Better safe.

The red devil is dreaded for many reasons, not least of which is cardiotoxicity. Nonetheless, it remains a component of many of the most effective systemic therapy regimens for breast cancer. The Italian phase 3 SAFE trial analyzed 174 women receiving first-line anthracycline-based chemo for localized breast cancer were randomized to one year of: [1] placebo, [2] the ACE-inhibitor ramipril 5 mg daily, [3] the beta-blocker bisoprolol 5 mg daily, or [4] both bisoprolol and ramipril. The primary endpoint of a reduction of ≥10% in left ventricular ejection fraction at 12 months occurred in 8 (19%) with placebo, 5 (12%) with ramipril, 5 (11%) with bisoprolol, and 3 (7%) with both ramipril and bisoprolol. What’s more, the co-primary endpoint of a worsening of ≥10% in global longitudinal strain at 12 months occurred in 15 (36%) with placebo, 7 (16%) with ramipril, 6 (14%) with bisoprolol, and 6 (14%) with ramipril and bisoprolol. The authors will continue to monitor longer term changes, but this first analysis is certainly promising. | Livi, JAMA Oncol 2021