Exercise as a diagnostic and therapeutic tool for the prevention of cardiovascular dysfunction in breast cancer patients

Abstract

Background Anthracycline chemotherapy may be associated with decreased cardiac function and functional capacity measured as the peak oxygen uptake during exercise ([Formula: see text] peak). We sought to determine (a) whether a structured exercise training program would attenuate reductions in [Formula: see text] peak and (b) whether exercise cardiac imaging is a more sensitive marker of cardiac injury than the current standard of care resting left ventricular ejection fraction (LVEF). Methods Twenty-eight patients with early stage breast cancer undergoing anthracycline chemotherapy were able to choose between exercise training (mean ± SD age 47 ± 9 years, n = 14) or usual care (mean ± SD age 53 ± 9 years, n = 14). Measurements performed before and after anthracycline chemotherapy included cardiopulmonary exercise testing to determine [Formula: see text] peak and functional disability ([Formula: see text] peak < 18 ml/min/kg), resting echocardiography (LVEF and global longitudinal strain), cardiac biomarkers (troponin and B-type natriuretic peptide) and exercise cardiac magnetic resonance imaging to determine stroke volume and peak cardiac output. The exercise training group completed 2 × 60 minute supervised exercise sessions per week. Results Decreases in [Formula: see text] peak during chemotherapy were attenuated with exercise training (15 vs. 4% reduction, P = 0.010) and fewer participants in the exercise training group met the functional disability criteria after anthracycline chemotherapy compared with those in the usual care group (7 vs. 50%, P = 0.01). Compared with the baseline, the peak exercise heart rate was higher and the stroke volume was lower after chemotherapy ( P = 0.003 and P = 0.06, respectively). There was a reduction in resting LVEF (from 63 ± 5 to 60 ± 5%, P = 0.002) and an increase in troponin (from 2.9 ± 1.3 to 28.5 ± 22.4 ng/mL, P < 0.0001), but no difference was observed between the usual care and exercise training group. The baseline peak cardiac output was the strongest predictor of functional capacity after anthracycline chemotherapy in a model containing age and resting cardiac function (LVEF and global longitudinal strain). Conclusions The peak exercise cardiac output can identify patients at risk of chemotherapy-induced functional disability, whereas current clinical standards are unhelpful. Functional disability can be prevented with exercise training.

Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology

“…43 Regarding the early detection of cardiac injury, exercise cardiac magnetic resonance imaging has been shown to be a more sensitive marker of cardiotoxicity than the current standard of care tools to assess resting left ventricular ejection fraction in breast cancer patients. 44 Also, the use of biomarkers has emerged as a valuable tool for the early identification and monitoring of cardiotoxicity. In particular, cardiac troponin and B-type natriuretic peptide (BNP) elevation during chemotherapy allows the identification of patients more prone to develop myocardial dysfunction and cardiac events.…”

Regional differences in exercise training implementation in heart failure: findings from the Exercise Training in Heart Failure (ExTraHF) survey

“…Exercise intolerance, frequently manifested by fatigue or shortness of breath on minimal exertion, is a hallmark of HF 1 : one of the principal goals of treatment is to improve exercise capacity, and interventions designed to change this leading symptom in HF have been shown to improve outcomes . ETP is an important adjunct to non‐pharmacological treatment that has a proven positive effects on mortality, morbidity, exercise capacity and quality of life . Based on the analysis of 801 patients enrolled in nine randomized controlled clinical trials, the ExTraMATCH collaborative group calculated a 35% ( P < 0.05) lower risk for mortality and a 28% ( P < 0.05) lower risk for the composite endpoint of mortality or hospitalization in favour of ETP .…”

Confronting the reality of COVID

“…The value of maintaining or improving exercise capacity over time is grossly underappreciated, but it is an important way to decrease the risk of premature death, not only in patients with CVD, but also in patients with common non-communicable chronic diseases such as diabetes mellitus, metabolic syndrome and breast cancer. 4,5 Here, a retrospective analysis of 1561 individuals undergoing a cardiac rehabilitation programme is showing that directly measured peak oxygen consumption (VO 2 ) as well as a change in peak VO 2 over time were highly predictive of the risk of future readmissions for CVD and all-cause mortality. Importantly, the prognostic power of the change in peak VO 2 with serial testing was independent of baseline peak VO 2 and clinical history.…”