Implementing Cardioprotective Strategies for Patients Undergoing Cancer Treatment

Cancer therapies are improving patients’ lifespans, but they are also leaving patients with more comorbid cardiovascular risk factors that need to be managed appropriately. There are several cardioprotective strategies to implement when treating patients with cancer during their treatment and into survivorship, explained Aaron Adkisson, PharmD, ambulatory clinical pharmacist, cardio-oncology/general cardiology, University of Kentucky.

This transcript has been lightly edited for clarity.

Transcript

How can cardio-oncology management be incorporated into broader treatment for patients?

That's a good question. You know, there are several cardioprotection strategies that can be implemented. For example, if we're thinking about patients who are treated with doxorubicin, we have several different ways that we can help manage their heart failure if they were to progress to actually clinically overt heart failure. But let's say that they don't have that. Let's say that they are getting a high dose of doxorubicin, a high total lifetime dose around 250 mg/m² of body surface area. We can initiate therapy such as dexrazoxane that is an iron chelating agent. It's an iron chelator that reduces free radical generation caused by doxorubicin. And there's been plenty of good data to show that it reduces incidence of clinical cardiac events and incidence of heart failure. Also, it does not negatively impact your important oncologic outcomes like progression-free survival.

Then we also have other agents, for example, in a patient treated with doxorubicin, we can use medication such as atorvastatin. That's a new one that has hit cardio-oncology and this is something that a general practitioner definitely can start in one of these patients. Not even just in my cardio-oncology practice, this is something that I'll recommend in my general cardiology practice, as well. If we were to have a patient who had exposure to doxorubicin in the past—say they had around, again, 250 mg/m² body surface area total lifetime dose—I'll recommend to go ahead and start atorvastatin 40 mg. That's based off the STOP-CA trial.¹ We saw a reduction in incidence of worsening cardiac function in patients treated with doxorubicin and receiving atorvastatin.

Then, this kind of applies broadly to a lot of areas of cardioprotection, but let's say in our breast cancer patients, if they were to also receive trastuzumab, which is a HER2 inhibitor, we can initiate other cardioprotective therapies such as β-blockers like carvedilol or metoprolol succinate and then ACE [angiotensin-converting enzyme] inhibitors and ARBs [angiotensin receptor blockers]. If we were to start those in a patient treated with trastuzumab, we can allow for what we call “permissive cardiotoxicity,” and if a patient were to present with a reduced ejection fraction and they were concerned about worsening of that ejection fraction, we could start these therapies. There have been studies that show that whenever you start these therapies, we are able to continue the trastuzumab without having to hold it, without having any dose-limiting cardiotoxicities, that kind of thing.

Reference

1. Neilan TG, Quinaglia T, Onoeu T, et al. Atorvastatin for anthracycline-associated cardiac dysfunction: the STOP-CA randomized clinical trial. JAMA. 2023;330(6):528-536. doi:10.1001/jama.2023.11887