Baker Heart and Diabetes Institute, PO Box 6492, Melbourne, Victoria, 3004, Australia.
Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia.
Curr Oncol Rep. 2022 Jun;24(6):687-694. doi: 10.1007/s11912-022-01242-y. Epub 2022 Mar 3.
Anthracycline chemotherapy carries a risk of myocardial dysfunction and heart failure even at relatively low doses, and the clinical prediction of cancer treatment-related cardiac dysfunction (CTRCD) is inexact. Careful imaging or biomarker surveillance during chemotherapy can identify CTRCD before the development of heart failure. Currently, this surveillance is performed using ejection fraction (EF). While this is a reliable and reproducible test with three-dimensional techniques, the most widely used imaging technique is two-dimensional echocardiography, for which EF measurements have broad confidence intervals.
The use of global myocardial strain (GLS) provides a more reliable and reproducible means of assessing global cardiac function and shows meaningful changes before a significant change of EF. Observational studies have shown that although absolute measurements of GLS, both at baseline and during therapy, are predictive of CTRCD risk, the most reliable approach is to assess the change of GLS with therapy - a meaningful relative change of 10-15% being significant. A clinical trial comparing GLS to EF surveillance did not show a significant change of EF in the overall study group, but did show that patients managed with a the GLS-guided approach were less likely to develop a meaningful change of cardiac function to an abnormal level. In at-risk patients, there is good evidence for the protective value of neurohormonal antagonists and statins: the use of GLS enables these benefits to be directed to those most likely to benefit, while minimizing their use in the majority of people, who do not need them. Although GLS requires an element of training and efforts to ensure uniformity, it has proven to be a feasible, robust, and reproducible technique, ready for wide adoption.
即使在相对较低的剂量下，蒽环类化疗也会导致心肌功能障碍和心力衰竭，而癌症治疗相关心脏功能障碍（CTRCD）的临床预测并不准确。在化疗过程中进行仔细的影像学或生物标志物监测可以在心力衰竭发生之前识别 CTRCD。目前，这种监测是使用射血分数（EF）进行的。虽然使用三维技术时 EF 是一种可靠且可重复的测试，但最广泛使用的影像学技术是二维超声心动图，EF 测量值的置信区间较宽。
使用整体心肌应变（GLS）提供了一种更可靠和可重复的评估整体心脏功能的方法，并且在 EF 发生显著变化之前显示出有意义的变化。观察性研究表明，尽管 GLS 的基线和治疗期间的绝对测量值都可预测 CTRCD 风险，但最可靠的方法是评估治疗期间 GLS 的变化——10-15%的有意义的相对变化是显著的。一项将 GLS 与 EF 监测进行比较的临床试验并未显示整个研究组的 EF 发生显著变化，但确实表明采用 GLS 指导方法的患者不太可能出现心脏功能向异常水平的有意义变化。在高危患者中，神经激素拮抗剂和他汀类药物具有良好的保护价值：使用 GLS 可以使这些益处惠及最有可能受益的患者，同时最大限度地减少它们在大多数不需要它们的人中的使用。虽然 GLS 需要一定的培训和努力来确保一致性，但它已被证明是一种可行、稳健且可重复的技术，准备广泛采用。
