Risk of Cardiac (Heart) Problems Due to Anthracycline Chemotherapy During Childhood

What is the risk?

A group of chemotherapy medications called anthracyclines can cause heart (cardiac) problems (also called cardiac toxicities). 

Anthracycline chemotherapies are doxorubicin, daunorubicin, epirubicin, idarubicin, and mitoxantrone. 

Heart problems linked to these medications are:

• Cardiomyopathy (when your heart has a hard time pumping blood) or left ventricular dysfunction (your heart muscle becomes weak). 
• Arrhythmias (your heart beats too fast, too slow, or irregularly).

Cardiac (heart) toxicities can cause symptoms like:

• Shortness of breath (at rest or while moving).
• Having a hard time breathing when lying down (orthopnea). You may find you need more pillows at night.
• Chest pain.
• Feeling like your heart is racing, throbbing, or beating irregularly.
• Being unable to exercise due to fatigue.
• Dizziness/lightheadedness.
• Swelling of your arms or legs (edema).
• Cough or wheezing that won't go away.

Tell your provider right away if you have any of these symptoms. A yearly history and physical by your primary care provider should include a cardiac exam and a review of any symptoms you may have. If you are having chest pain or a hard time breathing, call 911 or go to your nearest emergency room right away.

Am I at risk?

If you received anthracycline medication when you were younger, you are at risk of heart problems. These problems can start soon after you are done treatment, or even up to years later, so heart health is important for cancer survivors. Your risk of heart problems is linked to:

• The total dose of the anthracycline chemotherapy you had (over the whole course of your life). Often, higher doses mean a higher risk of having a heart problem.
• The age you were when you had the medication. Survivors who were younger when they had treatment are at a slightly higher risk.

The risk is higher if you also had radiation therapy to your chest. Radiation, even without chemotherapy, can cause early disease in the arteries in your heart. This can raise the risk of heart attack and other heart problems.

What else can raise my risk of heart problems?

Some things, like anesthesia and pregnancy, can cause extra stress on your heart and raise your risk of a heart problem. For this reason, you should see a cardiologist before any planned surgery or if you are pregnant or trying to get pregnant.

Other health problems that can raise your risk are:

• Heart disease (coronary artery disease).
• High blood pressure (hypertension).
• High cholesterol.
• Diabetes.
• Obesity.

If you have heart valve problems, you may need antibiotics before having some medical procedures or work done on your teeth to prevent infection. Talk with your provider to see if you need this.

Some medications can raise your risk of heart problems. These include diet pills, ephedra, cocaine, and performance-enhancing drugs. Always talk with your provider or pharmacist before starting any new supplements, vitamins, medications, or diets. 

How can I lower my risk?

There are ways you can help keep your heart healthy, like keeping a healthy lifestyle:

• Don't smoke or use drugs.
• Keep a healthy weight.
• Get regular exercise. Talk to your provider if you want to start an exercise plan or play sports.
• Eat a diet high in fruits and vegetables.
• Have your weight, blood pressure, and cholesterol checked as needed by your provider.

What tests do I need to check my heart health?

There are some tests that the Children’s Oncology Group (COG) recommends once you enter “long-term follow-up” from cancer treatment. This is often 2 years after you are done treatment.

• You should have an electrocardiogram (EKG) and an echocardiogram at this time as a baseline measurement.
• An echocardiogram may be done every 2 to 5 years, depending on the dose of anthracycline medicine or radiation you received.
• If you had a higher dose of radiation or a combination of radiation to the heart and anthracycline chemotherapy, you may be referred to a cardiologist for stress testing 5 to 10 years after treatment.
• All survivors should have a physical exam by a healthcare provider at least once a year. Your provider should check your heart health, blood pressure, and risk for other health concerns like high cholesterol and diabetes.

How can I learn more about my risk?

• Going to a cancer survivorship clinic can be helpful to learn about your risk and ways to lower your risk. Find a clinic on our list or call local cancer centers to see if they have a clinic for childhood cancer survivors.
• Make a survivorship care plan with Smart ALACC (Smart Adult Living After Childhood Cancer).
• Visit the Children’s Oncology Group website to learn more about risks and recommendations.
• Talk with your provider about your plan for follow-up care.