Doxorubicin Cardiotoxicity

Doxorubicin and other anthracyclines such as daunorubicin, epirubicin and mitoxantrone are commonly employed chemotherapeutic drugs which may be associated with significant cardiotoxicity. ERNA provides an accurate, reproducible and non-invasive method of serially monitoring left ventricular function. It has been recommended that ERNA be obtained prior to chemotherapy and if left ventricular function is normal (EF >50%) subsequent studies be obtained at a total doxorubicin dose of 250-300 mg/m2, at 400-450 mg/m2, and before each subsequent dose. Cardiotoxicity, defined by a decrease in the EF of >10% and an EF <50% is predictive of subsequent clinical cardiac failure if treatment is continued. If there is left ventricular dysfunction (EF <50%) on the pre-chemotherapy ERNA, additional studies should be obtained prior to each dose, with treatment discontinued if the EF falls by 10% or the EF decreases to 30% (Fig. 8).

Valvular Heart Disease

Echocardiography is preferred for the non-invasive assessment of patients with valvular heart disease since it provides information on valve structure in addition to assessing ventricular function. ERNA provides an alternative method of assessing ventricular function in patients with technically suboptimal echocardiographic studies or in patients with borderline left ventricular dysfunction for whom an independent assessment of left ventricular function may be helpful. Surgery is recommended when patients with valvular regurgitation develop symptoms or resting left ventricular dysfunction (EF <50% in aortic regurgitation and <60% in mitral regurgitation). Although the exercise ejection fraction response in asymptomatic patients with severe aortic regurgitation is an independent predictor of death, left ventricular dysfunction or the development of symptoms, there are no data to support aortic valve surgery based only on a fall in ejection fraction with exercise.

Figure 8. Flow chart outlining the use of ERNA in monitoring doxorubicin cardiotoxicity.

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