Adriamycin cardiomyopathy: prevention

PAWAN

pathophysiology
TIMAO U, AND DINENDER

and
KUMAR and Department

K SINGAL,

NATASHA

ILISKOVIC,

Institute of Cardiovascular Sciences, St. Boniface General Hospital Research Centre of Physiology, Faculty of Medicine, University of Manitoba, Winnipeg, Canada ABSTRACT Current knowledge about adriamycin cardiomyopathy indicates that the major cause of this condition is increased oxidative stress although the drugs antitumor action in patients may involve other mechanisms. Controversies about the different antioxidants in preventing cardiomyopathy likely stem from the fact that antioxidants must be effective in both the lipid and water phases, and the dose must be optimal, in order to be protective. Probucol, an antioxidant and promoter of endogenous antioxidants, is one such agent. Conducting clinical trials with an optimal dose of probucol is the next step and should make this great anticancer drug safer and more efficient in the fight against the cancer.-Singal, P. K, iliskovic, N., Li, T., Kumar, D. Adriamycin cardiomyopathy: pathophysiology and prevention. FASEBJ. 11, 931-936 (1997)
Key Words: oxidative pro bucol slress

heart failure

antioxidants

OF ADRIAMYCIN (DOXORUBICIN), an antitumor antibiotic, in the early 1960s represented a major advancement in the fight against cancer, as the drug was found to be very effective a varietyof softand in solid human malignancies (1, 2). This enthusiasm quickly waned, however, when it became obvious that adriamycin had the very serious side effect of causing cardiornyopathy leading to congestive heart failure (CHF)2 (3-6). In thisreview,we discusscurrent concepts about the pathophysiology of adriamycin cardiomyopathy and different approaches for its prevention. During earlyclinical trials ith adriamycin, w electrocardiogram (EKG) modifications including tachycardia, ST segment depression, and T wave changes were observed (7). But ittook a retrospectiveanalysis of 399 patient charts to firmly establish the occurrence of CHF due to adriamycin (3). This study also made it clear that CHF was a dose-dependent phenomenon. An incidence of >5% was seen at a 501550 mg/m2 body surface area, increasing to >30% at over 601 mg/rn2 (3).Thus, the dose of 500mg was considered the upper limitin order to minimize the riskof adriamycin cardiomyopathy and CHF. SubseDISCOVERY

quent studies showed that cardiornyopathy could occur at a much smaller dose of adriamycin in patients with risk factors such as age, some underlying heart conditions, previous or concurrent radiation therapy (5), and concomitant chemotherapy (8). More recently, a long-term follow-up study revealed that patients who were asymptomatic of cardiac toxicity at the time of complete remission of cancer after treatment with adriamycin showed within the next 4 to 20 years an unusually high incidence of cardiovascular complications typical of adriamycin cardiornyopathy (9). Because of its high antitumor efficacy, adriamycin, despite the risk, has remained in use. Although the use of adriarnycin as a single agent has been restricted, itforms a valuable component of various regimens of chemotherapy. Therefore, there isstill need to find ways to avoid a or minimize the cardiotoxic side effects of adriamycm in the treatment of cancer patients. One approach has been to optimize the way in which the drug isadministered in order to reduce its peak concentrations in the plasma. Slow infusion of the drug over 6-96 h in contrast to a rapid infusion over a few minutes has significantly decreased the incidence of cardiotoxicity (10, 11), but this approach increases hospital stay and adds to the cost. Another approach has been to synthesize analogs of adriamycin that would be effectively cytotoxic against cancer but not cardiotoxic. However, a better analog of adriamycin with the same or improved therapeutic index and lesscardiotoxicityhas not been found yet (12). A third focus of the research has been to develop an effective combination therapy that would prevent cardiotoxicity but not interfere with antitumor properties of adriamycin (13). There has been some success with the first two approaches, but the occurrence of cardiovascular events has not been eliminated. Nevertheless, a better understanding of the effectsof adriamycin and a clear differentiation of the antitumor action from the cardiotoxic effects

Correspondence: St. Boniface General Hospital Research Centre, 351 Tache Ave., Room R3022, Winnipeg, Manitoba, Canada R2H 2A6. 2Abbreviations: CHF, congestive heart failure; EKG, electrocardiogram; HDL, high-density lipoprotein.

