Cardiovascular risk stratification in cancer survivors: time for a better approach?

Long-term cancer survivors are a growing population as consequence of the development of groundbreaking cancer therapies. Late-onset cancer therapy-related cardiovascular toxicity (CRT-CVT) remains a major concern, particularly in patients with breast cancer, as it can compromise both life expectancy and quality of life. Traditionally, left ventricular ejection fraction (LVEF) has been the cornerstone for identifying myocardial damage. However, it has limited sensitivity for diagnosing heart failure with preserved LVEF or detecting early subclinical myocardial damage, highlighting the need for more refined risk stratification tools.

This study aimed to evaluate the feasibility of Fast-SENC images to assess late-onset CRT-CVT risk and identify patients who would truly benefit from long-term follow-up.

The CARDIOBREAST Registry is a single-centre, prospective registry including patients with breast cancer who received a total cumulative doxorubicin dose (TCDD) ≥200 mg/m² at least five years before enrollment. All patients undergo clinical evaluation, ECG, biomarkers, echocardiography, and cardiac MRI (CMR). For this study, we analysed patients with available CMR Fast-SENC images for Myohealth Score assessment. The score was calculated as the average of longitudinal and circumferential left and right ventricular strain.

Patients were stratified using ESC Cardio-Oncology Guidelines criteria into two groups: patients with high risk based on radiotherapy dose and TCDD criteria or previous CRT-CVT (cases) and patients with low risk and no previous CRT-CVT event (controls). Data were analysed using R software.

131 patients with breast cancer (100% women; mean age 60 years) were included in the analysis, with a mean follow-up of 9.85 years. 116 were controls and 15 cases (13 with a prior CRT-CVT event and 2 based on risk score) (Table 1). The median LVEF of the total sample was 63.4 (60.0,67.8), with similar values in the control (63.5 [60.1–67.7 and case groups (61.9% [58.7–67.2]). Median echo-based global longitudinal strain (GLS) value was -20.44 (-22.28,-19.00), with no significant differences between controls (-20.35 [-22.36 to -19.00]) and cases (-20.85 [-21.44 to -18.44]). Conversely, the median Myohealth score was significantly lower in cases (59 [50–84]) compared to controls (81 [72–87], p<0.008) (Figure 1). Additionally, 28.24% of patients lacked GLS values due to poor echocardiographic image quality.

In breast cancer survivors, the MyoHealth Score enhances risk stratification compared to conventional echocardiographic parameters. While LVEF and GLS values showed no significant differences between groups, the MyoHealth Score was significantly lower in patients with prior CRT-CVT events or other high-risk conditions. Integrating MyoHealth into risk assessment for cancer survivors may allow for more tailored long-term follow-up strategies.Table 1.

Baseline Characteristics.