The care for patients with cancer has advanced greatly over the past decades. A combination of earlier cancer diagnosis and greater use of traditional and new systemic treatments has decreased ...cancer-related mortality. Effective cancer therapies, however, can result in short- and long-term comorbidities that can decrease the net clinical gain by affecting quality of life and survival. In particular, cardiovascular complications of cancer treatments can have a profound effect on the health of patients with cancer and are more common among those with recognized or unrecognized underlying cardiovascular diseases. A new discipline termed cardio-oncology has thus evolved to address the cardiovascular needs of patients with cancer and optimize their care in a multidisciplinary approach. This review provides a brief introduction and background on this emerging field and then focuses on its practical aspects including cardiovascular risk assessment and prevention before cancer treatment, cardiovascular surveillance and therapy during cancer treatment, and cardiovascular monitoring and management after cancer therapy. The content of this review is based on a literature search of PubMed between January 1, 1960, and February 1, 2014, using the search terms cancer, cardiomyopathy, cardiotoxicity, cardio-oncology, chemotherapy, heart failure, and radiation.
The aim of this study was to assess whether serial quantitative assessment of right ventricular (RV) function by speckle-based strain imaging is affected by pulmonary hypertension–specific therapies ...and whether there is a correlation between serial changes in RV strain and clinical status. RV longitudinal systolic function was assessed using speckle-tracking echocardiography in 50 patients with pulmonary arterial hypertension (PAH) before and after the initiation of therapy. The mean interval to follow-up was 6 ± 2 months. Subsequent survival was assessed over 4 years. Patients demonstrated a mean increase in RV systolic strain from −15 ± 5 before to −20 ± 7% (p = 0.0001) after PAH treatment. Persistence of or progression to a severe reduction in free wall systolic strain (<−12.5%) at 6 months was associated with greater disease severity (100% were in functional class III or IV vs 42%, p = 0.005), greater diuretic use (86% vs 40%, p = 0.02), higher mean pulmonary artery pressure (67 ± 20 vs 46 ± 17 mm Hg, p = 0.006), and poorer survival (4-year mortality 43% vs 23%, p = 0.002). After adjusting for age, functional class, and RV strain at baseline, patients with ≥5% improvement in RV free wall systolic strain had a greater than sevenfold lower mortality risk at 4 years (hazard ratio 0.13, 95% confidence interval 0.03 to 0.50, p = 0.003). In conclusion, serial echocardiographic assessment of RV longitudinal systolic function by quantitative strain imaging independently predicts clinical deterioration and mortality in patients with PAH after the institution of medical therapy.
Background Pulmonary arterial hypertension (PAH) is a devastating illness of pulmonary vascular remodeling, right-sided heart failure, and limited survival. Whether strain-based measures of right ...ventricular (RV) systolic function predict future right-sided heart failure and/or death is untested. Methods RV longitudinal systolic strain and strain rate were evaluated by echocardiography in 80 patients with World Health Organization group 1 pulmonary hypertension (PH) (72% were functional class FC III or IV). Survival status was assessed over 4 years. Results All patients had a depressed RV systolic strain (−15% ± 5%) and strain rate (−0.80 ± 0.29 s−1 ). Of the parameters assessed, average RV free wall systolic strain worse than −12.5% identified a cohort with greater severity of disease (82% were FC III/IV), greater RV systolic dysfunction (RV stroke volume index 26 ± 9 mL/m2 ), and higher right atrial pressure (12 ± 5 mm Hg). Patients with an RV free wall strain worse than −12.5% were associated with a greater degree of disease progression within 6 months, a greater requirement for loop diuretics, and/or a greater degree of lower extremity edema, and it also predicted 1-, 2-, 3-, and 4-year mortality (unadjusted 1-year hazard ratio, 6.2; 2.1–22.3). After adjusting for age, sex, PH cause, and FC, patients had a 2.9-fold higher rate of death per 5% absolute decline in RV free wall strain at 1 year. Conclusions Noninvasive assessment of RV longitudinal systolic strain and strain rate independently predicts future right-sided heart failure, clinical deterioration, and mortality in patients with PAH.
Abstract Background Cardiovascular disease among hemodialysis (HD) patients is linked to poor outcomes. The Acute Dialysis Quality Initiative Workgroup proposed echocardiographic (ECHO) criteria for ...structural heart disease (SHD) in dialysis patients. The association of SHD with important patient outcomes is not well defined. Objectives This study sought to determine prevalence of ECHO-determined SHD and its association with survival among incident HD patients. Methods We analyzed patients who began chronic HD from 2001 to 2013 who underwent ECHO ≤1 month prior to or ≤3 months following initiation of HD (n = 654). Results Mean patient age was 66 ± 16 years, and 60% of patients were male. ECHO findings that met 1 or more and ≥3 of the new criteria were discovered in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died: 108 (26%) died within 6 months. Five-year mortality was 62%. Age- and sex-adjusted structural heart disease variables associated with death were left ventricular ejection fraction (LVEF) ≤45% (hazard ratio HR: 1.48; confidence interval CI: 1.20 to 1.83) and right ventricular (RV) systolic dysfunction (HR: 1.68; CI: 1.35 to 2.07). An additive of higher death risk included LVEF ≤45% and RV systolic dysfunction rather than neither (HR: 2.04; CI: 1.57 to 2.67; p = 0.53 for test for interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access, RV dysfunction was independently associated with death (HR: 1.66; CI 1.34 to 2.06; p < 0.001). Conclusions SHD was common in our HD study population, and RV systolic dysfunction independently predicted mortality.
