Decoding chemotherapy-related cardiac dysfunction prediction: left ventricular strain imaging or HFA-ICOS score?

Baseline HFA-ICOS score and serial left ventricular global longitudinal strain (LV-GLS) measurements are recommended for predicting cancer therapy-related cardiac dysfunction (CTRCD). However, their integration to improve prognostic accuracy remains unclear.

This study aimed to develop a predictive model for CTRCD using baseline HFA-ICOS scores and the relative decline of LV-GLS in patients on anthracycline or trastuzumab.

We prospectively enrolled 443 chemotherapy-naïve women with breast cancer and cardiovascular risk factors, scheduled to receive anthracycline (n=333) or trastuzumab (n=110). They were stratified by the HFA-ICOS risk score. The left ventricular ejection fraction (LVEF) and LV-GLS were evaluated using echocardiography at baseline, before each treatment cycle, and every three months in the first year post-chemotherapy. CTRCD was a new LVEF reduction >= 10 percentage points to an LVEF <50%, irrespective of symptoms. The persistent decline in the LVEF was confirmed by two subsequent echocardiography reports.

By HFA-ICOS stratification, 258 patients (58.2%) were low-, 180 (40.6%) moderate-, and five (1.2%) high-risk. The proportions of low- and moderate-risk patients were similar in the anthracycline and trastuzumab groups. Twenty-four (7.2%) and seven (6.4%) patients treated with anthracycline and trastuzumab, respectively, displayed asymptomatic CTRCD. The baseline HFA-ICOS stratification did not enhance the predictive value of the relative reduction of LV-GLS during the study period. The area under the receiver operating characteristic curve (AUC) for the baseline HFA-ICOS score >= 2, the relative decline of LV-GLS >15%, and the integrated model of these two established tools in patients receiving anthracycline was 0.66 (95% CI 0.61 – 0.71), 0.93 (95% CI 0.89 – 0.96), and 0.91 (95% CI 0.84 – 0.97), respectively. Regarding prediction of CTRCD due to trastuzumab, LV-GLS also demonstrated the best performance with an AUC of 0.97 (95% CI 0.88 – 0.99), compared to the HFA-ICOS score (AUC 0.66, 95% CI 0.48 – 0.93) and the integrated model (AUC 0.96, 95% CI 0.86 – 0.99).

Contemporary anthracycline and trastuzumab-based regimens resulted in similarly low incidences of CTRCD. The baseline increased HFA-ICOS score did not provide incremental value in predicting CTRCD due to both anthracycline and trastuzumab when incorporated into the model of new relative reduction of LV-GLS > 15%.

Predictive performance of three models