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have resulted in greater success with combination therapies in subclinicalstudies (13-15).

more recently it has become possible to distinguish the mechanisms underlying these dual effects of adriamycin, as discussed here. Cardiomyopathic

CUNICAL

CHARACTERISTICS

changes

The effects of adriamycin on the cardiovascular system can be categorized as acute and chronic. Acute effects include tachycardia, hypotension, and various EKG changes (3, 16-18). These effectsusuallyoccur during or soon after adnamycin administration. However, the acute effects of adriamycin are never of major concern because these are generally reversible and/or clinically manageable. Chronic effects,n the o other hand, are irreversible cardiomyopathic changes leading to congestive heart failure with grave prognosis (3, 6). Although improvement of decreased ventricular function can be seen in some cases with conventional heart failure therapy, it is temporary and these patients usually go into heart failureeven years later (9). Thus, patients generally are refractory to conventional therapies,and heart transplantation is the only option available. Adriamycin cardiomyopathy can occur within months or sometimes years after the treatment has been completed (3, 9). Typical clinical characteristics of advanced adriamycin cardiomyopathy are a profound decrease in blood pressure and markedly elevated heart rate,a decrease in ejection fraction,and ventricular dilationwith subsequent failure(3).The cardiomyopathy is also characterized by a specific ultrastructural pathology. The main features in cardiac biopsies from patients are cytoplasmic vacuolization due to dilationof the sarcotubules and lossof myofibrils (3, 19). The severity of adriamycin-induced heart damage can be determined by quantification of these ultrastructural changes according to the Billingham scale (20, 21).

ANIMAL

MODEL

A powerful tool to study different aspects of adriamycin cardiotoxicity and its prevention was made availableby the development of differentsmall animal models (13, 22). Adriamycin-induced cardiac changes in ratscloselymimic severalfeatures of the cardiomyopathy seen in humans (23-25). The rat model is considered suitable because it emulates structuralas well as functional changes observed in patientsand ishighly reproducible (24, 26).

Several changes that might play a role in the pathogenesis of adriamycin-induced cardiomyopathy have been described. The list includes inhibition of nucleic acid and protein synthesis (19, 27, 28), release of vasoactive amine (29); alterations in adrenergic function (23); abnormalities in mitochondria (30); lysosomal changes (26); modifications of sarcolemmal Ca2 transport (31); attenuations in adenylate cyclase, NaKtATPase, and Ca2-ATPase activities (32); imbalance in myocardial electrolytes (33); formation of free radicals (34-36); lipid peroxidation (26, 34, 37) and depletion of non-protein tissue suifhydryl groups (38-40). However, most of the studies support the view that an increase in oxidative stress evidenced by an increase in free radicals and lipid peroxidation aswell as a decrease in antioxidants and suifflydryl groups plays an important role in the pathogenesis of adriamycin cardiomyopathy (13, 34). Increased oxidative stress by adriamycin can be explained by its chemical structure, which is very prone to the generation of free radicals. Adriamycin is a tetracyclic aglycone to which an amino sugar is attached via a glycosidic bond. The quinone ring, which isa part of the tetracycline moiety, undergoes redox cycling between quinone and semiquinone. During this process, electrons generated are captured by oxidizing agents including oxygen, which then initiates chain reaction leading to the genera ation of free radicalspecies,followed by cardiomyocyte injuryand cardiomyopathy (34). Direct support for thisconcept of oxidative stresswas provided by the detection by electron spin resonance spectroscopy of adnamycin-generated oxygen species (4143). Cytochrome P450 reductase and xanthine oxidase have also been found to catalyze the reduction of the anthraquinone to a semiquinone free radical (44, 45). Indirect support was offered by studies that found an increase in tissue malondialdehyde, which isa product of lipidperoxidation (31,37).Adriamycin has also been shown to depress different antioxidants, thus contributing to increased oxidative stress (15,38). Several review articles (13,34,46) provide the reader with more details of adriamycin-induced free radical production and lipid peroxidation as well as descriptions of adriamycin-caused subcellularchanges leading to heart failure. Antitumor

