ACEIs, ARBs, beta-blockers could prevent chemo-related cardiotoxicity

Patients undergoing chemotherapy for breast or haematological cancers could potentially reduce their risk of chemotherapy-related cardiotoxicity with the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARBs), or beta-blockers as primary prevention, according to a systematic review and meta-analysis presented at the recent EuroEcho 2019 conference.

“Cardioprotective medications are not habitually prescribed in patients with cancer and our study suggests that they should be considered,” said study author Dr Sergio Moral from the Hospital Universitari Josep Trueta, Hospital Santa Caterina, Girona, Spain.

“[The results showed that] for every 10 patients treated, one case of cardiotoxicity could be avoided,” he said.

Moral and his colleagues reviewed nine randomized trials comprising 913 patients who underwent chemotherapy for breast or haematological malignancies and who did/did not receive ACE inhibitors, ARBs, or beta-blockers as primary prevention against chemo-related cardiotoxicity. Of these, 37 percent (n=337) received a beta-blocker, 17 percent (n=152) received an ACE inhibitor or an ARB, 5 percent (n=45) received both a beta-blocker and ACE inhibitor, and 41 percent (n=379) did not receive any of the drugs and served as controls.

Over the 1-year follow-up period, 12 percent of patients (n=108) developed cardiotoxicity, defined in this study as a reduction in left ventricular ejection fraction (LVEF) to <50 percent or a ≥10 percent reduction in LVEF, and/or clinical heart failure during the first year of follow-up.

Patients who received primary prevention therapy had a significantly reduced risk of developing cardiotoxicity compared with patients who did not receive these medications (relative risk [RR], 0.381, 95 percent confidence interval [CI], 0.160–0.911; p=0.030). [EuroEcho 2019, abstract P367]

In a subgroup analysis which assessed the medications separately, beta-blockers (RR, 0.477, 95 percent CI, 0.178–1.275; p=0.140) and ACE inhibitors/ARBs (RR, 0.283, 95 percent CI, 0.027–2.982; p=0.293) reduced the risk of chemotherapy-related cardiotoxicity, though the effect with both medication groups was nonsignificant.

There was no significant between-group difference in the studies that compared the two treatments (RR, 0.743, 95 percent CI, 0.325–1.698; p=0.481).

“Cancer and cardiovascular [CV] disease share common risk factors which also influence susceptibility to cardiotoxicity. Consequently, cancer patients are advised to eat healthily, quit smoking, control their weight, and exercise,” said Moral.

“Our study provides support for the routine use of beta-blockers, ACE inhibitors, or ARBs in patients receiving cancer treatment but the decision should be made on a case by case basis,” said Moral. He added that more research is required to establish which patients would acquire the greatest benefit from primary CV protection and the most effective type of medication for this purpose, as well as the optimal dose and duration of therapy.