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Heart Failure and Chemotherapy (Patient Case #903)


A 74-year-old female is referred to cardiology prior to multi-agent chemotherapy for breast cancer (resected, with lymph involvement). Doxorubicin is one of the agents. Her baseline LVEF is 45%, but she is asymptomatic. Is the doxorubicin absolutely contraindicated or can it be used based on risk-vs-benefit? Which cardioprotective strategies are used for patients undergoing anthracycline chemotherapy?


HEALTHCASTS COMMUNITY RESPONSE

Total respondents:   60

Case assessed:       January 2020

BACKGROUND

Doxorubicin is an anthracycline chemotherapy drug. It is used to decrease and/or stop the growth of cancerous cells by blocking topo isomerase 2. Use of doxorubicin can result in myocardial damage as cumulative doses of doxorubicin >350 mg/m2 can be harmful to the heart. On average the left ventricular ejection fraction (LVEF) should be between 50% and 70%. The patient’s baseline LVEF of 45% is considered low, which increases the risk of heart failure.

CONTRAINDICATED OR RISK-VS-BENEFIT?

The majority of Healthcasts community respondents (77%) agreed that the use of doxorubicin for this patient is not contraindicated. 20% of respondents who did not specify if doxorubicin was contraindicated advised against using it in this case, suggesting alternative treatment options. Less than 2% of respondents felt doxorubicin is absolutely contraindicated in this scenario.  

CARDIOPROTECTIVE STRATEGIES

There are three distinct types of doxorubicin-induced cardiotoxicity (acute, chronic, and late-onset). Although most respondents agreed that prescribing doxorubicin is not contraindicated for this patient, they advised that different cardioprotective therapy agents be administered prophylactically in conjunction with the doxorubicin to prevent cardiotoxicity.

Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), beta blockers, diuretics and chemo protection drugs were all suggested.


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