Skip to main content
Download PDF

Right heart function deteriorates in breast cancer patients undergoing anthracycline-based chemotherapy

Echo Research & Practice volume 3, pages 79–84 (2016)Cite this article

Abstract

Background: Cardiotoxicity from anthracycline-based chemotherapy is an important cause of early and late morbidity and mortality in breast cancer patients. Left ventricular (LV) function is assessed for patients receiving anthracycline-based chemotherapy to identify cardiotoxicity. However, animal studies suggest that right ventricular (RV) function may be a more sensitive measure to detect LV dysfunction. The purpose of this pilot study was to determine if breast cancer patients undergoing anthracycline-based chemotherapy experience RV dysfunction.

Methods: Forty-nine breast cancer patients undergoing anthracycline-based chemotherapy at the Ottawa Hospital between November 2007 and March 2013 and who had 2 echocardiograms performed at least 3 months apart were retrospectively identified. Right atrial area (RAA), right ventricular fractional area change (RV FAC) and RV longitudinal strain of the free wall (RV LSFW) were evaluated according to the American Society of Echocardiography guidelines.

Results: The majority (48/49) of patients were females with an average age of 53.4 (95% CI: 50.1-56.7 years). From baseline to follow-up study, average LV ejection fraction (LVEF) decreased from 62.22 (95% CI: 59.1-65.4) to 57.4% (95% CI: 54.0-60.9) (P = 0.04). During the same time period, the mean RAA increased from 12.1 cm2 (95% CI: 11.1-13.0 cm2) to 13.8 cm2 (95% CI: 12.7-14.9 cm2) (P = 0.02), mean RV FAC decreased (P = 0.01) from 48.3% (95% CI: 44.8-51.74) to 42.1% (95% CI: 38.5-45.6%), and mean RV LSFW worsened from -16.2% (95% CI: -18.1 to -14.4%) to -13.81% (95% CI: -15.1 to -12.5%) (P = 0.04).

Conclusion: This study demonstrates that breast cancer patients receiving anthracycline-based chemotherapy experience adverse effects on both right atrial size and RV function. Further studies are required to determine the impact of these adverse effects on right heart function and whether this represents an earlier marker of cardiotoxicity.

References

  1. Carver JR, Shapiro CL, Ng A, Jacobs L, Schwartz C, Virgo KS, Hagerty KL, Somerfield MR, Vaughn DJ for the ASCO Cancer Survivorship Expert Panel 2007 ASCO Cancer Survivorship Expert Panel. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. Journal of Clinical Oncology 25 3991–4008. ((doi:10.1200/JCO.2007.10.9777)

    Article  CAS  Google Scholar 

  2. Suter TM, & Ewer MS 2013 Cancer drugs and the heart: importance and management. European Heart Journal 34 1102–1111. ((doi:10.1093/eurheartj/ehs181)

    Article  CAS  Google Scholar 

  3. Tanindi A, Demirci U, Tacoy G, Buyukberber S, Alsancak Y, Coskun U, Yalcin R, & Benekli M 2011 Assessment of right ventricular functions during cancer chemotherapy. European Journal of Echocardiography 12 834–840. ((doi:10.1093/ejechocard/jer142)

    Article  Google Scholar 

  4. Kharin SN, Krandycheva VV, Strelkova MV, Tsvetkova AS, & Shmakov DN 2012 Doxorubicin-induced changes of ventricular repolarization heterogeneity: results of a chronic rat study. Cardiovascular Toxicology 12 312–317. ((doi:10.1007/s12012-012-9172-0)

    Article  CAS  Google Scholar 

  5. Oliveira GH, Dupont M, Naftel D, Myers SL, Yuan Y, Tang WH, Gonzalez-Stawinski G, Young JB, Taylor DO, & Starling RC 2014 Increased need for right ventricular support in patients with chemotherapy-induced cardiomyopathy undergoing mechanical circulatory support: outcomes from the INTERMACS Registry (Interagency Registry for Mechanically Assisted Circulatory Support). Journal of the American College of Cardiology 63 240–248. ((doi:10.1016/j.jacc.2013.09.040)

    Article  Google Scholar 

  6. Ghio S, Gavazzi A, Campana C, Inserra C, Klersy C, Sebastiani R, Arbustini E, Recusani F, & Tavazzi L 2001 Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. Journal of the American College of Cardiology 37 183–188. ((doi:10.1016/S0735-1097(00)01102-5)

    Article  CAS  Google Scholar 

  7. Anavekar NS, Skali H, Bourgoun M, Ghali JK, Kober L, Maggioni AP, McMurray JJ, Velazquez E, Califf R, Pfeffer MA, et al. 2008 Usefulness of right ventricular fractional area change to predict death, heart failure, and stroke following myocardial infarction (from the VALIANT ECHO Study). American Journal of Cardiology 101 607–612. ((doi:10.1016/j.amjcard.2007.09.115)

