Table 1.
Strategies to reduce anthracycline-induced chemotherapy.9
| CARDIOPROTECTIVE STRATEGY |
Limit cumulative dose (mg/m2)
|
| Alter administration (continuous infusion) |
| Use fewer cardiotoxic anthracycline analogues (epirubicin, idarubicin, and mitoxantrone) |
| Choose lipossomal formulations |
| Administer cardioprotective drugs (discussed in “Prevention” section) |
Figure 1.
Sequential levels of troponin I during chemotherapy treatment.43
Table 2.
A summary of the most important clinical trials in primary prevention of cardiotoxicity.16,40–47 LVEF: left ventricular ejection fraction
| STUDY | PATIENTS | CHEMOTHERAPY REGIMEN | CARDIOPROTECTIVE DRUG | PRIMARY OUTCOME | FOLLOW-UP (MONTHS) |
|---|---|---|---|---|---|
| Cardinale44 2006 | 114 | Epirubicin | Enalapril | Cardiotoxicity incidence: | 12 |
| Idarubicin | Control: 43% | ||||
| Daunorubicin | Enalapril: 0% | ||||
| P < .001 | |||||
| Kalay40 2006 | 50 | Doxorubicin | Carvedilol | LVEF change pre/post chemotherapy: | 6 |
| Epirubicin | Placebo: 68.9%/52.3%; P < .001 | ||||
| Carvedilol: 70.5%/69.7%; P = .30 | |||||
| Georgakopoulos45 2010 | 125 | Doxorubicin | Metoprolol | No difference in cardiotoxicity | 12 |
| Enalapril | P = .55 | ||||
| Bosch46 2013 | 201 | Idarubicin | Carvedilol | Mean change in LVEF reduction (%): | 6 |
| Daunorubicin | Enalapril | Control: −3.28 | |||
| Enalapril + Carvedilol: −0.17% | |||||
| P = .04 | |||||
| Kaya41 2013 | 45 | Doxorubicin | Nebivolol | LVEF change pre/post chemotherapy: | 6 |
| Epirubicin | Placebo: 66.6%/57.5%; P = .001 | ||||
| Nebivolol: 65.6%/63.8%; P = .50 | |||||
| Gulati42 2016 | 126 | Epirubicin | Metoprolol | Mean change in LVEF reduction (%): | 6 |
| Candesartan | Placebo: −2.6 | ||||
| Candesartan: 0.8; P = .026 | |||||
| Metoprolol: −1.6%; P = .77 | |||||
| Pituskin16 2017 | 94 | Trastuzumab | Bisoprolol | Mean change in LVEF reduction (%): | 12 |
| Perindopril | Placebo: 5% | ||||
| Perindopril: 3% | |||||
| Bisoprolol: −1 % | |||||
| P = .01 | |||||
| Avila43 2018 | 200 | Doxorubicin | Carvedilol | No change in LVEF | 6 |
| P = .84 | |||||
| Guglin47 2019 | 468 | Trastuzumab | Lisinopril | Cardiotoxicity rate: | 12 |
| Carvedilol | Placebo: 32% × lisinopril 30%, carvedilol 29% | ||||
| P = .27, P = .35 |