ABC | Volume 112, Nº1, January 2019

Original Article Left Ventricular Regional Wall Motion Abnormality is a Strong Predictor of Cardiotoxicity in Breast Cancer Patients Undergoing Chemotherapy Márcio Vinícius Lins de Barros, 1,2 Ariane Vieira Scarlatelli Macedo, 2 Sebastian Imre Sarvari, 3 Monica Hermont Faleiros, 2 Patricia Tavares Felipe, 2 Jose Luiz Padilha Silva, 4 Thor Edvardsen 3 Faculdade de Saúde e Ecologia Humana, 1 Vespasiano, MG – Brazil Rede Materdei de Saúde, 2 Belo Horizonte, MG – Brazil University of Oslo, 3 Oslo – Noruega Universidade Federal do Paraná, 4 Curitiba, PR – Brazil Mailing Address: Márcio Vinícius Lins de Barros • Rua Paracatu, 1451 Apt 500. Postal Code 30180-091, Santo Agostinho, Belo Horizonte, MG – Brazil E-mail: mvbarros@cardiol.br, marciovlbarros@gmail.com Manuscript received March 30,2018, revised manuscript July 05, 2018, accepted July 23,2018 DOI: 10.5935/abc.20180220 Abstract Background: Chemotherapeutic agents of anthracyclines class and humanized monoclonal antibodies are effective treatments for breast cancer, however, they present a potential risk of cardiotoxicity. Several predictors have been recognized as predictors in the development of cardiac toxicity, and the evaluation of left ventricular segmental wall motion abnormalities (LVSWMA) has not been studied. Objective: To analyze prospectively the role of LVSWMA among echocardiographic parameters in the prediction of development of cardiotoxicity in breast cancer patients undergoing treatment with chemotherapy. Methods: Prospective cohort of patients diagnosed with breast cancer and in chemotherapy treatment with potential cardiotoxicity medications including doxorubicin and trastuzumab. Transthoracic echocardiograms including speckle tracking strain echocardiography were performed at standard times before, during and after the treatment to assess the presence (or lack thereof) of cardiotoxicity. Cardiotoxicity was defined by a 10% decrease in the left ventricular ejection fraction, on at least one echocardiogram. Multivariate logistic regression models were used to verify the predictors related to the occurrence of cardiotoxicity over time. Results: Of the 112 patients selected (mean age 51,3 ± 12,9 years), 18 participants (16.1%) had cardiotoxicity. In the multivariate analysis using the logistic regression model, those with LVWMA (OR = 6.25 [CI 95%: 1.03; 37.95], p < 0,05), LV systolic dimension (1.34 [CI 95%: 1.01; 1.79], p < 0,05) and global longitudinal strain by speckle tracking (1.48 [CI 95%: 1.02; 2.12], p < 0,05) were strongly associated with cardiotoxicity. Conclusion: In the present study, we showed that LVWMA, in addition to global longitudinal strains, were strong predictors of cardiotoxicity and could be useful in the risk stratification of these patients. (Arq Bras Cardiol. 2019; 112(1):50-56) Keywords: Ventricular Dysfunction, Left; Drug Therapy; Cardiotoxicity; Breast Neoplasms; Anthracyclines; Trastuzumab. Introduction The introduction of new chemotherapeutic agents, and the use of advanced and precise radiotherapy techniques in the last decades have dramatically improved breast cancer survival. 1 Chemotherapeutic drugs of the anthracycline class, and the humanized monoclonal antibodies, such as trastuzumab, are widely used and highly effective agents for breast cancer treatment. 2 Unfortunately, anthracyclines can induce cardiotoxic effects, and the severity of these adverse effects is compounded by concomitant use of trastuzumab. 3 Chemotherapy may induce numerous cardiovascular complications, including hypertension, congestive heart failure, thromboembolic diseases, ischemic heart disease, QT prolongation, and bradycardia. 3 When used in combination, anthracyclines and trastuzumab may result in heart failure in up to 27% of patients. 4 Among cancer survivors, a third will die of cardiovascular disease. Thus, the need for optimal cardiac care in the cancer population has become evident. Early detection of cardiac dysfunction may allow implementation of cardioprotective strategies before potentially irreversible myocardial damage has occured. 5 The definition of cancer therapy-related cardiac dysfunction (CTRCD) is based on a serial decline in left ventricular (LV) ejection fraction (EF). Two-dimensional echocardiography (2DE) is increasingly used for monitoring cardiac function during cancer treatment due to its widespread availability and safety. Echocardiography allows assessment of systolic and diastolic function, pulmonary pressures, valvular function, right ventricular function, and the pericardium. 6 Reduction in LV EF likely occurs late in the natural history of CTRCD patients as reduction in LV EF may not be overt until a substantial amount of myocardial reserve has been 50