Dr Salah Mabrouk Assiut university South Egypt Cancer Institute Tel (202) 01004081234 email: salahmab76@yahoo.com

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‫للشاعر إبراهيم علي بديوي ) سوداني (‬

2. Chemotherapy
Induced
Cardotoxicity
By
Salah Mabrouk
Assisstant lecturer of
Medical Oncology
SECI, Assiut University

3. Definition of cardotoxicity
Chemotherapy induced cardotoxicity
– Anthracyclines
Epidemiology Pathogenesis
Risk factors Stages
Diagnosis Prevention
Treatment
– Non-anthracyclines
Incidence Pathogenesis
Risk factors Diagnosis
Prevention &Treatment
Radiotherapy induced cardotoxicity

4. Definition of cardiac toxicity
Damage to the heart muscle by a toxin that may
cause arrhythmias (changes in heart rhythm) or
cardiomyopathy and heart failure.

5. Anthracyclines
Epidemiology
•First recognized: Mid to late 1970’s
•Incidence : 18-65%
•Mortality >20%

6. Anthracyclines
The most well-known is doxorubicin
(Adriamycin®).
Other anthracyclines are:
– Epirubicin (farmarubicin®)
– Daunorubicin (Cerubidine®)
– Idarubicin (Idamycin®)
– Mitoxantrone

7. Pathogenesis

8. Pathogenesis
Multiple mechanisms appear to be involved
1. Free Radical formation:
–Enzymatic reaction in mitochondria.
–Non-enzymatic reaction with Iron.
2. Cytochrome C release apoptotic signal.
3. Fewer antioxidant defenses, highly oxidative
metabolism.
4. Anthracycline affinity for cardiolipin, results in drug
accumulation.
5. Genetic polymorphisms in NAD(P)H oxidase and
Doxorubicin efflux transporters

9. I- Free radical formation
A- Enzymatic reaction in mitochondria
Quinone
Amino
residue
Sugar
residue

10. I- Free radical formation
Enzymatic reaction in mitochondria
Anthracyclines might undergo redox activation* through their interaction
with several flavoprotein oxidoreductases
This semiquinone can rapidly auto-oxidize using molecular oxygen (O2) as an electron acceptor,
returning to the parent compound which is then available for a new redox cycle.
This reaction leads to the formation of superoxide anion (O2−),
Driven by superoxide dismutases (SOD), or spontaneously in acidic pH,
superoxide anion is converted into hydrogen peroxide (H2O2)
which, in the presence of traces of transition metals such as iron or copper,
will be converted to the very reactive oxidizing species, hydroxyl radical (HO).

11. I- Free radical formation
B- Non-enzymatic reaction with Iron
Anthracyclines can directly form complexes with
ferrous iron displaced from its sites of storage
within the cell.
These complexes are apt to generate ROS in
the presence or the absence of reducing
components.

12. • Free radicals
– Molecules containing an odd number of electrons
• H2O2, hydroxyl radicals
– Are highly reactive and damaging to tissues such as proteins, lipids, and
nucleic acids, leading to modifications that are more likely to have an effect on
the nucleus, the sarcoplasmic reticulum, or the mitochondria – cellular
organelles that are in close proximity to the site of generation of ROS
– Are countered by antioxidants and by intracellular enzymes (flavoenzyme)
The heart is predisposed to oxidative stress because of relatively low levels of
antioxidant enzymes
Mitochondria are particularly susceptible to free radical damage

13. Cytochrome C release apoptotic signal.
Apoptosis hypothesis for the cardiotoxicity of anthracyclines.
Apaf-1, Apoptotic protease activating factor-1;
TNF/FAS-R, tumor necrosis factor/Fas receptor.

14. Risk factors

15. Risk factors for anthracycline-induced cardiotoxicity
Treatment related
Cumulative dose of anthracycline
Dosing schedules
Previous anthracycline therapy
Radiation therapy
Co-administration of additional potentially cardiotoxic agents
Patient related
Age
Preexisting cardiovascular disease or cardiac risk factors
(hypertension, diabetes, increasing total cholesterol, Obesity and
Smoking)
Gender, female sex.

