Side Effect: Decreased Heart Function (Decreased LVEF)

What is Decreased Heart Function (Decreased LVEF)?

Decreased heart function, also known as reduced cardiac function, refers to the decreased ability of the heart to pump blood effectively. It is commonly measured by a decrease in the ejection fraction (EF), which is the percent of blood pumped out of the left ventricle with each heartbeat. A normal EF ranges between 55 to 70%. A decrease in EF can indicate heart failure, where the heart is not able to meet the body’s demands for blood and oxygen.

What does Decreased Heart Function (Decreased LVEF) look like?

Decreased heart function, particularly in patients with cancer, often presents with a range of symptoms that can significantly impact a patient’s quality of life. Patients may experience shortness of breath while being active as well as persistent fatigue and weakness, making it difficult to perform daily activities. Dizziness can occur, which can lead to balance issues and an increased risk of falls. Additionally, swelling in the legs or feet (also known as peripheral edema) is frequently observed due to the heart’s reduced ability to circulate blood efficiently. Symptoms may vary depending on how much heart function has decreased. It is important to talk to a healthcare provider about any of the above symptoms when they occur.

Who gets Decreased Heart Function (Decreased LVEF)?

Patients with cancer are at an increased risk of decreased heart function due to the exposure to certain medications and radiation therapy. Patients diagnosed with breast cancer, lymphoma, and sarcoma are three areas that may be at higher risk for decreased heart function. A list of common medications that can decrease heart function are below:

• Anti-HER2: trastuzumab (Herceptin®, Trazimera®, Kanjinti®), pertuzumab (Perjeta®), trastuzumab/pertuzumab/hyaluronidase (Phesgo®), lapatinib (Tykerb®), ado-trastuzumab emtansine (Kadcyla®), margetuximab (Margenza®),fam-trastuzumab deruxtecan-nxki (Enhertu®)
• Anthracyclines: doxorubicin (Adriamycin®), daunorubicin (Cerubidine®), epirubicin (Ellence®)
• Tyrosine kinase inhibitors: sunitinib (Sutent®), sorafenib (Nexavar®), pazopanib (Votrient®)
• Proteasome inhibitors: bortezomib (Velcade®)
• Immunotherapy: pembrolizumab (Ketruda®), nivolumab (Opdivo®), ipilimumab (Yervoy®), nivolumab-relatlimab (Opdualag®)

How to prevent Decreased Heart Function (Decreased LVEF)

Preventing decreased heart function in patients with cancer involves regular monitoring and proactive management strategies involving imaging and possibly medications. Lifestyle changes, like maintaining healthy diet and exercising regularly. However, the key to prevention is routine assessment of cardiac function by getting:

• Echocardiograms (ECHOs)
• Multigated acquisition scan (MUGA)
• Cardiac MRIs

These can detect early signs of decreased heart function. Heart protective medications are sometimes prescribed, which include:

• Beta-blockers – bisoprolol (Cardicor®), metoprolol (Lopressor®, Toprol XL®)
• ACE-inhibitors – lisinopril (Zestril®)

Patients receiving anthracycline therapy may also receive a medication to prevent anthracycline induced heart damage, called dexrazoxane (Zinecard®). Medications along with actively watching the heart and help identify a decrease in heart function early. This can ensure the therapeutic benefits of cancer treatment are maximized while keeping patients safe.

How to treat Decreased Heart Function (Decreased LVEF)

Treating decreased heart function, often referred to as heart failure, involves multiple types of treatment. Below are some common types of treatments:

Medications:

• Beta-blockers:
  
  • Mechanism: reduce heart rate, decrease blood pressure, and prevent further heart damage
  • Examples: metoprolol (Lopressor®, Toprol XL®), carvedilol (Coreg®), bisoprolol (Cardicor®)
• ACE inhibitors (angiotensin-converting enzyme inhibitors):
  • Mechanism: help relax blood vessels, lower blood pressure, and reduce strain on the heart
  • Examples: lisinopril (Zestril®), enalapril (Enalaprilat®, Vasotec®), ramipril (Altace®)
• ARBs (angiotensin II receptor blockers):
  
  • Mechanism: often used as an alternative to ACE inhibitors, help relax blood vessels and decrease blood pressure
  • Examples: losartan (Cozaar®), valsartan (Diovan®), candesartan (Atacand®)
• Diuretics:
  
  • Mechanism: help reduce fluid buildup in the body, alleviating symptoms like swelling and shortness of breath
  • Examples: furosemide (Lasix®), hydrochlorothiazide (Microzide®)
• Aldosterone Antagonists:
  
  • Mechanism: these help the body get rid of extra salt and water and decrease strain on the heart
  • Examples: spironolactone (Aldactone®), eplerenone (Inspra®)

Devices:

• Pacemakers: these devices are implanted under the skin and help regulate the heartbeat, especially in cases where the heart beats too slowly
• Implantable cardioverter-defibrillators (ICDs): these devices are implanted to monitor heart rhythms and deliver shocks if dangerous arrhythmias are detected.
• Cardiac resynchronization therapy (CRT): this involves a special type of pacemaker that coordinates the contractions of the heart by sending an electrical signal to both sides of the heart.

Monitoring and Lifestyle Changes:

• Careful monitoring of heart function: regular follow-ups with a cardiologist, ECHOs, stress tests, and blood tests to monitor heart function and detect decreased heart function early.
• Lifestyles changes:
  
  • Diet: low sodium, heart-healthy diet rich in fruits, vegetables, whole grains, and lean proteins
  • Exercise: regular, moderate physical activity tailored to each patient (example: 15–30-minute walks)
  • Weight management: maintain healthy weight to reduce burden on the heart.
  • Smoking cession: avoiding or quitting tobacco products to improve heart health.
  • Alcohol limitation: reducing alcohol intake to prevent further heart damage.

Minimizing Cardiotoxicity:

• To minimize toxicity to the heart, it is important to avoid or carefully manage the use of certain medications that can have adverse effects on the cardiovascular system. Examples of medications that should be used with caution or avoided are:
• NSAIDs: ibuprofen (Motrin®), naproxen (Aleve®), diclofenac (Voltaren®), indomethacin (Indocin®), celecoxib (Celebrex®)
• Diabetic medications: pioglitazone (Actos®), rosiglitazone (Avandia®), saxagliptin (Onglyza®), alogliptin (Nesina®)

Overall, by combining treatments and closely monitoring the patient’s condition, healthcare providers aim to improve heart function, help symptoms, and enhance quality of life for those with decreased heart function.