Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access
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Review

Volume 17, Number 4, August 2026, pages 267-276

Cardiovascular Autonomic Dysfunction in Cancer Therapy: Clinical Manifestations and Management

Figure

↓  Figure 1. Overview of mechanisms, clinical manifestations, and therapeutic targets in chemotherapy-associated cardiovascular autonomic dysfunction. Chemotherapy and malignancy can affect the central and peripheral autonomic nervous system through neurotoxicity and direct cardiotoxic effects, resulting in altered autonomic tone with sympathetic overactivity and reduced heart rate variability (HRV). These changes contribute to clinical manifestations including orthostatic hypotension, sinus tachycardia, palpitations, exercise intolerance, arrhythmias, and heart failure. Potential therapeutic strategies aimed at improving autonomic balance include structured exercise, mindfulness-based interventions, cryotherapy, and pharmacologic therapy.
Figure 1.

Tables

↓  Table 1. Selected Studies Evaluating Manifestations and Interventions in Chemotherapy-Associated Cardiovascular Autonomic Dysfunction
 
Ref. No.First authorPopulation studiednStudy designChemotherapyInterventionPrimary findings / conclusion
This table summarizes representative human studies evaluating clinical manifestations, physiologic markers, and therapeutic interventions related to cardiovascular autonomic dysfunction in patients receiving cancer therapy. Included studies encompass observational cohorts, case series, and randomized controlled trials assessing orthostatic hypotension, sinus tachycardia, heart rate variability, and autonomic tone across diverse oncology populations, as well as selected intervention trials involving symptom-directed management. Sample size (n) reflects the final analyzed cohort when available. ALL: acute lymphoblastic leukemia; ANS: autonomic nervous system; HFrEF: heart failure with reduced ejection fraction; HRV: heart rate variability; n: number.
6StoneAdvanced cancer patients (palliative care cohort)185Observational, prospective cohortNot specifiedNoneCardiovascular autonomic dysfunction highly prevalent; up to ∼80% demonstrated definite/severe dysfunction. Associated with fatigue and reduced survival.
7IwańskiBroad oncology patients223Observational, cross-sectionalNot specifiedNoneCancer patients receiving chemotherapy demonstrated clinically significant orthostatic hypotension consistent with autonomic dysfunction.
8DermitzakisOvarian cancer patients31Observational, prospective cohortPaclitaxel, carboplatinNonePaclitaxel-carboplatin chemotherapy impaired parasympathetic heart innervation and autonomic responses.
9JerianOvarian cancer patients2Case seriesPaclitaxelNonePaclitaxel precipitated severe autonomic neuropathy with incapacitating cardiovascular symptoms.
10LinBreast cancer patients34Observational prospectiveAnthracyclines ± taxaneNoneAdjuvant chemotherapy impaired cardiovascular responses and reduced exercise tolerance during treatment.
12RodriguesAnthracycline-related HFrEF patients16Observational, cross-sectionalAnthracycline-basedNoneAnthracycline-related HFrEF showed sympathetic overactivity and reduced exercise capacity compared with controls.
13GuimarãesBreast cancer patients20Case seriesAnthracyclines ± trastuzumabNoneNuclear imaging showed early cardiac sympathetic hyperactivity during treatment.
14KobayashiPediatric hematologic cancer patients38Observational, retrospective cohortAnthracyclines and/or vincristineNonePediatric chemotherapy reduced HRV versus controls.
15CaruPediatric ALL survivors203Observational, cross-sectionalDoxorubicin-basedDexrazoxaneChildhood ALL survivors showed autonomic dysfunction; dexrazoxane attenuated doxorubicin-associated effects.
16NousiainenAdult lymphoma patients27Observational, prospective cohortDoxorubicin-basedNoneDoxorubicin-induced left ventricular dysfunction was associated with an early change in sympathovagal balance towards sympathetic predominance
17TjeerdsmaAsymptomatic breast cancer patients52Observational, prospective cohortAnthracycline-basedNoneAutonomic abnormalities preceded echocardiographic changes during early anthracycline cardiotoxicity.
19HemuBroad oncology patients622Observational, retrospective cohortNot specifiedNoneSinus tachycardia in cancer patients is associated with higher cardiovascular events and mortality.
20CerenBreast cancer patients136Observational, cross-sectionalNot specifiedNoneImpaired HRV predicted worse cardiovascular risk profiles including increased occurrence of atrial fibrillation.
21Luna-AlcalaBreast cancer patients50Observational, prospective cohortAnthracyclines and trastuzumabNoneReduced HRV predicted early cardiotoxicity before echocardiographic left ventricular dysfunction.
22MostardaBreast cancer patients18Randomized controlled trialNot specifiedExerciseShort-term combined exercise training improved cardiorespiratory fitness and autonomic modulation in breast cancer patients.
26InbaraBreast cancer patients59Randomized controlled trialAnthracycline-basedYogaYoga therapy showed protective effects on ANS functioning as measured by resting heart rate and HRV.
27ParkBroad oncology patients28Randomized controlled trialNot specifiedMindfulness therapyMindfulness therapy improved HRV, reduced distress, anger, and sleep disturbance and increased quality of life.
28LouisHealthy adults40Randomized controlled trialNoneCryotherapyWhole-body cryotherapy acutely increased parasympathetic activity but effects decreased with habituation.
32HohneckBroad oncology patients52Randomized cross-over designNot specifiedSound therapyA single sound intervention improved cardiovascular parameters commonly associated with increased stress, including HRV (in the short term).
34LowPatients with neurogenic orthostatic hypotension162Randomized controlled trialNoneMidodrineMidodrine significantly improved standing blood pressure and orthostatic symptoms versus placebo.
35Irizarry-CaroOncology patients with heart failure85Observational, retrospective cohortNot specifiedMidodrineMidodrine use in patients with cancer and heart failure showed no major adverse effects, worse cardiovascular outcomes, or increased risk of mortality.
36KaufmannPatients with neurogenic orthostatic hypotension162Randomized controlled trialNoneDroxidopaDroxidopa improved orthostatic symptoms and standing blood pressure compared with placebo.