16. Treatment related risk factors
1- Cumulative dose
• Can occur at any dose
• Highly variable
–Serious adverse effects may occur with small
dose
–>no adverse effects with very high dose
• The standard cumulative doses
Doxorubicin : 450–550 mg/m2
Epirubicin : 900–1000 mg/m2, why???

17. Induction Treatment Of AML
Cumulative doses of anthracyclines
•ADR & DNR: - 450 mg/m 2 if CP A
is a ls o give n.
- 550 mg/m 2 if not.
•Ida rubicin: 75 mg/m 2 .
•Mitoxa ntrone : 140 mg/m 2 .

19. Doxorubicin versus Epirubicin cumulative doses
on a mg/m2 basis, Epirubicin is less cardiotoxic than
doxorubicin, and can, therefore, be administered at
higher cumulative doses (up to a total of 900 mg/m2
versus a total of 450 mg/m2 for doxorubicin before
cardiotoxicity limits further therapy).
However, to achieve the same clinical benefit as
doxorubicin, epirubicin tends to be given at 25–50%
higher doses, which potentially negates the
advantages of any higher cumulative dose threshold.
van Dalenet al, Cochrane Database Syst Rev (2006)

20. Treatment related risk factors
2- Dosing schedule
• Single large dose > smaller, frequent dosing
• The dose every 3 weeks > weekly doses
• Bolus injection (peak levels) > continuous
infusion

21. Treatment related risk factors
3- History of mediastinal irradiation
• Amplifies preexisting CAD
• Exacerbation of vascular injury
• Pericardial effusion
• Pericardial fibrosis (restrictive disease)
• Myocardial fibrosis (valvular disease)
4-Administration of other cardiotoxic medications
(cyclophosphomides, actinomycin D, bleomycin,
cisplatin, methotraxate, trastuzumab)

22. Patient related risk factors
Cumulative probability of developing doxorubicin-induced chronic heart failure [27]
1- Age of patient
Barrett-Lee, P. J. et al. Ann Oncol 2009 0:mdn728v1-728; doi:10.1093/annonc/mdn728

23. Patient related risk factors
2- Preexisting cardiovascular disease or cardiac
risk factors
Hypertension
Diabetes
increasing total cholesterol)
Obesity
Smoking

24. Patient related risk factors
3- Gender, female sex.
Controversy?????

25. Clinical manifestation, stages

26. Type I and Type II Treatment-Related Cardiotoxicity
Type I
– Cumulative-dose related
– Irreversible (cell death)
– Typical biopsy changes
– Doxorubicin is the model
Type II
– Not cumulative-dose related
– Largely reversible (cell dysfunction)
– Absence of anthracycline-like biopsy changes
– Trastuzumab is the model

27. Clinical manifestation, stages
Acute cardiotoxicity
ECG changes and Arrhythmias
Subacute cardiotoxicity
Pericarditis (infrequent)
Myocarditis (infrequent)
Chronic cardiotoxicity
Contractile dysfunction
Heart failure

28. Stages
• Acute Toxicity
– Rare
– Directly connected with the administration of a
single dose or after a course of the antibiotic
• Often asymptomatic and rarely fatal
• Synergistic action between drug and
hypokalemia
• Tends to be reversible, and usually transient.
• Result of an autonomic defect

29. ECG CHANGES AND ARRHYTHMIAS
Occur during or within 24 hours of doxorubicin administration.
The most common ECG abnormalities reported are
1. Nonspecific ST-T wave changes
2. Decreased QRS voltage
3. Sinus tachycardia
4. Supraventricular tachyarrhythmia
5. Premature ventricular and atrial contractions
6. T-wave abnormalities
7. QT interval prolongation
8. Rarely, sudden death and life-threatening ventricular arrhythmias

30. • Subacute Toxicity
– Occurs days to weeks post treatment
– Rare and often asymptomatic
– Includes
1. Toxic pericarditis
2. Toxic Myocarditis

31. Chronic Cardiotoxicity
Include:
1. Contractile dysfunction (CHRONIC CARDIOMYOPATHY)
2. Heart failure
This is the most severe form of doxorubicin
cardiotoxicity
Cardiomyopathy is DOSE-RELATED.
Morphologic damage increases progressively
with increasing doses

