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Peer reviewed: True, BACKGROUND: Anthracyclines form the backbone of many systemic chemotherapy regimens but are accompanied by dose-limiting cardiotoxicity. We elucidate the progression and severity of cardiac function over time, in the absence of cardioprotection, which less is known about. METHODS: This PRISMA-guideline-adherent review was registered on PROSPERO (CRD42022373496). RESULTS: 26 studies met the eligibility criteria including a total of 910 patients. The overall reduction in post-anthracycline pooled mean left ventricular ejection fraction (LVEF) in placebo arms of the included randomised-controlled trials was 4.5% (95% CI, 2.6 to 6.4). The trend in LVEF showed a progressive decline until approximately 180 days, after which there was no significant change. Those receiving a cumulative anthracycline dose of 300 mg/m2 experienced a more profound reduction. The overall pooled risk of a 10% absolute decline in LVEF from baseline, or a decline to an LVEF below 50%, was 17% (95% CI: 11 to 24; I2 = 71%). Sensitivity analyses of baseline LVEF and trastuzumab treatment status did not yield significant differences. CONCLUSION: While the mean LVEF decline in patients without cardioprotective therapy was clinically small, a vulnerable subset experienced significant impairment. Further research to best identify those who benefit most from cardioprotective therapies when receiving anthracyclines is required.

Acute ischemic strokes (AIS) are closely linked with air pollution, and there is some evidence that traditional cardiovascular risk factors may alter the relationship between air pollution and strokes. We investigated the effect of atrial fibrillation (AF) on the association of AIS with air pollutants. This was a nationwide, population-based, case-only study that included all AIS treated in public healthcare institutions in Singapore from 2009 to 2018. Using multivariable logistic regression, adjusted for time-varying meteorological effects, we examined how AF modified the association between AIS and air pollutant exposure. A total of 51,673 episodes of AIS were included, with 10,722 (20.7%) having AF. The odds of AIS in patients with AF is higher than those without AF for every 1 µg/m3 increase in O3 concentration (adjusted OR [aOR]: 1.005, 95% CI 1.003-1.007) and every 1 mg/m3 increase in CO concentration (aOR: 1.193, 95% CI 1.050-1.356). However, the odds of AIS in patients with AF is lower than those without AF for every 1 µg/m3 increase in SO2 concentration (aOR: 0.993, 95% CI 0.990-0.997). Higher odds of AIS among AF patients as O3- and CO concentrations increase are also observed in patients aged ≥65 years and non-smokers. The results suggest that AF plays an important role in exacerbating the risk of AIS as the levels of O3 and CO increase.