Cardiotoxicity remains a major challenge in cancer care because cardiovascular complications can interrupt or even prevent completion of anti-cancer therapy, potentially compromising treatment outcomes, reports Medscape.
The question of the extent to which guideline-recommended heart failure therapies protect cardiac function in patients on anti-cancer treatment was recently addressed in a meta-analysis presented at the European Society of Cardiology Congress (ESC Congress 2026) in Vienna, Austria.
Researcher Ymke Appels, from Erasmus Medical Centre, Cardiovascular Institute, Rotterdam, The Netherlands, said: “ESC guidelines for cardio-oncology recommend using certain treatments in patients … who show signs of cardiac dysfunction, but the evidence comes largely from small studies, from expert opinion, and/or by adapting other guidelines such as those on heart failure.
“We conducted a meta-analysis of data from published studies to better understand how much different heart failure-recommended therapies prevent cardiac deterioration in patients being treated with anti-cancer drugs.”
The analysis involved systematically searching biomedical literature databases for studies of patients treated with these drugs that evaluated the effects of therapies recommended in the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2023 update.
Randomised controlled trials and retrospective and prospective non-randomised studies were included.
The drug classes assessed were renin-angiotensin-aldosterone system (RAAS) inhibitors (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and angiotensin receptor neprilysin inhibitors), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors. Statins were also considered.
In total, 49 studies were identified, which involved 6 998 patients. The analysis mainly investigated the effects of the different therapies on left ventricular ejection fraction (LVEF), a measure of the heart’s pumping ability. Across 23 studies assessing RAAS inhibition, LVEF improved by 2.88% compared with placebo or standard of care (P < .001).
Over the 22 beta-blocker studies, there was a more modest LVEF improvement of 1.20% compared with placebo or standard of care (P = .05). Notably, across the eight studies involving a combination of RAAS inhibition and beta-blockers, LVEF improved by 2.98% (P < .001).
Significant positive changes in global longitudinal strain, a marker of cardiac contraction, were also seen with RAAS inhibitors, beta-blockers, and the combination of the two treatments, reported the team.
Mineralocorticoid antagonists appeared to show encouraging protective effects, with an LVEF increase of 4.68% compared with placebo or standard of care, but these data were derived from only two studies. The one study with SGLT2 inhibition showed an LVEF improvement of 3.20%. Statins were investigated in seven studies and showed an LVEF increase of 2.49% compared with placebo or standard of care (P < .001).
Wouter Meijers, MD, PhD, cardiologist in Rotterdam and the study’s principal investigator, concluded: “By pooling together study results, we have confirmed that guideline-recommended heart failure therapies – particularly a combination of RAAS inhibitors plus beta-blockers – protect heart function in patients.
“The number of studies with other heart failure therapies was low, highlighting the need for further randomised trials, particularly of newer cardiovascular treatments, to fully understand their place in cardio-oncology.”
Study details
Cardioprotective effects of medical therapy for cancer therapy-related cardiac dysfunction: a systematic review and meta-analysis
Y Appels, R Parvan, CGS Mohan et al.
Presented at ESC Congress Vienna on 19 June 2026
Abstract
Background
Cancer therapy-related cardiac dysfunction (CTRCD) limits optimal cancer therapy regimens. Although heart failure guideline-recommended medical therapy (GRMT) has been proposed as a cardioprotective strategy, robust evidence from randomised controlled trials (RCTs) remains insufficient due to limited study availability and heterogeneous outcomes. We conducted a comprehensive systematic review and meta-analysis to investigate the cardioprotective potential of GRMT in patients receiving cancer therapy.
Methods
EMBASE and PubMed were systematically searched for RCTs evaluating GRMT for the prevention of CTRCD in cancer patients treated with any established anti-cancer drug cocktail. Two independent reviewers performed study selection, data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias 2 (RoB 2) tool. GRMT classes included RAAS inhibitors, beta-blockers, mineralocorticoid antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Statins were additionally considered. Studies were stratified by cancer treatment: 1) anthracycline-based, 2) anti-HER2-based, and 3) combined anthracycline/anti-HER2 regimens. Primary outcome was a change in left ventricular ejection fraction (LVEF) in patients treated with versus without GRMT. Random-effect meta-analyses were conducted using STATA and presented as weighted mean differences (WMD). Anthracycline-mediated CTRCD data were visualised in the attached forest plots.
Results
A total of 36 RCTs comprising 3968 patients were included. RAAS-inhibition significantly improved LVEF in anthracycline-mediated (group 1: WMD 3.64; [95% Confidence Interval 0.21 – 7.08]), and anti-HER2-mediated CTRCD (group 2: 4.15 [2.49-5.81]), but not in anthracycline/anti-HER2 regimens (group 3: 0.08 [-1.19-1.36]). Beta-blockers demonstrated a similar pattern (group 1: 1.05 [0.04-2.06]; group 2: 4.01 [2.07-5.96]; group 3: 0.67 [-0.68-2.01]). Statins were associated with a LVEF preservation in group 1 (2.54 [1.51-3.56]), however no claim could be made for group 2, as evidence was limited to a single study. MRAs and combined RAAS-inhibitors/beta-blockers therapies showed protective effects in group 1, although robust conclusions were limited due to sparse numbers of RCTs. No RCT data were available on SGLT2i.
Conclusion
RAAS inhibitors and beta-blockers significantly improved LVEF in patients exhibiting anthracycline- or anti-HER2-mediated CTRCD, whereas no beneficial effect was observed in patients with combination regimens. We hypothesise that severity of established CTRCD in this subgroup might be too advanced for significant LVEF improvements. Moreover, statins hold promise in the prevention of anthracycline- and/or anti-HER2-mediated CTRCD. Other GRMT classes, i.e. MRAs and SGLT2i, remain under-represented in RCTs, despite their potential cardioprotective properties. These findings emphasise the need for future trials focusing on modern HF therapies in oncology patients.
ESC congress presentation (Open access)
Medscape Medical News article – Can the heart be protected during cancer therapy? (Open access)
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