Overview
Heart failure in AML remains a critical concern for patients undergoing induction therapy with anthracycline-based regimens. A comprehensive meta-analysis led by researchers in the Netherlands analyzed 41 studies totaling 5,995 AML patients. The study quantified the burden of heart failure and highlighted substantial variability depending on the specific anthracycline used. These findings reinforce the need for systematic cardiac surveillance and standardized reporting of cardiovascular adverse events during AML treatment.
Key Findings from the Meta-analysis
The pooled proportion of heart failure among AML patients treated with anthracyclines was 3.2%. Yet, the risk was not uniform across drugs:
– Daunorubicin: 2.3%
– Idarubicin: 5.0%
– Mitoxantrone: 10.2%
These figures underscore the cardiotoxic potential of anthracyclines, particularly with certain agents. Beyond symptomatic heart failure, the analysis revealed that secondary cardiovascular adverse events were common but frequently underreported, limiting our understanding of the true cardiovascular burden.
Why Cardiotoxicity Persists as a Concern
Anthracyclines have long been a cornerstone in achieving remission in AML, but their dose-dependent cardiotoxic effects pose a significant risk, especially for patients with existing cardiovascular risk factors. Traditional grading systems for adverse events tend to miss asymptomatic declines in cardiac function, which means early, reversible changes can go undetected until more overt and potentially irreversible damage occurs.
Gaps in Monitoring and Reporting
The review highlights critical gaps in practice and documentation:
– Cardiac monitoring during therapy was infrequent, reducing opportunities to identify early changes in heart function.
– Reporting of cardiovascular adverse events lacked consistency across studies, making it hard to compare data or pool results effectively.
– A substantial proportion of subclinical cardiotoxicity likely remains unrecognized due to reliance on symptomatic criteria.
These gaps collectively suggest that patients may miss timely interventions that could prevent progression to overt heart failure.
Recommendations for Clinical Practice in AML
To mitigate cardiotoxicity and improve outcomes, clinicians should adopt a proactive approach to cardiac health in AML patients receiving anthracyclines:
– Routine cardiac monitoring for all patients during and after anthracycline therapy, regardless of symptom presence.
– Standardized reporting of all cardiovascular adverse events using uniform criteria to enable better data synthesis and evidence-based refinements in practice.
– Incorporation of subclinical indicators into monitoring programs, including serial imaging and biomarker assessments where feasible.
– Implementation of comprehensive surveillance protocols that include echocardiography and cardiometabolic biomarkers to detect early declines in function.
– Consideration of cardioprotective strategies and dose-modification decisions when early signs of cardiotoxicity appear, balancing oncologic efficacy with cardiac safety.
Practical Steps for Healthcare Teams
1) Establish a multidisciplinary cardio-oncology workflow that coordinates oncologists, cardiologists, and nursing staff for ongoing assessment.
2) Use baseline and follow-up echocardiograms to track ejection fraction and emerging functional changes.
3) Integrate biomarker surveillance (e.g., troponin, natriuretic peptides) as part of routine monitoring in high-risk patients.
4) Ensure adverse events are captured using standardized criteria in electronic medical records and clinical trial reporting.
5) Educate patients about potential cardiac symptoms and the importance of reporting subtle changes promptly.
Implications for Research and Future Directions
Further work is needed to refine risk stratification by anthracycline type, optimize monitoring intervals, and determine the most effective combinations of imaging and biomarkers for early detection. Given the underreporting of cardiovascular adverse events, future studies should prioritize complete and consistent cardiovascular outcome data to better quantify real-world risks and guide dose optimization and protective strategies.
Conclusion
The new evidence confirms that heart failure is a meaningful risk for AML patients treated with anthracyclines, with substantial heterogeneity by drug type. The path forward emphasizes routine cardiac surveillance, standardized adverse event reporting, and proactive management of subclinical cardiotoxicity. By integrating these practices, clinicians can improve long-term cardiac and oncologic outcomes for individuals battling AML.
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.
