New Evidence on Cardiotoxicity in AML Treatment
A comprehensive new systematic review analyzed 41 studies involving 5,995 patients with acute myeloid leukemia (AML) who received anthracycline-based regimens during remission induction. The pooled rate of heart failure in this population was 3.2%, with notable differences depending on the anthracycline used: 2.3% with daunorubicin, 5.0% with idarubicin, and 10.2% with mitoxantrone. While cardiotoxicity has long been a concern in AML therapy, these findings provide a clearer, aggregated picture of risk across commonly used agents and highlight the substantial variation among them.
The study also draws attention to secondary cardiovascular adverse events, which were common but frequently underreported in the existing literature. This underlines a broader issue in clinical reporting: the need for consistent documentation of cardiovascular outcomes to accurately gauge the true burden of treatment-related heart problems in AML patients.
Why Anthracyclines Pose a Cardiac Risk
Anthracyclines remain a cornerstone of AML therapy due to their demonstrated efficacy in achieving remission. However, their dose-dependent cardiotoxic effects are well established, particularly in patients with preexisting cardiovascular risk factors. The risk is not limited to symptomatic heart failure; subclinical dysfunction can precede overt symptoms, often going undetected when monitoring relies solely on clinical observation.
The current grading systems for adverse events frequently miss early declines in cardiac function. This gap means that reversible changes may progress unnoticed, potentially advancing to irreversible heart failure if not identified and managed promptly.
Gaps in Monitoring and Recommendations for Practice
The meta-analysis identified that routine cardiac monitoring during AML therapy is inconsistent and frequently underutilized. Echocardiography, cardiopulmonary testing, and cardiac biomarkers were not uniformly employed across studies, limiting the ability to catch early subclinical cardiotoxicity. Standardizing monitoring protocols could facilitate earlier detection of cardiac injury and enable timely interventions that preserve heart function without compromising leukemia control.
Another critical issue is the lack of standardized reporting for cardiovascular adverse events. Without uniform criteria, comparing outcomes across trials and centers becomes challenging, hindering our understanding of the true impact of anthracyclines on cardiac health.
Practical Implications for AML Care
Clinicians treating AML with anthracyclines should consider implementing routine, proactive cardiac surveillance for all patients, regardless of symptoms. Suggested components include baseline and periodic echocardiography to monitor left ventricular function and incorporation of cardiac biomarkers (such as troponin and natriuretic peptides) to detect subclinical injury.
Standardized reporting of cardiovascular adverse events is equally important. Using uniform criteria will improve data quality and enable meaningful cross-study comparisons, guiding future therapy decisions and survivorship care plans.
Early detection is key. When cardiotoxicity is identified at a subclinical stage, timely intervention—such as dose modification, cardio-protective strategies, or closer heart function monitoring—may prevent progression to advanced heart failure. This approach can help AML patients maintain both high-quality cancer outcomes and long-term cardiac health.
Looking Ahead: Turning Data into Action
The study by Geels and colleagues emphasizes the need for ongoing research into cardiotoxicity risk stratification, improved monitoring tools, and better adverse event reporting. Future work should explore optimization of anthracycline dosing, alternative regimens with lower cardiac risk, and the role of cardio-oncology teams in the AML care pathway. By aligning monitoring practices with robust data, clinicians can better balance the effectiveness of leukemia therapy with the preservation of heart function.
Key Takeaways for Clinicians
- Heart failure risk during AML therapy with anthracyclines varies by drug, with mitoxantrone showing the highest signal in the current analysis.
- Subclinical cardiotoxicity is common and underdetected with traditional symptom-based monitoring.
- Routine cardiac surveillance and standardized adverse-event reporting are essential to improve outcomes.
Reference: Geels J et al. Heart failure in patients with acute myeloid leukemia (AML) treated with anthracycline agents during remission induction therapy: a systematic review and meta-analysis. Leukaemia. 2025; https://doi.org/10.1038/s41375-025-02753-w.
