Role of HFA-ICOS score in breast cancer and its relationship with left and right ventricular strain

Abstract Background Anthracycline cardiotoxicity is a significant complication of oncological therapy. Cardiovascular risk stratification is crucial to identify vulnerable patients. The HFA-ICOS score offers a standardized tool for categorizing baseline risk, supporting personalized management. While global longitudinal strain (GLS) is the gold standard for detecting subclinical cardiotoxicity, the role of right ventricular strain (RVS) remains unclear. Aim We aim to assess the risk of anthracycline-induced cardiotoxicity in breast cancer patients, emphasizing HFA-ICOS score-based risk stratification for personalized care. Additionally, the HFA-ICOS score and echocardiographic parameters relationship, including GLS and RVS, was explored. Methods The study, conducted in collaboration with a Medical Oncology Department, included patients who underwent clinical and anthropometric evaluations. Cardiovascular risk was classified as low or moderate-to-high using the HFA-ICOS score. Cardiovascular risk factors such as hypertension, diabetes, smoking, hypercholesterolemia, and family history of cardiovascular disease were recorded and compared between risk groups. Baseline echocardiographic assessments with color Doppler imaging measured left ventricular ejection fraction (LVEF), GLS, and RVS. Follow-up echocardiograms were longitudinally performed at after a cumulative anthracycline dose of 180 mg/m², at the end of treatment, and during post-therapy follow-up. Changes in GLS, RVS, and LVEF were analyzed by risk group. Results We enrolled 67 breast cancer patients undergoing anthracycline chemotherapy, with a mean age of 50.8±11 years. Most patients (60) had a low cardiovascular risk profile, while only seven were classified as moderate-to-high risk. Hypertension was the most common risk factor (present in 9 patients, 6 of whom were high-risk), followed by smoking status. At enrollment, echocardiography showed no anatomical or functional abnormalities, with normal LVEF, GLS, and RVS values across all patients. Patients with moderate-to-high risk showed a significantly lower RVS from the 180 mg/m² to the 6-month follow-up compared to the low-risk group (Figure 1). Additionally, the moderate-to-high risk group showed a significant reduction in RVS at 180 mg/m² (p = 0.04), at the end of treatment (p = 0.02), and at 6-month follow-up (p = 0.01) compared to baseline (Figure 1). This reduction was not observed in low-risk patients. Additionally, 57% of moderate to high-risk patients experienced a GLS reduction 15% during therapy, independent of LVEF, compared to 28% of low-risk patients. Conclusion The HFA-ICOS score effectively stratified subclinical cardiovascular toxicity patients on anthracycline therapy. Early RVS reduction emerges as a key marker of cardiotoxicity, particularly in high-risk patients. Including RVS analysis in routine monitoring may enable earlier interventions potentially improving management.