Clinical Scorecard: CMR Strain Analysis of Right Ventricular and Biatrial Function Reveals Myocardial Impairment Following Breast Cancer Treatment
At a Glance
Category
Detail
Condition
Cancer therapy-related cardiac dysfunction (CTRCD) following anthracycline-based chemotherapy and radiotherapy in breast cancer patients
Key Mechanisms
Anthracycline-induced irreversible cardiotoxicity affecting myocardial strain parameters including right ventricular and biatrial function; radiotherapy-associated cardiac toxicity
Target Population
Female breast cancer patients undergoing anthracycline-based chemotherapy and radiotherapy
Care Setting
Oncology and cardiology outpatient and imaging centers with access to cardiac magnetic resonance imaging
Key Highlights
Anthracycline chemotherapy, especially doxorubicin and epirubicin, is associated with significant risk of CTRCD, with incidence up to 67% for doxorubicin and around 20% for epirubicin.
Cardiac magnetic resonance (CMR) imaging with feature tracking (FT) provides superior reproducibility and spatial resolution for myocardial strain analysis compared to echocardiography.
Biatrial strain parameters (reservoir, conduit, booster) and right ventricular strain analysis can detect early subclinical myocardial impairment preceding changes in left ventricular ejection fraction.
Guideline-Based Recommendations
Diagnosis
Perform cardiac risk stratification before initiating anthracycline-based chemotherapy and radiotherapy as per European Society of Cardiology (ESC) guidelines.
Use echocardiography as first-line imaging for baseline cardiac function assessment in cancer patients.
Utilize cardiac magnetic resonance imaging for detailed and reproducible assessment of myocardial strain, especially when echocardiographic results are inconclusive.
Management
Monitor myocardial strain parameters, particularly left ventricular global longitudinal strain (GLS), to detect early subclinical cardiotoxicity.
Consider relative changes in LV GLS exceeding 15% and/or reductions in LVEF as indicators of CTRCD.
Incorporate multidisciplinary care involving oncology and cardiology to balance cancer treatment benefits and cardiac risk.
Monitoring & Follow-up
Conduct baseline CMR imaging prior to chemotherapy initiation and follow-up imaging approximately 13 months after baseline to assess longitudinal changes in myocardial strain.
Include right ventricular and biatrial strain analysis in follow-up assessments to detect early myocardial impairment.
Use intraclass correlation coefficient (ICC) to ensure reproducibility and reliability of strain measurements.
Risks
Anthracycline chemotherapy carries a risk of irreversible cardiotoxicity leading to cardiomyopathy and heart failure.
Radiotherapy may contribute to cardiac toxicity, though evidence remains controversial.
Delayed detection of CTRCD can result in increased morbidity and mortality in breast cancer survivors.
Patient & Prescribing Data
Breast cancer patients receiving anthracycline-based chemotherapy (epirubicin) and radiotherapy, including HER2+ patients receiving trastuzumab.
Anthracycline regimen consisted of four cycles of epirubicin (90 mg/m²) with cyclophosphamide, followed by paclitaxel; trastuzumab was added sequentially in HER2+ patients. CMR imaging was used to monitor cardiac function before and after treatment.
Clinical Best Practices
Employ CMR feature tracking for comprehensive assessment of right ventricular and biatrial myocardial strain in addition to left ventricular parameters.
Manually contour epicardial and endocardial borders carefully to exclude papillary muscles, trabeculae, and septum in strain analyses for accuracy.
Use longitudinal strain parameters (reservoir, conduit, booster) for atrial function assessment as early predictors of myocardial impairment.
Ensure imaging and strain analyses are performed by experienced radiologists to maintain high interobserver agreement.
