Proteasome Inhibitor-Related Cardiotoxicity: Mechanisms, Diagnosis, and Management


Purpose of Review

Multiple myeloma is the second most common hematologic malignancy in the USA, with over 32,000 new cases and nearly 13,000 deaths expected in 2019. The past few decades in myeloma research have yielded significant advances, leading to the expansion of novel anti-myeloma agents. This review describes the incidence and mechanisms of cardiotoxicity for the FDA-approved proteasome inhibitors in myeloma and proposes strategies to assess and manage resultant cardiovascular adverse events.

Recent Findings

Proteasome inhibition precipitates protein aggregation and alters transcriptional activation of NF-κB targets which contributes to a pro-apoptotic signaling cascade in myeloma cells. Similar effects in cardiomyocytes and vascular smooth muscle endothelium, along with off-target downregulation of autophagy and signaling alterations of nitric oxide homeostasis, may be linked to observed cardiotoxic effects. There is preliminary evidence for cardioprotective potential for rutin, dexrazoxane, and apremilast that could have clinical applicability in the future.


Of the proteasome inhibitors used in clinical practice, carfilzomib is the most strongly associated with cardiotoxicity. Patients with anticipated carfilzomib treatment should undergo assessment and optimization of baseline cardiovascular risk, with close monitoring during treatment. Previous clinical trials were not specifically designed to assess proteasome inhibitor-related cardiotoxicity, creating a need for future studies to identify and risk stratify vulnerable individuals and to develop potential cardioprotective strategies in attenuating cardiac injury.

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Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Correspondence to Eric H. Yang.

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Perry Wu declares that he has no conflict of interest. Ohad Oren declares that he has no conflict of interest. Morie A. Gertz is supported by grants/research funding from Spectrum Pharmaceuticals, the Amyloidosis Foundation, the International Waldenstrom’s Macroglobulinemia Foundation, and the National Institutes of Health National Cancer Institute (SPORE MM SPORE 5P50 CA186781–04); has received compensation from Ionis/Akcea, Alnylam, Prothena, Celgene, Janssen, Spectrum Pharmaceuticals, Annexon Biosciences, Apellis, Amgen, Medscape, Physicians’ Education Resource, AbbVie (Data Safety Monitoring Board), and Research To Practice for service as a consultant; has received speaker’s honoraria from Teva, Johnson and Johnson, Medscape, and DAVA Oncology; has served on advisory boards for Pharmacyclics and Proclara Biosciences; has assisted in the development of educational materials for i3 Health; and has received royalties from Springer Publishing. Eric H. Yang declares that he has no conflict of interest.

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Wu, P., Oren, O., Gertz, M.A. et al. Proteasome Inhibitor-Related Cardiotoxicity: Mechanisms, Diagnosis, and Management. Curr Oncol Rep 22, 66 (2020).

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  • Carfilzomib
  • Bortezomib
  • Chemotherapy-induced cardiomyopathy