32. Diagnosis and monitoring
Clinical picture
Electrocardiogram (ECG)
Echocardiogram
Laboratory markers
• Troponin I & T
• B-type natriuretic peptide (BNP)
Cardiac biopsy
Multi Gated Acquisition (MUGA) scan

33. Echocardiography
Benefits
Provides a wide spectrum of information on cardiac
morphology and function
Does not expose patients to ionising radiation
Tissue Doppler imaging may improve detection of systolic and
diastolic dysfunction
Limitations
Image quality limits use in some patients
LVEF measurements time consuming and operator dependent
Not sensitive for the early detection of preclinical cardiac
disease
Both FS( fractional shortening ) and LVEF are affected by
preload and afterload

34. Echocardiography
Nousiainen: Eur J Haematol, 62:135-141, 1999

35. Biomarkers
1. Cardiac troponin I (TnI&T), a contractile protein in the
myocardium.
2. B-type natriuretic peptide (BNP), cardiac hormone
Benefits
Troponin is a highly specific and sensitive biomarker
for detection of myocardial damage
Potentially useful screening tool
It can be used to predict, at a very early stage, the
development of future ventricular dysfunction, as well
as its severity .
Limitation
Data regarding clinical value are limited

36. Magnetic resonance imaging
Benefit
Valuable tool to assess myocardial function and
damage
Limitations
High costs of repeated examinations
Limited availability

37. Computed tomography
Benefits
Image quality similar to magnetic resonance
imaging with Lower cost
Limitations
High radiation dose
Limited availability

38. Scintigraphy
Benefit
Sensitive method to detect myocyte damage
in patients after doxorubicin therapy
Limitation
Larger prospective trials required to ascertain
potential role

39. Multiple uptake gated acquisition scan (MUGA scan)
Benefits
Well-established and well-validated method to
determine ejection fraction
Can also assess regional wall motion and diastolic
function (nonstandard)
Limitations
No information on valve function
LVEF measurements are not sensitive for the early
detection of preclinical cardiac disease

40. Endomyocardial biopsy
• Microscope Changes
1– Mitochondrial defects
2– Diminished cardiac myocyte calcium handling properties
3– Decreased vascularization
4– Apoptosis
5– Fibrosis causing increased cardiac stiffness

41. Endomyocardial biopsy
Benefits
Provides histological evidence of cardiotoxicity
Limitations
Invasive
Small sample of myocardium tested

42. Prevention

43. Prevention
1. Screening for risk factors and prevention of cardiac
events
2. Dose limitation(< 550mg /m2 )
3. Dosing Schedules modification
4. Use different forms of athracyclines that cause less
cardiotoxicity (Liposomal preparations)
5. Use agents to prevent the cardiotoxicity
6. Use cardioprotective agent (Dexrazoxane)

44. Screening for risk factors and prevention of
cardiac events
Assess for preexisting cardiac risk factors
Reduce cardiac risk
LVEF assessment:
1. ≤ 30%→Don’t give anthracyclines.
2. 30%–50%→ give with monitoring of LVEF .
3. ≥ 50% →repeat evaluation at 250–300 mg/m2 and
again at 450 mg/m2 cumulative dose:
• A 10% decrease in LVEF or a drop from ≥ 50% to ≤ 50% or from
30%–50% to ≤ 30% → stop anthracyclines

45. Dose limitation
keep the total lifetime cumulative dose below
the recommended threshold.
– 550 mg/m2 for doxorubicin
– 900 mg/m2 for epirubicin.
– When combined with paclitaxel, the cumulative
doxorubicin dose should not exceed 360 mg/m2,
and doxorubicin should be given before paclitaxel.

46. Dosing Schedules
It should be as possible in:
• Smaller, frequent dosing
• Weekly doses
• Continuous infusion, controversy???