MECHANISMS The subcellular basis for adriamycin-induced cardiomyopathy as well as its antitumor action were earlier thought to involve a common pathway. However,
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action

Because adriamycin has been shown to produce free radicals, it was suggested earlier that free radical injury might be a mechanism of adriamycin antitumor

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action (47, 48). The formation of free radicals in breast cancer cellsas well as in some other celltypes exposed to high concentrations of adriamycin was established (48-51). Another important point supporting the concept of free radical-mediated antitumor action is that adriamycin easily binds with iron, forming an adriamycin-iron complex. Adriamycin bound to iron can also complex with DNA. These complexes can stimulate the production of partiallyreduced forms of oxygen (52-54). These radicals are formed in the neighborhood of DNA strands (52, 53), and free radical-induced DNA damage as well as strand breaks are extensively described in literature (55). A careful review of the available literature reveals that relatively high in vitro concentrations of adriamycin were used to demonstrate the free radical-mediated DNA damage in tumor cells (56). Doses used in in vivo conditions are much lower, suggesting that a free radical mechanism might not be the primary cause of the antitumor activity adriamycin. This of point issupported by a multitude of studiesin which the addition of differentantioxidants such asvitamin C (57, 58), superoxide dismutase (58), N-acetylcysteine (37, 59), glutathione (60), catalase (58), and probucol (15) did not compromise adriamycin cytotoxicity in a variety of tumor cells. However, other mechanisms explain inhibition of DNA replication by adriamycin, and thus its cytotoxicity and antitumor action, without the involvement of free radicals. direct intercalationof adriamycin A between DNA base pairs (61) interfereswith DNA replication; this is a cooperative interaction between adriamycin and DNA (62). Adriamycin-mediated inhibition of DNA topoisomerase 11(63) has also been shown to inhibit DNA replication. Adriamycin-topoisomerase Il-DNA complex prevents repairing of the broken DNA strands (64). At lower adriamycin concentrations similar to that observed in clinical situations, L1210 cells had only DNA topoisomerase IImediated, protein-associated strand breaks (65), whereas with increased adriamycin concentrations, cellsdied mainly due to directstrand breaks, not the protein-associatedones (50). Thus, adriamycin can exert an antitumor effect without involving free radical production. Antitumor action at low concentrations of adriamycin independent of free radical mediation has been reconciled with the free radicalmediated cardiotoxic effect of the drug seen at higher cumulative doses in a scheme shown in Fig. 1.

Figure 1. Distinction between the cardiotoxic and antitumor mechanisms of action of adriamycin. It is proposed that probucolinterupts thefreeradical-mediated pathwayand prevents cardiotoxic effects of adriamycin.

riamycin-induced apoptosis of hair follicle ells(68). c Renal and intestinal epithelial cells from adriamycintreated spontaneously hypertensive rats showed apoptosis whereas none was observed in cardiomyocytes (69).Additional studies dealing with the possible role of apoptosis in adriamycin cardiotoxicity are needed before ruling out its role in the lossof myocardialfunction.

ANTIOXIDANTS COMBINATION

AND ADRIAMYCIN THERAPY

IN

Apoptosis
Programmed cell death, or apoptosis, is a phenomenon that has attracted much attention in recent years. Adriamycin-induced apoptosis was observed in tumor cells (66, 67). Alopecia, or loss of hair due to chemotherapy, was suggested to be the resultof ad-

