Impaired Cardiac and Skeletal Muscle Energetics Following Anthracycline Therapy for Breast Cancer

Circ Cardiovasc Imaging. 2023 Oct;16(10):e015782. doi: 10.1161/CIRCIMAGING.123.015782. Epub 2023 Oct 17.


Background: Anthracycline-related cardiac toxicity is a recognized consequence of cancer therapies. We assess resting cardiac and skeletal muscle energetics and myocyte, sarcomere, and mitochondrial integrity in patients with breast cancer receiving epirubicin.

Methods: In a prospective, mechanistic, observational, longitudinal study, we investigated chemotherapy-naive patients with breast cancer receiving epirubicin versus sex- and age-matched healthy controls. Resting energetic status of cardiac and skeletal muscle (phosphocreatine/gamma ATP and inorganic phosphate [Pi]/phosphocreatine, respectively) was assessed with 31P-magnetic resonance spectroscopy. Cardiac function and tissue characterization (magnetic resonance imaging and 2D-echocardiography), cardiac biomarkers (serum NT-pro-BNP and high-sensitivity troponin I), and structural assessments of skeletal muscle biopsies were obtained. All study assessments were performed before and after chemotherapy.

Results: Twenty-five female patients with breast cancer (median age, 53 years) received a mean epirubicin dose of 304 mg/m2, and 25 age/sex-matched controls were recruited. Despite comparable baseline cardiac and skeletal muscle energetics with the healthy controls, after chemotherapy, patients with breast cancer showed a reduction in cardiac phosphocreatine/gamma ATP ratio (2.0±0.7 versus 1.1±0.5; P=0.001) and an increase in skeletal muscle Pi/phosphocreatine ratio (0.1±0.1 versus 0.2±0.1; P=0.022). This occurred in the context of increases in left ventricular end-systolic and end-diastolic volumes (P=0.009 and P=0.008, respectively), T1 and T2 mapping (P=0.001 and P=0.028, respectively) but with preserved left ventricular ejection fraction, mass and global longitudinal strain, and no change in cardiac biomarkers. There was preservation of the mitochondrial copy number in skeletal muscle biopsies but a significant increase in areas of skeletal muscle degradation (P=0.001) in patients with breast cancer following chemotherapy. Patients with breast cancer demonstrated a reduction in skeletal muscle sarcomere number from the prechemotherapy stage compared with healthy controls (P=0.013).

Conclusions: Contemporary doses of epirubicin for breast cancer treatment result in a significant reduction of cardiac and skeletal muscle high-energy 31P-metabolism alongside structural skeletal muscle changes.

Registration: URL: https://www.

Clinicaltrials: gov; Unique identifier: NCT04467411.

Keywords: anthracycline; breast cancer; cardiac energetics; chemotherapy; skeletal muscle.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adenosine Triphosphate
  • Anthracyclines* / adverse effects
  • Antibiotics, Antineoplastic* / adverse effects
  • Biomarkers
  • Breast Neoplasms* / drug therapy
  • Breast Neoplasms* / pathology
  • Epirubicin* / adverse effects
  • Female
  • Humans
  • Longitudinal Studies
  • Middle Aged
  • Muscle, Skeletal / diagnostic imaging
  • Phosphocreatine
  • Prospective Studies
  • Stroke Volume
  • Ventricular Function, Left


  • Adenosine Triphosphate
  • Anthracyclines
  • Antibiotics, Antineoplastic
  • Biomarkers
  • Epirubicin
  • Phosphocreatine

Associated data