47. Liposomal preparations of
athracyclines
Figure : Liposomes –
(left) = aqueous soluble drug encapsulated in aqueous compartment; (centre)
= a hydrophobic drug in the liposome bilayer;
(right) C = hydrophilic polyoxyethylene lipids incorporated into liposome

48. Figure : Accumulation of liposomes within solid tumours —
(left) liposomes in normal tissue
(right) liposome extravasation from the disorganised
tumour vasculature

49. There are two formulations of liposomal
anthracyclines:
1. Nonpegylated.
2. Pegylated.
N.B. : Peg =polyethylene glycol
Non-toxic and non-immunogenic
Hydrophilic (aqueous-soluble)
Highly flexible – provides for surface treatment or
bioconjugation

50. Types of liposomal anthracyclines include:
– Liposomal daunorubicin (DaunoXome®)
– Pegylated liposomal doxorubicin
(Doxil® or Caelyx ®)
Pegylated liposomal doxorubicin has shown a
similar anti-cancer effect to doxorubicin, but
with less cardiac toxicity.

51. Liposomal preparations of athracyclines
(Caelyx®)
Liposomes are preferentially taken
up by tissues enriched in phagocytic
reticuloendothelial cells
In many trials, it appears to be as
effective as standard doxorubicin
Side effects:
mucositis and palmoplantar
erythrodysesthesia

52. Cardioprotective agent
(Dexrazoxane= Cardioxane®)
Dexrazoxane is an oral iron chelator
It prevents the formation of the semiquinone-iron
which leads to reactive oxygen production
It has been tested in multiple clinical trials and has
been shown to reduce cardiac toxicity
The recommended dosage ratio of
dexrazoxane:doxorubicin is 10:1; doxorubicin should
be given within 30 minutes of giving dexrazoxane

53. Dexrazoxane

54. Anthracycline Cardiotoxicity : Effects of Different Drugs, Scheduling,
and Cardiac P rotection with Dexrazoxane
15
Epirubicin 1000 mg/m2
4
Epirubicin < 900 mg/m2
Dauno 1000 mg/m2 12
Dauno 500 mg/m2 1.5
Doxo (400-499 mg/m2) + Dexrazoxane 1
Doxo low dose weekly > 600 mg/m2 5.4
Doxo bolus > 550 mg/m2 10
Doxo 1000 mg/m2 20
Doxo 500 mg/m2
7
0 5 10 15 20 25
CH (%)
F
Hensley M et al J Clin Oncol 1999; 17(10):3333-3355
L

55. ASCO Recommendations
Not recommended for initial therapy
Breast patients receiving more than 300
mg/m2 of doxorubicin
Consideration in patients with other
malignancies receiving more than 300 mg/m2
of doxorubicin

56. Dexrazoxane and response to
chemotherapy
Some data suggests that dexrazoxane may
decrease response to chemotherapy
One phase III trial published by Swain in
1997 showed a significant decrease in
response in the dexrazoxane group.
There has been no difference in overall
survival or progression free survival in this
trial

57. New prevention strategies
In addition to new biomarkers for risk stratification,
there are new potential approaches to prevention of
anthracycline cardiotoxicity.
These include
1. Angiotensin-converting enzyme (ACE) inhibitors
2. Angiotensin II receptor blockers (ARBs)
3. Carvedilol.

58. ACE inhibitors
They may prevent doxorubicin cardiotoxicity by reducing left
ventricular remodelling and limiting oxidative stress.
Troponin positive patients followed for 12 months subsequent to chemotherapy treatment
demonstrating a cardioprotective effect of enalapril as measured by preserved LVEF.
Orange boxes indicate patients with persistent troponin elevation and purple boxes are
troponin positive patients that returned to baseline

59. Angiotensin receptor blockers
ARBs have been found to have intrinsic
antioxidant and mediate a cardioprotection
Nakamae and colleagues found that valsartan
significantly reduced changes in the left
ventricular end-diastolic diameter.

60. Recovery of LV dysfunction with standard
HF therapy
Jensen, et al. Annals of Oncology. 2002. 13:499-709.

61. Carvedilol
Carvedilol blocks beta1, beta2 and alpha1
adrenoceptors and has potent antioxidant and anti-
apoptetic properties.
Early research in animals has shown that the use of
carvedilol can prevent chemotherapeutic
cardiotoxicity.
Kalay and associates conducted the first human
clinical trial investigating the prophylactic use of
carvedilol in this clinical setting.
Further large randomised trials are needed???