 

↓  Table 2. Offending Agents, Burden (Scope of the Problem), and Mechanisms in Cardiovascular Autonomic Dysfunction
 
ExamplesEstimated burdenProposed mechanisms
This table summarizes commonly implicated cancer-related factors and therapies with proposed mechanisms of autonomic injury, based on previously published studies.
Platinum agents and taxanesCisplatin, carboplatin, paclitaxel, docetaxelReported in up to ∼20% of casesMitochondrial dysfunction, oxidative stress, impaired axonal transport, small fiber/autonomic nerve injury
Vinca alkaloidsVincristine, vinblastineWell-described autonomic involvement with variable prevalenceMicrotubule disruption leading to axonal degeneration of autonomic fibers
AnthracyclinesDoxorubicinHigher prevalence with cumulative dosing; reported up to ∼80% in select cohortsOxidative stress, mitochondrial injury, autonomic imbalance affecting cardiac regulation
Proteasome inhibitorsBortezomib, carfilzomibRecognized but variable prevalenceMitochondrial dysfunction, endoplasmic reticulum stress, neurotoxicity
Immune checkpoint inhibitorsNivolumab, pembrolizumab, ipilimumabRare but clinically significantImmune-mediated neuropathy, ganglionitis, inflammatory injury
Radiation therapyThoracic or neck radiationDose- and field-dependent; often delayedFibrosis, vascular injury, baroreceptor and autonomic pathway damage
Cancer itselfAdvanced solid tumors, metastatic diseaseDetected in a majority of patients with advanced disease when systematically assessed (up to 80%)Systemic inflammation, oxidative stress, cachexia, metabolic derangements, paraneoplastic effects
Comorbid conditionsDiabetes mellitus, malnutrition, deconditioningCommon contributors that amplify riskAutonomic neuropathy, metabolic stress, reduced physiologic reserve