Long-term effectiveness of empiric cardio-protection in patients receiving cardiotoxic chemotherapies: A systematic review & bayesian network meta-analysis

Ahmed Sayed, Omar M. Abdelfattah, Malak Munir, Omar Shazly, Ahmed K. Awad, Hazem S. Ghaith, Khaled Moustafa, Maria Gerew, Avirup Guha, Ana Barac, Michael G. Fradley, George S. Abela, Daniel Addison

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background: Cardioprotective therapies represent an important avenue to reduce treatment-limiting cardiotoxicities in patients receiving chemotherapy. However, the optimal duration, strategy and long-term efficacy of empiric cardio-protection remains unknown. Methods: Leveraging the MEDLINE/Pubmed, CENTRAL and clinicaltrials.gov databases, we identified all randomised controlled trials investigating cardioprotective therapies from inception to November 2021 (PROSPERO-ID:CRD42021265006). Cardioprotective classes included ACEIs, ARBs, Beta-blockers, dexrazoxane (DEX), statins and mineralocorticoid receptor antagonists. The primary end-point was new-onset heart failure (HF). Secondary outcomes were the mean difference in left ventricular ejection fraction (LVEF) change, hypotension and all-cause mortality. Network meta-analyses were used to assess the cardioprotective effects of each therapy to deduce the most effective therapies. Both analyses were performed using a Bayesian random effects model to estimate risk ratios (RR) and 95% credible intervals (95% CrI). Results: Overall, from 726 articles, 39 trials evaluating 5931 participants (38.0 ± 19.1 years, 72.0% females) were identified. The use of any cardioprotective strategy associated with reduction in new-onset HF (RR:0.32; 95% CrI:0.19–0.55), improved LVEF (mean difference: 3.92%; 95% CrI:2.81–5.07), increased hypotension (RR:3.27; 95% CrI:1.38–9.87) and no difference in mortality. Based on control arms, the number-needed-to-treat for ‘any’ cardioprotective therapy to prevent one incident HF event was 45, including a number-needed-to-treat of 21 with ≥1 year of therapy. Dexrazoxane was most effective at HF prevention (Surface Under the Cumulative Ranking curve: 81.47%), and mineralocorticoid receptor antagonists were most effective at preserving LVEF (Surface Under the Cumulative Ranking curve: 99.22%). Conclusion: Cardiotoxicity remains a challenge for patients requiring anticancer therapies. The initiation of extended duration cardioprotection reduces incident HF. Additional head-to-head trials are needed.

Original languageEnglish (US)
Pages (from-to)82-92
Number of pages11
JournalEuropean Journal of Cancer
StatePublished - Jul 2022


  • Cardio-oncology
  • Cardio-protection
  • Heart failure
  • Long-term outcomes
  • Malignancy

ASJC Scopus subject areas

  • Oncology
  • Cancer Research


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