62. Non-anthracycline

63. ANTINEOPLASTIC AGENT MAJOR CARDIAC SIDE EFFECT INCIDENCE
Cyclophosphamide/ifosfamide Myocarditis, CHF 25%/17%
Paclitaxel/docetaxel Hypotension, hypertension, bradycardia, atrial 0.5%
and ventricular arrhythmia
Fluorouracil MI, angina, hypotension, coronary vasospasm 1.6%–68%
Rituximab Hypotension, hypertension, arrhythmia 25%
Arsenic trioxide QT prolongation, tachycardia 8%–55%
Trastuzumab CHF 7%–28%
Thalidomide Pulmonary hypertension Unknown
Etoposide MI, hypotension 1%–2%
Vinca alkaloids MI, autonomic cardioneuropathy 25%
Pentostatin MI, CHF, acute arrhythmia 3%–10%
Cytarabine Arrhythmia, pericarditis, CHF Unknown
Interferon (at high doses) Arrhythmia, dilated cardio- myopathy, ischemic Unknown
heart disease
Busulfan Endocardial fibrosis Unknown
Cisplatin Acute MI Unknown

64. 5-FLUOROURACIL (5-FU)
INCIDENCE: 1.6%–68%
Onset:
– in the first 72 hours of the initial treatment cycle
Risk factors
– Infusional administration
– concurrent radiotherapy
– pre-existing cardiac disease
Pathogenesis:
– coronary spasm

65. 5-FLUOROURACIL (5-FU)
Characteristics:
• The second most common
• Not dose related
• Clinically ranges from angina pectoris within
hours of a dose to myocardial infarction.
• Capecitabine (Xeloda), the oral prodrug of 5-
FU, is also reported to have similar cardiac
toxic effects.

66. 5-FLUOROURACIL (5-FU)
Prevention and management.
Careful clinical monitoring
Administration of 5-FU should be stopped immediately in
patients who develop a cardiac event.
These patients should not be retreated with this agent.
The role of prophylactic calcium channel blockers and
nitrates remains unclear.
Most patients respond to conservative antianginal
therapy and supportive care.

67. CYCLOPHOSPHAMIDE
Incidence:
• 25%
• The life-threatening incidence is 5% to 10% of patients.
Pathogenesis
– It causes cardiac necrosis, may be related to acrolein
– also cause ischemic cardiac toxicity.
Risk factors
– High dose regimens carry greater risk i.e after the use of
very high does (120-140mg/kg) in preparation for bone
marrow transplant.
– Prior treatment with anthracycline or mediastinal irradiation

68. Manifestation
Minor toxicities
– Minor ECG changes
• ST-T wave segment changes
• Supraventricular arrhythmias
– Pericarditis-with or without effusion
Severe toxicities:
– ECG voltage loss
– Progressive heart failure
– Pericarditis with or without tamponade
N.B,: Ifosfamide (Ifex) belongs to the same class of drugs and in one series is
reported to have had significant cardiotoxicity in 17% of patients treated with the drug

69. CYCLOPHOSPHAMIDE
Prevention and management.
There are no established guidelines.
Baseline MUGA scan or ECHO are done to measure left
ejection fraction prior to transplant (Exclusion criteria – EF <
50%)
Close clinical monitoring of patients for signs and symptoms of
congestive heart failure.
If suspect, further therapy should be stopped and a complete
evaluation, including ECG and an echocardiogram, performed to
assess LVEF.
These patients should be treated symptomatically for congestive
heart failure.
Repeat treatment with an alkylating agent can be instituted once
LVEF returns to ≥ 50%.

70. Vinca alkaloids, bleomycin, and cisplatin
Pathogenesis:
– Vasospasm, in addition to electrolyte wasting with cisplatin.
Manifestation:
– MI
– Arrhythmia with cisplatin
– Autonomic cardioneuropathy with Vinca alkaloids
– Raynaud phenomenon

71. Taxanes
Incidence : 0.5%
Pathogenesis:
– It may be related to the cremaphor vehicle in
paclitaxel
Manifestations:
– Hypotension
– Hypertension
– Atrial and ventricular arrhythmia sp. Bradycardia
– Myocardial infarction
Taxanes interfere with the metabolism and excretion
of anthracycline and potentiate its cardiotoxicity.

