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Canadian Journal of Cardiology

Cancer Therapy-Related Cardiac Dysfunction: Unresolved Issues

      Abstract

      An increasing awareness of chemotherapy and radiotherapy as preventable causes of cardiac failure among large numbers of patients surviving cancer has contributed to the development of cardio-oncology as a subspecialty. Perhaps the most important driver has been that the aging of the population undergoing cancer therapy has provided an increasing number of patients at risk for the development of heart failure. Cardio-oncology has many unresolved questions. In this article the 6 most important unresolved issues requiring additional research are discussed: (1) the frequency of overt heart failure as a manifestation of cardiotoxicity; (2) the optimal diagnostic approach to cardiotoxicity in the context of large numbers of patients requiring repeated testing; (3) the need for better risk prediction; (4) alternatives to the use of ejection fraction as the cornerstone of evaluation; (5) definition of the best strategy for protection; and (6) the need for evidence-based algorithms to guide late follow-up. When this evidence base is mature, we will have a better understanding of the magnitude of the problem of cardiotoxicity, who best to screen (and how), who justifies the use of cardioprotective therapy, and how all at-risk patients should be followed over the decades following cancer therapy.

      Résumé

      Le fait que la chimiothérapie et la radiothérapie soient de plus en plus reconnues comme des causes évitables d’insuffisance cardiaque chez un grand nombre de survivants du cancer a contribué à l’émergence de la cardio-oncologie comme sous-spécialité. Le facteur le plus important a peut-être été celui du vieillissement de la population traitée pour un cancer, ce qui a fait croître le nombre de patients présentant un risque d’apparition d’une insuffisance cardiaque. Or, la cardio-oncologie comporte de nombreuses questions non résolues. Cet article traite des six plus importants problèmes non résolus pour lesquels des recherches supplémentaires s’imposent : (1) la fréquence de l’insuffisance cardiaque patente comme manifestation d’une cardiotoxicité; (2) la méthode optimale pour diagnostiquer la cardiotoxicité chez un grand nombre de patients nécessitant des analyses répétées; (3) la nécessité d’une meilleure prédiction du risque; (4) la recherche de solutions de rechange à l’utilisation de la fraction d’éjection comme pierre angulaire de l’évaluation des patients; (5) la définition de la meilleure stratégie de protection; et (6) la nécessité d’algorithmes s’appuyant sur des données probantes qui guideront le suivi à long terme. Lorsque cet ensemble de données probantes sera constitué, nous aurons une meilleure compréhension de l’ampleur du problème de la cardiotoxicité, du ciblage optimal des patients à soumettre au dépistage (et des meilleures méthodes de dépistage), des critères justifiant le recours à un traitement cardioprotecteur et de la façon dont tous les patients à risque devraient être suivis pendant les décennies qui suivent un traitement anticancéreux.
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