Cardiologic follow-up of patients treated with trastuzumab in an European university referral centre: do we follow the guidelines?
Authors: Roldan Guerra A , Ruiz Ortiz M , Esteban Martinez F , Delgado Ortega M , Rodriguez Almodovar A , Barreiro Mesa L , Urbano Sanchez C , Aguayo Cano N , Diaz Andrade M , Gonzalez Manzanares R , Maestre Luque L C , Herrera Flores J , Torres Zamudio A , Pan Alvarez-Ossorio M , Mesa Rubio D 
Published: January 2025

Abstract

Introduction
The 2022 Clinical Practical Guidelines of the European Society of Cardiology recommend a close follow-up by imaging techniques in patients on trastuzumab therapy, with at least 4-5 echocardiograms by year, even though it has been reported a low incidence of cardiotoxicity in previous registries. However, the degree of application of these recommendations in various clinical settings is unknown. Our aim was to investigate the "real-life" management of the cardiological follow-up of patients treated with trastuzumab in a European referral university hospital, with special focus on the profile of this population, the imaging tests performed and the incidence of cardiotoxicity.

Methods
All patients treated with trastuzumab at a Spanish reference university hospital during 2022 were included. Medical records were reviewed between March and September 2023. We analyzed risk factors for cardiotoxicity according to definitions by guidelines, the imaging techniques performed and cardiotoxicity events.

Results
Of a total of 176 patients treated, 6 were excluded because they were participating in clinical trials, thus 170 patients were included in the study (97% female, mean age 57 +/- 12 years). The most frecuent tumor was breast cancer (95,3%) followed by gastric (3,5%) and head and neck cancers (1,2%). Cardiotoxicity risk was low, moderate, high and very high in 21,8%, 49,4%, 15,9% and 12,9% of patients. Along treatment time of 13 [10-16] months (median [p25-75]), a total of 429 imaging techniques were performed (1,7 [0,9-2,8] per patient-year): 276 echocardiograms (64%) -of wich 146 were advanced echocardiograms (3D echo or speckle tracking imaging)- and 153 radionuclid ventriculographies (36%). The median number of imaging techniques by year was similar among patients with low, moderate or high/very high risk: 1,2 [0,6-2,2], 1,8 [1,0-2,6] and 2,0 [0,7-3,0], p=0,18. Ventricular dysfunction (ejection fraction &lt; 50%) in follow-up was observed in 3,5% of patients, and it was significantly more frequent in those with very high risk of cardiotoxicity (0% low risk, 2,4% moderate risk, 0% high risk and 18,2% very high risk, p=0,001). Moreover, 0,6% patients needed hospital admission for heart failure, all of them with very high risk (4,5% of this group, p=0,08 versus other groups). Other clinical data, complementary tests and follow-up are shown in the table.

Conclusions
The majority of patients treated with trastuzumab in a tertiary center in our setting have a low or intermediate risk of cardiotoxicity. After a median follow-up of 13 months, a median of 1,7 [0,9-2,8] imaging tests/year were performed, with no significant differences by risk group. The most frequently performed cardiac imaging technique was echocardiography, but more than one third of the tests were radionuclid ventriculography. The incidence of ventricular dysfunction and hospital admission for heart failure were significantly higher in the very high risk group.