72. Taxanes
Prevention and management.
No risk factors; however, patients with underlying
cardiac disease should be clinically monitored
Asymptomatic bradycardia→ No any intervention.
neither be stopped nor the dose reduced in these
patients.
Symptomatic cardiac dysfunction → supportive ttt
Slow infusion of paclitaxel and doxorubicin or
increased time (24 h) between doxorubicin and
paclitaxel treatments decreased cardiotoxicity.
Newer paclitaxel formulations, such as nanoparticle
albumin-bound paclitaxel

73. Cardiotoxicity
Associated With Biologic
Agents

75. Trastuzumab
Incidence:
• 2% risk of developing cardiac dysfunction if
used alone
• Increased risk if given with doxorubicin and
cyclophosphosphamide (16-27%)
• Increased risk if given with paclitaxel (2-13%) •
Manifestation:
Cardiomyopathy
Arrythmias

76. Trastuzumab (Herceptin®)
• Risk factors for the cardiomyopathy:
􀂾 If given with doxorubicin
􀂾 If prior chest radiation therapy
􀂾 If diabetes
􀂾 If history heart valve disease
􀂾 If history heart artery disease
• In other words, risk if prior heart disease
• Not dose related.

77. Bird, B. R.J. H. et al. Clin Cancer Res 2008;14:14-24
Copyright ©2008 American Association for Cancer Research

78. Type Type I (myocardial damage) Type II (myocardial dysfunction)
Agent Doxorubicin Trastuzumab
Response May stabilize, but underlying
damage appears to be permanent High likelihood of recovery
to and irreversible; recurrence in
Therapy months or years may be related to
sequential cardiac stress
Dose Cumulative, dose related Not dose related
Free radical formation, oxidative Blocked ErbB2 signaling
Mechanism
stress/damage
Decreased ejection fraction by Decreased ejection fraction by
Cardiac ultrasound or nuclear ultrasound or nuclear determination:
testing determination: global decrease in global decrease in wall motion
wall motion
High probability of recurrent
Effect of dysfunction that is progressive, Increasing evidence for
Rechallenge may result in intractable heart the relative safety of rechallenge;
failure and death additional data needed
Effect of late
sequential High Low

79. Algorithm for continuation and discontinuation of trastuzumab based on
interval left ventricular ejection fraction (LVEF) assessments.

80. RITUXIMAB
Incidence: 25%
Include:
– Reversible or transient infusion-related hypotension
– Arrhythmia
– Acute myocardial infarction, ventricular fibrillation,
and cardiogenic shock.
Most of these reactions (80%) occur during the
first infusion and may be associated with a
cytokine-release phenomenon

81. RITUXIMAB
Prevention and management.
Discontinued in patients who develop significant
arrhythmia or other severe cardiotoxicity.
Careful monitoring during and after infusion is
warranted, especially in patients with pre-existing
cardiac disease.
It is recommended that patients avoid taking
antihypertensive medication the morning of rituximab
infusion and delay taking these drugs until all transient
cardiac side effects of rituximab have completely
resolved.

82. Sunitinib
Sunitinib caused mitochondrial injury
Release of cytochrome C
Caspase activation ATP depletion
Apoptosis Necrosis
LV
Myocyte loss dysfunction

83. Imatinib
Cardiac death, myocardial infarction, and
congestive heart failure
Hypertension
Fluid retention manifesting as pericardial effusion
Tachycardia
Hypotension
Flushing

84. Imatinib
ER stress response
JNK
BAX activation
Release of cytochrome C
Caspase activation ATP depletion
Apoptosis Necrosis
LV
Myocyte loss dysfunction

86. Nilotinib
QT prolongation ( 2.1%)
sudden death (0.6% )
Nilotinib prolongs the QT interval in a concentration-
dependent manner.
Rare
– myocardial ischemia
– atrial fibrillation
– pericardial effusion
– Cardiomegaly
– bradycardia

87. Dasatinib
Both pericardial effusions and cardiac
failure associated with dasatinib therapy
may be caused by similar mechanisms
to those associated with imatinib
arrhythmia and palpitations. Severe
pericardial effusions
QT prolongation

