Side Effect: Heart Failure

What is Heart Failure?

Heart failure (HF) is a complex clinical syndrome that is characterized by the inability of the ventricles of the heart to fill or pump blood appropriately, which decreases the amount of oxygenated blood that is delivered to the body. Heart failure is categorized by staging (A, B, C, or D) and limitations of activity based upon symptoms (New York Heart Association Classification I, II, III, or IV).

Abbreviated Overview of the 4 Stages of Heart Failure:

Abbreviated Overview of the New York Heart Association (NYHA) Classification

What does Heart Failure look like?

Symptoms of HF can vary, however common symptoms of HF include:

• shortness of breath when standing or lying flat
• chest pain
• fatigue with activity or at rest
• lack or loss of appetite
• cough
• lower leg swelling

Diagnosing HF is complex and is based on a comprehensive clinical history, physical examination and other tests to assess for specific cardiac dysfunction:

Electrocardiogram (ECG or EKG): looks at electrical activity of the heart.

Echocardiogram (ECHO): looks at the structure and function of the heart. This test is important for determining the percentage of blood the left heart ventricle pumps out with each heart beat (also called left ventricular ejection fraction or LVEF).

• HF with reduced ejection fraction (HFrEF): LVEF < 40%
• HF with mildly reduced ejection fraction (HFmrEF): LVEF 41-49%
• HF with preserved ejection fraction (HFpEF): LVEF > 50%

Blood tests such as B-type natriuretic peptide (BNP) or NT-proBNP may be done to check for increased blood volume.

Who gets Heart Failure?

There are many risk factors for developing heart failure, these include:

• Ischemic heart disease
• History of myocardial infarction (MI) or heart attack
• Hypertension
• Valvular heart disease
• Cardiomyopathy
  • Familial or genetic
  • Stress-induced
  • Peripartum
• Cocaine or methamphetamine substance abuse
• Myocarditis
• Rheumatologic or autoimmune disorders
• Infiltrative cardiac disease (sarcoid, hemochromatosis)
• Endocrine or metabolic disorders (thyroid, acromegaly, pheochromocytoma, diabetes, obesity)

Certain chemotherapy agents such as anthracyclines (example: doxorubicin (Adriamycin®), epirubicin (Ellence®), liposomal doxorubicin (Doxil®)) and anti-HER2 therapy (examples: trastuzumab (Herceptin®), pertuzumab (Perjeta®)) can cause damage to the heart muscle increasing the risk of heart failure.

How to prevent Heart Failure

• Preventing heart failure in patients with cancer can be challenging. Patients should be carefully screened before certain types of treatment known to increase the risk of HF in order to identify any risk factors that could increase the risk of developing heart failure.
• During treatment, patients should be monitoring closely for any signs or symptoms of heart failure. In some cases, ECHOs may be done throughout treatment to ensure that the heart is pumping blood appropriately.
• In patients receiving anthracycline therapy, a medication may be given to prevent anthracycline induced heart damage, called dexrazoxane (Zinecard®).
• It is important to have a healthy lifestyle such as maintaining regular physical activity, keeping a normal weight, managing blood pressure and blood glucose if you have high blood pressure or diabetes, and avoiding tobacco products.
• Eating a well-balanced diet with whole grains and plant-based foods may also protect against developing heart failure.

How to treat Heart Failure

Treatment for heart failure is complex and may require stopping the therapy that may be causing the heart failure.

In addition to lifestyle modifications such as reducing sodium and fluid intake, one or more medications may be prescribed to treat heart failure, these medications may include:

Angiotensin-Converting Enzyme Inhibitors (ACE-I):

• Captopril (Capoten®)
• Enalapril (Vasotec®)
• Lisinopril (Prinivil®, Zestril®)

Angiotensin Receptor Blockers (ARBs):

• Candesartan (Atacand®)
• Losartan (Cozaar®)
• Valsartan (Diovan®)

Beta-Blockers:

• Bisoprolol (Zebeta®)
• Carvedilol / Carvedilol CR (Coreg®)
• Metoprolol succinate (Troprol®) / metoprolol tartrate (Lopressor®)

Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2s):

• Dapagliflozin (Farxiga®)
• Empagliflozin (Jardiance®)

Mineralocorticoid receptor antagonists (MRA):

• Spironolactone (Aldactone®)
• Eplerenone (Inspra®)

Diuretics:

• Loop diuretics
  • Bumetanide (Bumex®)
  • Furosemide (Lasix®)
  • Torsemide (Demadex®)
• Thiazide diuretics
  • Chlorothiazide (Diuril®)
  • Chlothalidone (Thalitone®)
  • Hydrochlorothiazide (HydroDiuril®, HCTZ)
  • Indapamide (Lozol®)
  • Metolazone (Zaroxolin®)

Other:

• Sacubitril + valsartan (Entresto®)
• Isosorbide dinitrate (Isordil®)
• Hydralazine (Apresoline®)
• Ivabradine (Corlanor®)
• Vericiguat (Verquvo®)
• Digoxin (Lanoxin®)