Clinical, Echocardiographic, and Biomarker Associations With Impaired Cardiorespiratory Fitness Early After HER2-Targeted Breast Cancer Therapy

Figures

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  Figure 1. Comparison of VO2peak for Various Clinical and Imaging Measures The bar graphs compare predicted VO2 peak for patients with and without CTRCD during treatment and post–cancer treatment risk factors, cardiovascular medications, and echocardiography parameters. The P values represent between group differences in VO2peak for univariable analyses. Abnormal LVEF <54%; abnormal GLS <18%. The dashed line indicates threshold for functional independence (VO2peak = 18 mL O2•kg−1•min−1). CVD = cardiovascular disease; GLS = global longitudinal strain; LVEF = left ventricular ejection fraction, E/e’ = left ventricular filling pressures.

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  Figure 2. Incremental Value of Biomarker and Imaging Parameters to Predict VO2peak GLS provided incremental value over clinical measures alone and over clinical/biomarker/and other echocardiography measures to predict VO2peak. Clinical risk factors were age, cardiac medications, CVD risk factors, CTRCD during treatment, radiation exposure, and epirubicin equivalent dose; biomarkers included B-type natriuretic peptide and high-sensitivity troponin I. LVMI = left ventricular mass index; other abbreviations as in Figure 1.

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  Figure 3. Tree Diagram for Detection of Compromised Functional Independence The 7 groups have different probabilities of loss of functional independence as shown in the box plots. Y-axis = probability. Probabilities are calculated based on the number of participants within each group that had VO2peak impairment confirmed via CPET. Red bars = the probability of patients with VO2peak <18 mL O2•kg−1•min−1; green bars = probability of patients with VO2peak ≥18 mL O2•kg−1•min−1. The 7 groups are also shown in the Central Illustration. n indicates the number of participants meeting the criteria in that branch. GLS = global longitudinal strain.

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  Figure 4. Receiver-Operating Characteristic Curves for the Optimal Tree Model The table inserts provide the estimated probability of compromised functional independence at each node of the tree model shown in Figure 3. AUC = area under the curve.

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  Central Illustration. A Proposed Decision Support Algorithm for Cardio-Oncology and Cardiac Rehabilitation (CORE) Using study results, the algorithm provides a potential approach (to be validated in future studies) to investigations, referrals, follow-up, and interventions in women with HER2+ breast cancer post-treatment based on probability of compromised functional independence. Group numbers refer to Figure 3. Proportion of patients in each group: group 1 (20%), group 2 (5%), group 3 (9%), group 4a (22%), group 4b (6%), group 5 (12%), group 6 (16%), group 7 (10%). 1Probabilities calculated based on number of participants within each group that had VO2peak impairment confirmed via cardiopulmonary exercise test. 2These suggestions are based on author opinion and should be targets for future research studies. 3CVD risk factor management includes pharmaceutical and behavioral (eg, physical activity promotion, nutrition support, smoking cessation) interventions. Duration of CVD risk factor management and follow-up by cardio-oncology programs will depend on findings during surveillance. Longer term follow-up may be needed in the highest risk groups.