89. Bevacizumab
(Avastin®)
Heart Attacks and Chemotherapy
• May occur with bevacizumab (Avastin®)
􀂾 Antibody to VEGF (Vascular Endothelial Growth
Factor) Thus blocks new blood vessel growth.
Avastin can cause heart attacks, angina, CHF, high
blood pressure, strokes, and clots
Risk is 2%, especially if prior heart disease
Risk is 14%, if given together with doxorubicin

90. Bevacizumab (Avastin®)
• Heart toxicity can manifest as:
􀂾 Decreased muscle function (EF)
􀂾 Congestive heart failure
􀂾 Rhythm problems
􀂾 High blood levels of heart enzymes, such as troponin
T and troponin I
􀂾 High blood levels of heart hormones, such as BNP
􀂾 Inflammation of the pericardium
􀂾 Inflammation of the heart muscle

91. ARSENIC TRIOXIDE
Arsenic trioxide is a novel agent currently used in
various hematologic malignancies.
Incidence: 8-55%
It is associated with prolongation of the QT interval and
potentially serious cardiac arrhythmia.
Cardiotoxicity associated with arsenic trioxide is usually
acute and occurs during or immediately after infusion.
Hypokalemia or hypomagnesemia predisposes patients
to the cardiotoxic effects of arsenic trioxide.

92. Prevention and management.
A baseline ECG should be done before starting therapy to
assess the rhythm pattern and QT interval.
This monitoring should be repeated weekly during induction
and biweekly during consolidation.
If the QT interval is > 500 ms, the patient should be
evaluated for potential risk versus benefit with further
therapy.
Prior to each infusion, electrolytes should be checked and
corrected if low.
Recommended levels of potassium and magnesium are > 4
mEq/L and > 1.8 mg/dL, respectively.
Patients who develop cardiac symptoms should be
hospitalized with close cardiac monitoring and correction of
electrolytes.
Arsenic trioxide can usually be restarted once the QTc
interval is < 460 ms.

93. THALIDOMIDE
Thalidomide is an immunomodulatory agent currently
used in the treatment of multiple myeloma and other
malignancies.
It is rarely associated with any cardiovascular side
effects, but recently, pulmonary hypertension has
occurred in a patient receiving thalidomide .
Both symptoms and pulmonary pressure resolved
after cessation of thalidomide.
The exact etiology of this phenomenon remains
unclear. Patients typically complain of shortness of
breath and dyspnea on exertion.

94. THALIDOMIDE
Prevention and management.
High-resolution computed tomography (CT)
and D-dimer should be performed to rule out
pulmonary embolism.
Diagnosis is made by echocardiogram with
Doppler studies to assess pulmonary artery
pressure.
Further therapy with thalidomide should be
stopped, as this is a reversible phenomenon

95. MITOXANTRONE
Transient arrhythmias (7%)
Cardiac ischemia (5%)
Edema (10%)
Hypertension (4%) E
Congestive heart failure, cardiomyopathy (2.6%)

96. MITOXANTRONE
The recommended maximum cumulative dose of
mitoxantrone is 140 mg/m2
The cumulative dose is lower with prior
anthracycline therapy

97. Other drugs
Busulfan (Myleran):
Cardiac tamponade or endomyocardial
fibrosis
Bleomycin
Pulmonary fibrosis:

98. Radiation Therapy
• Factors that increase the risk of heart
damage:
1. 􀂾 Extent of the coronary arteries in the field
2. 􀂾 Total radiation dose
3. 􀂾 Radation dose per fraction
4. 􀂾 Anterior fields versus tangential fields
5. 􀂾 Patient age, especially under 20 years
6. 􀂾 Concomitant doxorubicin
7. 􀂾 Usual heart risk factors

99. Radiation Therapy
• Coronary artery disease
􀂾 Increased risk if combined with doxorubicin
• Pericarditis, acute or chronic
• Pericarditis and myocarditis
• Cardiomyopathy
• Diastolic dysfunction

100. Radiation Therapy
Recommendations for Radiation Therapy
• Use cardiac blocking during therapy
• Limit the concomitant use of doxorubicin
(although it can be used before or after)
• Minimize all other atherosclerotic risk factors