Using the Mueller maneuver (MM) to simulate obstructive sleep apnea (OSA), our aim was to investigate acute changes in left-sided cardiac morphologic characteristics and function which might develop ...with apneas occurring during sleep. Strong evidence supports a relation between OSA and both atrial fibrillation and heart failure. However, acute effects of airway obstruction on cardiac structure and function have not been well defined. In addition, it is unclear how OSA might contribute to the development of atrial fibrillation and heart failure. Echocardiography was used in healthy young adults to measure various parameters of cardiac structure and function. Subjects were studied at baseline, during, and immediately after performance of the MM and after a 10-minute recovery. Continuous heart rate, blood pressure, and pulse oximetry measurements were made. During the MM, left atrial (LA) volume index markedly decreased. Left ventricular (LV) end-systolic dimension increased in association with a decrease in LV ejection fraction. On release of the maneuver, there was a compensatory increase in blood flow to the left side of the heart, with stroke volume, ejection fraction, and cardiac output exceeding baseline. After 10 minutes of recovery, all parameters returned to baseline. In conclusion, sudden imposition of severe negative intrathoracic pressure led to an abrupt decrease in LA volume and a decrease in LV systolic performance. These changes reflected an increase in LV afterload. Repeated swings in afterload burden and chamber volumes may have implications for the future development of atrial fibrillation and heart failure.
How to Develop a Cardio-Oncology Clinic Snipelisky, David; Park, Jae Yoon; Lerman, Amir ...
Heart failure clinics,
04/2017, Letnik:
13, Številka:
2
Journal Article
Recenzirano
Cardiovascular demands to the care of cancer patients are common and important given the implications for morbidity and mortality. As a consequence, interactions with cardiovascular disease ...specialists have intensified to the point of the development of a new discipline termed cardio-oncology. As an additional consequence, so-called cardio-oncology clinics have emerged, in most cases staffed by cardiologists with an interest in the field. This article addresses this gap and summarizes key points in the development of a cardio-oncology clinic.
The purpose of this study was to describe the normal values for strain (S), systolic strain rate (SRs) and synchrony by speckle-tracking echocardiography (STE) in heart transplant (HTx) recipients ...who had normal left ventricular ejection fraction (LVEF) and no clinically significant complications.
We evaluated S and SRs in 40 HTx patients at 1 year after transplant and 82 healthy controls with STE using velocity vector imaging.
Mean (SD) global longitudinal S and SRs, respectively, were lower in the transplant group compared with controls -13.43% (2.39%) vs -17.28% (2.30%), p < 0.001; -0.83 (0.15) s(-1) vs -0.96 (0.13) s(-1), p < 0.001. These variables were good for differentiating between groups: area under the curve was 0.88 for S and 0.73 for SRs. The differences remained significant after adjustment for other clinical variables. Global circumferential S and SRs were similar between groups. The standard deviation of the global longitudinal S time to peak of the 16 segments for HTx and control groups, respectively, was 41.67 (13.53) milliseconds vs 32.57 (12.81) milliseconds (p < 0.001). With 58.2 milliseconds as a cutoff value to define left ventricular synchrony, only 3 (8%) of the HTx patients and 4 (5%) of the control subjects were above that value (p = 0.6).
To our knowledge, this is the first study describing normal values for S and SRs and synchrony by STE in a HTx population with normal LVEF: longitudinal S and SRs were reduced; circumferential deformation indexes were normal; and left ventricular synchrony was preserved.
Abstract Objectives The objective of this study was to determine the incidence of arrhythmias and device (internal cardiac defibrillator/cardiac resynchronization therapy defibrillator) therapies in ...patients with a diagnosis of cardiomyopathy and anthracycline exposure. Background The burden of arrhythmias in adult cancer survivors with anthracycline-related cardiomyopathy has not been studied, but might have important implications for clinical management and outcomes. Methods Retrospective cohort study of all patients with left ventricular dysfunction (LVD) who underwent internal cardiac defibrillator/cardiac resynchronization therapy defibrillator implantation at the Mayo Clinic from 1990 to 2012. Ninety-five patients were cancer survivors (on average, 5 years), 23 of which had anthracycline-related cardiomyopathy (CA-ACM) and 72 of which had non–anthracycline-related cardiomyopathy (CA-NACM). A second control group of 68 noncancer patients with ischemic heart disease-related LVD or dilated cardiomyopathy (ischemic heart disease IHD/DCM) was age- and gender-matched to patients with CA-ACM. All patients were followed for arrhythmias and appropriate ICD therapies, total mortality, heart transplantation, and left ventricular ejection fraction. Results More than 5.5 ± 3.0 years after device implantation, nonsustained ventricular tachycardia was the most common arrhythmia in patients with CA-ACM followed by atrial fibrillation and sustained ventricular tachycardia or fibrillation (73.9%, 56.6%, and 30.4%, respectively), which was not significantly different from CA-NACM and IHD/DCM. The 5-year rate of ICD therapies was 19.9% in the CA-ACM group versus 22.1% in the CA-NACM group and 32.6% in the IHD/DCM group (p = NS for both). Device therapy–free, heart transplantation–free, and/or overall survival as well as cardiac function dynamics over time were not different in patients with CA-ACM than in patients with CA-NACM and IHD/DCM. Conclusions This study indicates that the burden of arrhythmia in patients with anthracycline-related cardiomyopathy is not different from cancer and non-cancer patients with IHD-related LVD or DCM.
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