Add-on multidrug therapy based on quadruple therapy successfully treated worsening heart failure caused by　anthracycline-induced cardiomyopathy in a young adult cancer survivor: a case report

Background: In patients with heart failure and a reduced ejection fraction, the overall mortality and morbidity benefit is greatest when treated with the combination of sacubitril/valsartan, beta-blockers, mineralocorticoid-receptor antagonists, and sodium-glucose transporter-2 inhibitors, the so-called "fantastic four" or "quadruple therapy.” Adding vericiguat (an oral soluble guanylate cyclase stimulator) is thought to aid in the management of worsening heart failure after quadruple therapy. Among children and young adult cancer survivors, cardiovascular complications that develop more than ten years after anthracycline-based chemotherapy have a poor prognosis. The efficacy of multidrug therapy based on quadruple therapy for worsening heart failure among cancer survivors with anthracycline-induced cardiomyopathy has not been reported. Case Presentation A young adult cancer survivor who had undergone high-dose anthracycline chemotherapy experienced acute decompensated heart failure 20 years post-chemotherapy and developed worsening heart failure one and a half years after discharge. Initiation of quadruple therapy with necessitous ivabradine induction for the worsening heart failure demonstrated a trend toward improvement. Vericiguat was accelerated because of the risk of more severe cardiovascular events associated with ongoing aortic stenosis and the poor prognosis of anthracycline-induced cardiomyopathy. Heart failure symptoms continued to improve with significant cardiac reverse remodeling, and the patient successfully underwent aortic valve replacement for severe aortic stenosis. Conclusions: Multidrug therapy with add-on vericiguat and ivabradine based on quadruple therapy may successfully treat worsening heart failure among high-risk cancer survivors with severe anthracycline-induced cardiomyopathy.