiotoxicity
- Tomas G Neilan, MD
Tomas G Neilan, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Aarti Asnani, MD
Aarti Asnani, MD
- Harvard Medical School
- Debasish Tripathy, MD
Debasish Tripathy, MD
- Professor and Chair, Department of Breast Medical Oncology
- The University of Texas MD Anderson Cancer Center
- Marielle Scherrer-Crosbie, MD, PhD
Marielle Scherrer-Crosbie, MD, PhD
- Professor of Medicine
- Division of Cardiology
- University of Pennsylvania
- Section Editors
- Stephen S Gottlieb, MD
Stephen S Gottlieb, MD
- Section Editor — Heart Failure
- Professor of Medicine
- University of Maryland School of Medicine
- Harold Burstein, MD, PhD
Harold Burstein, MD, PhD
- Section Editor — Breast Cancer
- Associate Professor of Medicine
- Harvard Medical School
- Richard A Larson, MD
Richard A Larson, MD
- Editor-in-Chief — Hematology
- Section Editor — Leukemia
- Professor of Medicine
- University of Chicago Pritzker School of Medicine
The anthracyclines and related compounds (doxorubicin, daunorubicin, idarubicin, epirubicin, and the anthraquinone mitoxantrone) are among the chemotherapeutic agents implicated in cardiotoxicity. Anthracycline therapy is associated with an increase in the risk for developing heart failure with significant associated morbidity and mortality . While anthracyclines are associated with increased risk of cardiomyopathy, they are also important components of many chemotherapy regimens.
Management of anthracycline-induced cardiotoxicity will be reviewed here. The mechanism, clinical manifestations, monitoring, and diagnosis of anthracycline-induced cardiotoxicity and cardiovascular complications of other classes of chemotherapy agents are discussed separately. (See "Clinical manifestations, monitoring, and diagnosis of anthracycline-induced cardiotoxicity" and "Cardiotoxicity of nonanthracycline cancer chemotherapy agents" and "Cardiotoxicity of trastuzumab and other HER2-targeted agents".)
Approach to prevention — Optimum preventive management of cardiotoxicity requires a multidisciplinary approach with close collaboration between the treating oncologist, internist, and cardiologist. Limited data from small trials are available to guide prevention and management of cardiotoxicity.
Based on the limited data available and our clinical experience, we suggest the following approach. All patients should receive a baseline clinical cardiovascular assessment, including physical examination and an echocardiogram prior to initiation of anthracyclines. Although guidelines have not included baseline electrocardiogram in their recommendations, some UpToDate contributors find it helpful to obtain a baseline electrocardiogram to compare with future studies, in the event of new-onset cardiac signs or symptoms.
The decision to use an anthracycline is based on the baseline cardiac function, overall health status, and the availability of equivalent non-anthracycline-based alternative regimens. The baseline assessment is also used to identify patients proceeding with anthracycline therapy who should receive neurohormonal inhibition. (See "Clinical manifestations, monitoring, and diagnosis of anthracycline-induced cardiotoxicity", section on 'Approach to baseline assessment and monitoring' and "Adjuvant chemotherapy for HER2-negative breast cancer", section on 'Acceptable alternatives to anthracycline-based treatment' and "Adjuvant systemic therapy for HER2-positive breast cancer", section on 'Nonanthracycline-based therapy' and "Initial treatment of advanced stage diffuse large B cell lymphoma", section on 'Patients with cardiac disease'.)
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- PREVENTIVE MANAGEMENT
- Approach to prevention
- General measures
- Modification of anthracycline chemotherapy
- Cardioprotective strategies
- - Neurohormonal inhibition
- Beta blockers
- Angiotensin inhibitors
- Combined beta blockade and angiotensin inhibition
- - Investigational therapy
- ROLE OF CARDIOLOGY CONSULTATION
- MANAGEMENT OF HEART FAILURE OR SUBCLINICAL CARDIAC DYSFUNCTION OCCURRING AFTER TREATMENT INITIATION
- Approach to new LV systolic dysfunction or heart failure
- Management of anthracycline-induced heart failure
- - Treatment
- - Follow-up
- Management of subclinical dysfunction
- - Treatment
- Our approach
- Approaches of others
- - Follow-up
- SUMMARY AND RECOMMENDATIONS