One of the first antioxidants tested against adriamycm cardiomyopathy was vitamin E, with very encouraging findings (37). A bolus injection of vitamin E, 24 h before adriamycin injection, prevented the development of typicalultrastructural ardiomyopathic c changes in mice (37). However, in subsequent years, several conflicting reports appeared with respect to the efficacy of antioxidants in mitigating the process of cardiomyopathy. These differences may have been due to the experimental model as well as type and dose of the antioxidant used. Further research showed that vitamin E was cardioprotective only against acute cardiotoxicityof adriamycin, whereas it offered no protection against the development of chronic cardiomyopathy (70). A combined vitamin E/selenium supplementation also failed to reduce adriamycin-induced mortality in

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mice (71) or protect against adriamycin-induced cardiomyopathy in dogs (72). In the following years, many differentantioxidants were testedwith limited success:ascorbic acid (57), reduced glutathione (60), selenorganic compound PZ51 (73), oleanolic and ursolic acids (74), and ambroxol (75). It appears that a careful characterizationof the animal model and an optimization of the dose of the drug are of paramount importance in order to find consistency in the protective effects of a given antioxidant. Optimization of the dose of an antioxidant used is convincingly highlighted in a recent study using transgenic mice in which a 100-fold increase in catalase was found to be protective;a 200-fold increase in the same antioxidant enzyme offered no protection, whereas a 500-fold increase was found to promote adriamycin toxicity (76). The most attention has been aroused by the ironchelating agent ICRF-187 (77, 78). Pretreatment with this compound significantly reduced the appearance of adriamycin-induced cardiomyopathy in a dog model (79), supporting the pathogenic role of oxidative stress. This combination therapy was also introduced into clinical practice (80). However, problems with this combination therapy soon became obvious because of the potentiation of adriamycin haemotoxicity by ICRF-187 (80).

increase in endogenous antioxidant enzyme activities in the heart (13), making it an ideal agent for enhancing antioxidant defense in the lipid (i.e., in the membranes) as well as water (i.e., in the cytosol) compartments. That adriamycin increased plasma as well as cardiac lipids and probucol modulated these changes (83) could also indicate a role in keeping the progression of cardiomyopathy under check. Hence, the success of probucol-adriamycin combination therapy in an animal model justifies urgent clinical trials establishits effectin cancer patients. to Concerns that discouraged the use of probucol as a lipid-lowering agent (its HDL-lowering property) should not matter in its safe use in cancer patients. Decrease in HDL could be an issue only in the chronic use of probucol, whereas in the proposed protocol the usage would be for a limited time. Furthermore, the benefit of preventing cardiomyopathy and congestive heart failure definitely outweighs the consequences of a temporary decrease in plasma HDL levels of cancer patients. Thus, probucol may be unique in being an antioxidant, promoting endogenous antioxidants, lowering plasma lipids, and having no effect on the antitumor efficacy of adriamycin, making it an ideal drug for adjunct therapy.
Research cited in this paper was supported by grants from the Manitoba Heart and Stroke Foundation. P.K.S. was supported by the Medical Research Council of Canada and N.I. by the Manitoba Health Research Council.

Probucol:

an effective

antioxidant

Probucol was used in the 1970s and 1980s as a lipidlowering drug. Its use declined, however, because of an unfavorable effect on the plasma lipid profile demonstrated by a decrease in high-density lipoprotein (HDL) levels. At about the same time that probucol was determined to be unsuitable for hyperlipidemic pathologies, its strong antioxidant properties came to light (81, 82). The chemical structure of probucol resembles vitamin E in that it has two phenolic groups; vitamin E has only one and is considered to be an important biological antioxidant. Our laboratory has tested the beneficial effects of probucol against adriamycin-induced cardiomyopathy (14, 15, 83) in an established and reliable animal model (24). Combination therapy with probucol in one study showed a partial protection (14). However, in a subsequent study, when an optimal dose of probucol was used, complete prevention of the development of adnamycin-induced cardiomyopathy was seen (15). Decrease in endogenous antioxidants, increase in lipidperoxidation, hemodynamic and ultrastructural changes, and ascites as well as other signs of heart failuredue to adriamycin treatment were normalized with probucol administration (15). Probucol did not affectantitumor propertiesof adriamycin, as tested in the tumor-bearing mice (15). Another important finding was that probucol alone as well as in combination with adriamycin caused an

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