Abstract
With progressive advancements in cancer detection and treatment, cancer-specific survival has improved dramatically over the past decades. Consequently, long-term health outcomes are increasingly defined by comorbidities such as cardiovascular disease. Importantly, a number of well-established and emerging cancer treatments have been associated with varying degrees of cardiovascular injury that may not emerge until years following the completion of cancer treatment. Of particular concern is the development of cancer treatment related cardiac dysfunction (CTRCD) which is associated with an increased risk of heart failure and high risk of morbidity and mortality. Early detection of CTRCD appears critical for preventing long-term cardiovascular morbidity in cancer survivors. However, current clinical standards for the identification of CTRCD rely on assessments of cardiac function in the resting state. This provides incomplete information about the heart's reserve capacity and may reduce the sensitivity for detecting sub-clinical myocardial injury. Advances in non-invasive imaging techniques have enabled cardiac function to be quantified during exercise thereby providing a novel means of identifying early cardiac dysfunction that has proved useful in several cardiovascular pathologies. The purpose of this narrative review is (1) to discuss the different non-invasive imaging techniques that can be used for quantifying different aspects of cardiac reserve; (2) discuss the findings from studies of cancer patients that have measured cardiac reserve as a marker of CTRCD; and (3) highlight the future directions important knowledge gaps that need to be addressed for cardiac reserve to be effectively integrated into routine monitoring for cancer patients exposed to cardiotoxic therapies.
Highlights
Cancer-related survival has improved substantially over the past few decades due to advances in early detection and improved treatment regimens [1]
It is important to note that there is limited evidence demonstrating that the prevention of early cancer treatment related cardiac dysfunction (CTRCD) translates into reduced risk heart failure in the long term. This highlights the need for long-term studies the trajectory of CTRCD to heart failure events, and the need to provide a comprehensive assessment of cardiac function and heart failure risk that can account for transient changes in cardiac function that could result from acute side effects of cancer treatment such as anemia and hypotension
Recent work from our laboratory has shed some light on the evolution of cardiac reserve impairment in breast cancer patients undergoing anthracycline chemotherapy using exercise cardiac magnetic resonance imaging (exCMR) [154, 155]. In this series of studies, we found that exercise stroke volume tended to be lower shortly following anthracycline chemotherapy (P = 0.06) [155], over the following 12-months this evolved into a blunted augmentation of left-ventricular ejection fraction (LVEF) and SV during exercise, resulting in a reduction in peak exercise cardiac output (CO) [154]
Summary
Cancer-related survival has improved substantially over the past few decades due to advances in early detection and improved treatment regimens [1]. Of particular concern is an increased risk of cardiovascular disease, most notably amongst breast and hematologic cancer survivors [6, 7] This occurs due to a direct cardiovascular injury induced by a number of cancer treatments, alongside the indirect insults from common cardiovascular risk factors which can be exacerbated following a cancer diagnosis [8, 9]. These cardiotoxic effects can present as hypertension, heart rhythm disorders, thromboembolic events, ischemic heart disease, cardiac dysfunction, and heart failure [8, 10]. This highlights the need for long-term studies the trajectory of CTRCD to heart failure events, and the need to provide a comprehensive assessment of cardiac function and heart failure risk that can account for transient changes in cardiac function that could result from acute side effects of cancer treatment such as anemia and hypotension
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