Doxorubicin cardiotoxicity: Prevention of congestive heart failure with serial cardiac function monitoring with equilibrium radionuclide angiocardiography in the current era

Abstract

Background. Congestive heart failure (CHF) is among the most serious toxicities of doxorubicin, a potent cancer chemotherapeutic agent. Serial left ventricular ejection fraction (LVEF) monitoring during doxorubicin therapy for preventing CHF was proposed over 20 years ago. The current utility and cost-effectiveness of this approach in the present era are not known. Methods and Results. Clinical and follow-up data of 265 patients with cancer (age, 53 ± 14 years; 76% women) undergoing doxorubicin chemotherapy with serial equilibrium radionuclide angiocardiography (ERNA) monitoring (≥2 studies) were analyzed retrospectively. Patients with a normal baseline LVEF (≥50%) and a 10% or greater point fall in LVEF to a final value of less than 50% during doxorubicin therapy were considered “at risk” for CHF (n = 41). Over 679 ± 426 days of follow-up, 7 patients (2.6%) had CHF develop and 90 (34%) died (all cancer-related deaths, with none due to CHF). A comparison of “at-risk” (n = 41 [15%]) and “low-risk” (n = 224 [85%]) groups showed a higher incidence of CHF (12% vs 0.9%, P < .0001), lower baseline LVEF (58% ± 8% vs 64% ± 8%, P < .0001), lower value for the lowest LVEF (42% ± 8% vs 57% ± 7%, P < .0001), and higher rate of cancer-related deaths (59% vs 29%, P = .0003) in the former despite similar cumulative doxorubicin dose (304 ± 124 mg/m 2 vs 284 ± 110 mg/m 2, P = not significant). There were no differences in age, gender, cancer type, and co-morbidity. Cost analysis showed the overall cost of ERNA studies to be lower than the 1-year cost of caring for additional cases of CHF that would potentially be prevented by routine LVEF monitoring. Conclusions. An incipient fall in LVEF detected on serial ERNA during doxorubicin therapy provides an appropriate and cost-effective approach for predicting and preventing impending CHF. Use of this approach was associated with a low incidence of CHF (2.6%) and no CHF-related mortality in this study. (J Nucl Cardiol 2003;10:132-9)