    Article  Google Scholar 

  8. Plana JC, Galderisi M, Barac A, Ewer MS, Ky B, Scherrer-Crosbie M, Ganame J, Sebag IA, Agler DA, Badano LP, et al. 2014 Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 27 911–939. ((doi:10.1016/j.echo.2014.07.012)

    Article  Google Scholar 

  9. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, & Schiller NB 2010 Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. Journal of the American Society of Echocardiography 23 685–713. ((doi:10.1016/j.echo.2010.05.010)

    Article  Google Scholar 

  10. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, et al. 2015 Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 28 1–39. ((doi:10.1016/j.echo.2014.10.003)

    Article  Google Scholar 

  11. Gulati A, Ismail TF, Jabbour A, Alpendurada F, Guha K, Ismail NA, Raza S, Khwaja J, Brown TD, Morarji K, et al. 2013 The prevalence and prognostic significance of right ventricular systolic dysfunction in nonischemic dilated cardiomyopathy. Circulation 128 1623–1633. ((doi:10.1161/CIRCULATIONAHA.113.002518)

    Article  Google Scholar 

  12. Motoki H, Borowski AG, Shrestha K, Hu B, Kusunose K, Troughton RW, Tang WH, & Klein AL 2014 Right ventricular global longitudinal strain provides prognostic value incremental to left ventricular ejection fraction in patients with heart failure. Journal of the American Society of Echocardiography 27 726–732. ((doi:10.1016/j.echo.2014.02.007)

    Article  Google Scholar 

  13. Antoni ML, Scherptong RW, Atary JZ, Boersma E, Holman ER, van der Wall EE, Schalij MJ, & Bax JJ 2010 Prognostic value of right ventricular function in patients after acute myocardial infarction treated with primary percutaneous coronary intervention. Circulation Cardiovascular Imaging 3 264–271. ((doi:10.1161/CIRCIMAGING.109.914366)

    Article  Google Scholar 

  14. Grapsa J, Gibbs JS, Cabrita IZ, Watson GF, Pavlopoulos H, Dawson D, Gin-Sing W, Howard LS, & Nihoyannopoulos P 2012 The association of clinical outcome with right atrial and ventricular remodelling in patients with pulmonary arterial hypertension: study with real-time three-dimensional echocardiography. European Heart Journal Cardiovascular Imaging 13 666–672. ((doi:10.1093/ehjci/jes003)

    Article  Google Scholar 

  15. Raymond RJ, Hinderliter AL, Willis PW, Ralph D, Caldwell EJ, Williams W, Ettinger NA, Hill NS, Summer WR, de Boisblanc B, et al. 2002 Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. Journal of the American College of Cardiology 39 1214–1219. ((doi:10.1016/S0735-1097(02)01744-8)

    Article  Google Scholar 

  16. Nass N, McConnell MV, Goldhaber SZ, Chyu S, & Solomon SD 1999 Recovery of regional right ventricular function after thrombolysis for pulmonary embolism. American Journal of Cardiology 83 804–806. ((doi:10.1016/S0002-9149(98)01000-5)

    Article  CAS  Google Scholar 

  17. Zornoff LA, Skali H, Pfeffer MA, John Sutton M, Rouleau JL, Lamas GA, Plappert T, Rouleau JR, Moyé LA, Lewis SJ, et al. 2002 Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction. Journal of the American College of Cardiology 39 1450–1455. ((doi:10.1016/S0735-1097(02)01804-1)

    Article  Google Scholar 

  18. Anavekar NS, Skali H, Bourgoun M, Ghali JK, Kober L, Maggioni AP, McMurray JJ, Velazquez E, Califf R, Pfeffer MA, et al. 2008 Usefulness of right ventricular fractional area change to predict death, heart failure, and stroke following myocardial infarction (from the VALIANT ECHO Study). American Journal of Cardiology 101 607–612. ((doi:10.1016/j.amjcard.2007.09.115)

    Article  Google Scholar 

  19. Verhaert D, Mullens W, Borowski A, Popović ZB, Curtin RJ, Thomas JD, & Tang WH 2010 Right ventricular response to intensive medical therapy in advanced decompensated heart failure. Circulation Heart Failure 3 340–346. ((doi:10.1161/CIRCHEARTFAILURE.109.900134)

    Article  Google Scholar 

  20. Pirat B, McCulloch ML, & Zoghbi WA 2006 Evaluation of global and regional right ventricular systolic function in patients with pulmonary hypertension using a novel speckle tracking method. American Journal of Cardiology 98 699–704. ((doi:10.1016/j.amjcard.2006.03.056)

