Anthracycline Therapy Is Associated With Cardiomyocyte Atrophy and Preclinical Manifestations of Heart Disease

OBJECTIVES The goal of this study was to demonstrate that cardiac magnetic resonance could reveal anthracycline-induced early tissue remodeling and its relation to cardiac dysfunction and left ventricular (LV) atrophy. BACKGROUND Serum biomarkers of cardiac dysfunction, although elevated after chemotherapy, lack specificity for the mechanism of myocardial tissue alterations. METHODS A total of 27 women with breast cancer (mean age 51.8 +/- 8.9 years, mean body mass index 26.9 +/- 3.6 kg/m(2)), underwent cardiac magnetic resonance before and up to 3 times after anthracycline therapy. Cardiac magnetic resonance variables were LV ejection fraction, normalized T2-weighted signal intensity for myocardial edema, extracellular volume (ECV), LV cardiomyocyte mass, intracellular water lifetime (sic; a marker of cardiomyocyte size), and late gadolinium enhancement. RESULTS At baseline, patients had a relatively low (10-year) Framinghamcardiovascular event risk (median 5%), normal LV ejection fractions (mean 69.4 +/- 3.6%), and normal LV mass index (51.4 +/- 8.0 g/m(2)), a mean ECV of 0.32 +/- 0.038, mean sic of 169 +/- 69 ms, and no late gadolinium enhancement. At 351 to 700 days after anthracycline therapy (240 mg/m(2)), mean LV ejection fraction had declined by 12% to 58 +/- 6% (p < 0.001) and mean LV mass index by 19 g/m(2) to 36 +/- 6 g/m(2) (p < 0.001), and mean ECV had increased by 0.037 to 0.36 +/- 0.04 (p = 0.004), while mean sic had decreased by 62 ms to 119 +/- 54 ms (p = 0.004). Myocardial edema peaked at about 146 to 231 days (p < 0.001). LV mass index was associated with sic (b = 4.1 +/- 1.5 g/m(2) per 100-ms increase in sic, p = 0.007) but not with ECV. Cardiac troponin T (mean 4.6 +/- 1.4 pg/ml at baseline) increased significantly after anthracycline treatment (p < 0.001). Total LV cardiomyocyte mass, estimated as: (1 +/- ECV) +/- LV mass, declined more rapidly after anthracycline therapy, with peak cardiac troponin T>10 pg/ml. There was no evidence for any significant interaction between 10-year cardiovascular event risk and the effect of anthracycline therapy. CONCLUSIONS A decrease in LV mass after anthracycline therapy may result from cardiomyocyte atrophy, demonstrating that mechanisms other than interstitial fibrosis and edema can raise ECV. The loss of LV cardiomyocyte mass increased with the degree of cardiomyocyte injury, assessed by peak cardiac troponin T after anthracycline treatment. (Doxorubicin-Associated Cardiac Remodeling Followed by CMR in Breast Cancer Patients; NCT03000036) (c) 2018 by the American College of Cardiology Foundation.