Distinct risk profiles of heart failure and non-heart failure major adverse cardiovascular events among patients with early breast cancer: a competing-risk analysis

BACKGROUND: Cardiovascular complications are increasingly recognized among patients with breast cancer; however, heart failure has been the primary focus of studies to date. We aimed to evaluate the cumulative incidence of heart failure and other major adverse cardiovascular events among patients with early breast cancer and to identify risk factors. METHODS: We conducted a retrospective cohort study of patients with non-metastatic breast cancer who underwent curative surgery at a tertiary center during 2010-2019. The endpoints were heart failure and other major adverse cardiovascular events (stroke, atrial fibrillation, myocardial infarction, or cardiovascular death). The cumulative incidence was estimated using the cumulative incidence function, and risk factors were evaluated using Fine-Gray competing-risk regression models. Breast cancer recurrence and non-cardiovascular event-related death were treated as competing events. RESULTS: Over a median follow-up of 7.7 years, heart failure occurred in 24/1,328 (1.8%) patients, whereas other major adverse cardiovascular events occurred in 38 (2.9%). The cumulative incidence of heart failure differed according to perioperative systemic therapy (p = 0.002). Anthracycline use (subdistribution hazard ratio, 2.67; 95% confidence interval, 1.08-6.65; p = 0.034) and trastuzumab use (2.52; 1.00-6.33; p = 0.050) were independently associated with heart failure. By contrast, other major adverse cardiovascular events were associated with age (> 65 years; 3.75; 1.59-8.88; p = 0.003) and cardiovascular risk factors (4.02; 1.77-9.10; p < 0.001). CONCLUSIONS: Heart failure was primarily associated with cardiotoxic cancer therapies, and other events by patient-related cardiovascular risk factors. These findings highlight the importance of integrating cardiotoxicity surveillance with long-term cardiovascular risk management in breast cancer survivorship.