    Article  Google Scholar 

  21. La Gerche A, & Roberts TJ 2015 Straining the RV to predict the future. JACC: Cardiovascular Imaging 8 170–171. ((doi:10.1016/j.jcmg.2014.11.006)

    PubMed  Google Scholar 

  22. Park SJ, Park J-H, Lee HS, Kim MS, Park YK, Park Y, Kim YJ, Lee JH, Choi SW, Jeong JO, et al. 2015 Impaired RV global longitudinal strain is associated with poor long-term clinical outcomes in patients with acute inferior STEMI. JACC: Cardiovascular Imaging 8 161–169. ((doi:10.1016/j.jcmg.2014.10.011)

    PubMed  Google Scholar 

  23. Tandri H, Daya SK, Nasir K, Bomma C, Lima JA, Calkins H, & Bluemke DA 2006 Normal reference values for the adult right ventricle by magnetic resonance imaging. American Journal of Cardiology 98 1660–1664. ((doi:10.1016/j.amjcard.2006.07.049)

    Article  Google Scholar 

  24. Park JH, Negishi K, Kwon DH, Popovic ZB, Grimm RA, & Marwick TH 2014 Validation of global longitudinal strain and strain rate as reliable markers of right ventricular dysfunction: comparison with cardiac magnetic resonance and outcome. Journal of Cardiovascular Ultrasound 22 113–120. ((doi:10.4250/jcu.2014.22.3.113)

    Article  Google Scholar 

  25. Park JH, Park MM, Farha S, Sharp J, Lundgrin E, Comhair S, Tang WH, Erzurum SC, & Thomas JD 2015 Impaired global right ventricular longitudinal strain predicts long-term adverse outcomes in patients with pulmonary arterial hypertension. Journal of Cardiovascular Ultrasound 23 91–99. ((doi:10.4250/jcu.2015.23.2.91)

    Article  Google Scholar 

  26. Llesy SF, Milei J, Gonzalez Flecha BS, & Boveris A 1990 Myocardial damage induced by doxorubicins: hydrogenperoxide-initiated chemiluminescence and morphology. Free Radical Biology and Medicine 8 259–264. ((doi:10.1016/0891-5849(90)90071-P)

    Article  Google Scholar 

  27. Belham M, Kruger A, & Pritchard C 2006 The Tei index identifies a differential effect on left and right ventricular function with low-dose anthracycline chemotherapy. Journal of the American Society of Echocardiography 19 206–210. ((doi:10.1016/j.echo.2005.08.018)

    Article  Google Scholar 

  28. Cottin Y, Touzery C, Coudert B, Richebourg S, Cohen M, Toubeau M, Louis P, Wolf JE, & Brunotte F 1996 Diastolic or systolic left and right ventricular impairment at moderate doses of anthracycline? A 1-year follow-up study of women. European Journal of Nuclear Medicine 23 511–516. ((doi:10.1007/BF00833384)

    Article  Google Scholar 

  29. Yildirim A, Sedef Tunaoglu F, Pinarli FG, Ilhan M, Oguz A, Karadeniz C, Olguntürk R, Oguz D, & Kula S 2010 Early diagnosis of anthracycline toxicity in asymptomatic long-term survivors: dobutamine stress echocardiography and tissue Doppler velocities in normal and abnormal myocardial wall motion. European Journal of Echocardiography 11 814–822. ((doi:10.1093/ejechocard/jeq071)

    Article  Google Scholar 

Download references

Funding

Dr Girish Dwivedi is supported by a CIHR salary support award.

Author information

Authors and Affiliations

  1. Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Kevin Emery Boczar MD, Ian G. Burwash MD FRCPC & Girish Dwivedi DM PhD (UK) MRCP (UK)

  2. Department of Medicine (Oncology), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada

    Olexiy Aseyev MD PhD, Jeffrey Sulpher MD FRCPC & Susan Dent MD FRCPC

  3. Department of Medicine (Cardiology), The Ottawa Hospital, Ottawa, Ontario, Canada

    Christopher Johnson MD FRCPC & Michele Turek MD FRCPC

Authors
  1. Kevin Emery Boczar MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Olexiy Aseyev MD PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jeffrey Sulpher MD FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christopher Johnson MD FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ian G. Burwash MD FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michele Turek MD FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Susan Dent MD FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Girish Dwivedi DM PhD (UK) MRCP (UK)
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Girish Dwivedi DM PhD (UK) MRCP (UK).

Rights and permissions

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Boczar, K.E., Aseyev, O., Sulpher, J. et al. Right heart function deteriorates in breast cancer patients undergoing anthracycline-based chemotherapy. Echo Res Pract 3, 79–84 (2016). https://doi.org/10.1530/ERP-16-0020

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-16-0020

Echo Research & Practice

ISSN: 2055-0464

Contact us