INTRODUCING A NEW SUBSPECIALTY

OF CARDIOLOGY…

New subspecialty

• Cardio-Oncology

• curtainCardio-Oncology

IntroductionInternational Cardio-Oncology Society•Consortium of cardiac images supporting oncologists:

– University of Chicago- Chicago, IL– Huntsman Cancer Center- Salt Lake City, UT– University of Utah- Salt Lake City, UT– St. Louis University Cancer Center- St. Louis, MO– Washington University- St. Louis MO– Emory University- Atlanta, GA– Duke University- Durham, NC– Columbia University- New York, NY– Memorial Sloan-Kettering Cancer Center- New York, NY– University of Rochester Medical Center- Rochester, NY– West Virginia University- Morgantown, WV– Ottawa Hospital– Dartmouth College- Hanover, NH– University of Kansas Medical Center- Kansas City, KS– Cleveland Clinic- Cleveland, OH– Ochsner Medical Center- Jefferson, LA– Cardiac Arrhythmia Institute of Arizona- AZ

– Vanderbilt University- Nashville, TN– MD Anderson Cancer Center- Houston, TX– University of Texas Medical Branch- Galveston, TX– Centro Cardiologico Fondazione Monzino- Milan, Italy– University of Insubria- Como and Varese, Italy– The University Hospital of Bern- Berne, Switzerland– University of Tasmania- Tasmania, Australia– University of Manchester- Manchester, UK– St. Boniface Hospital- Winnipeg, Manitoba– Cardiac Care Critique- Tampa, FL– Moffitt Cancer Center- Tampa, FL– Florida Cancer Specialist- Tampa, FL– University of South Florida- Tampa, FL– University of Pennsylvania- Pittsburg, PA– Thomas Jefferson University- Philadelphia, PA– Stanford University- Stanford, CA– University of Michigan- Ann Arbor, MI

Monthly conference/webinar of consortium originates from Tampa monthly.

Case Study 1

• 41 yo Caucasian female• Diagnosed with left breast cancer in Feb 2012

after surveillance mammo, breast US, and core biopsy.

• Breast Cancer (G2) Type= Ductal, ER=pos, PR=neg, HER2 IHC= 3+, HER2 Flsh= N/A, Sentinal Lymph Node= N/A, OncoType Dx= Not available, Menopausal status= Pre-menopausal, BRCA=neg

• PMHx: Hashimoto’s hypothyroidism treated in 2004, iron deficiency anemia- 2009, hysterectomy- 2011, palpitations in past

• FHx: Breast cancer in mother and sister, although BRCA1/2 negative.

• Allergies: Keflex• SHx: Cigs-socially x 5 yrs, but not since

2003. Alcohol: weekly• Current Meds: Zofran 8 mg prn,

Lorazepam 1 mg prn, Vit D qd, Levothyroxine 75 mcg qd, Iron qd.

Case Study 1

Case Study 1

Treatment•Chemotherapy started March 8, 2012

– Carboplatin + Taxotere x 6 rounds– Herceptin x 1 year, q3weeks

•Double mastectomy August 1, 2012•Radiation therapy to left breast x 25 treatments (August-September 2012)•Reconstruction planned for May 2013

Case Study 1

Surveillance•Echocardiograms q3months

– March 2, 2012: EF 63%– June 5, 2012: EF 64%– September 12, 2012: EF 63%– January 7, 2012 @ new site: 48% (BP 103/71- EF

not decreased secondary to increase in afterload)• At this point, patient was referred to our office for

further investigation.

Case Study 1

Assessment•Symptoms: Patient c/o fatigue and shortness of breath on occasion, but not consistent. Has peripheral paresthesias secondary to chemotherapy. Denies chest pain, edema, cough, nausea, SOB at rest.•EKG

– NSR, HR 65, non-specific ST and T wave changes•Lab work ordered:

– Highly sensitive Troponin I: <0.006, negative – Troponin T: negative– BNP: 9.70

Case Study 1

Imaging Workup•Echocardiogram:

– GE vivid 9E and portable GE vivid-Q- 2D in 2 image planes as well as speckle tracking.

• EF: 65%• Global strain: -19%• Regional strain: normal

•Cardiac MRI: • Normal EF: ~60’s range• Main left, proximal LAD, proximal RCA: all normal

Case Study 1

Plan and Follow-up•Ejection fraction normal•Continue Herceptin treatment•Regular follow-ups with special attention to:

– BP monitoring– HS Trop I & BNP q3mo– Echo with strain upon completion of Herceptin

•Post treatment: – Yearly echos and Coronary MRI if chest pain,

especially LAD for any changes secondary to left breast radiation.

Case Study 2First Encounter, June 2002:•55 yo African American female•HPI: Abnormal EKG showing abnormal T vector. Patient c/o discomfort and fullness in chest, tingling of left arm x 3 weeks. • PMHx: Left breast carcinoma, lymph node negative in 1996

s/p left radical modified mastectomy with 6 cycles of 5FU 870 mg/ Cytoxan 870 mg/ Adriamycin 87 mg. Followed by Tamoxifen 10 mg BID x 5 yrs

• HTN x 30 yrs, hyperlipidemia, GERD•Meds: Atenolol 50 mg qd, pravachol, ASA. •FHx: Father: CABG x 2 in 50’s

Case Study 2

• Echo: 2+ MR, Trace TR, RVSP 37 mmHg, bulging intraatrial septum, No ASD

• Stress echocardiogram: exercised 9 min 47 sec– Normal SE– Maximal exercise test– No ischemic changes– Maximum HR achieved– Normal rate recovery– No wall motion abnormalities– 1-2 PVC’s– EKG changes secondary to long-standing HTN. No LVH

Case Study 2

August 2004•HPI: Murmur evaluation•PE: BP 120/82, HR 86, short grade 2/6 systolic murmur at the apex, upper left sternal border. No S3.•Echo: Dilated LA, mild MR, mild TR, RVSP 37 mmHg, small pericardial effusion adjacent IL wall, negative for LVH•Plan: CorCTA negative

Case Study 22006:•3/28/06: awakened with burning in chest, radiation to left arm, elevated HR x 30 mins. Meds: Atenolol, Vytorin. Plan: Nexium 20 mg qd and SE

– SE 4/6/06: reveals 3+ MR, LAE, no LVH, EF 50%, RVSP 32 mmHg, normal wall motion.– BNP 5/11/06: 80– Plan: SBE prophylaxis, tx with PPI, continue HTN tx

•12/18/06: Orthopnea, uses 1-3 pillows, chest fullness, SOB walking ½ block, palpitations, loss of stamina, exhausted after vacuuming. Symptoms more frequent and severe last 6 weeks. No pedal edema.

– BNP 234.7– Echo changes: mild global LV dysfunction, EF 50% 48%, LVEDD 50 59.5, LA 60, RVSP 32 48– Class II III– Start Diovan 80 mg qd, sodium restriction

•12/27/06 TEE: 3-4+ MR, no evidence of prolapse or flail leaflet. – Review with Dr. W. Randolph Chitwood, consider whether she is a candidate for MVR.

Case Study 22007:•1/18/07: BNP: 274.0•2/26/07: c/o SOB when walking.

– Echo: Severe MR, moderate TR, RVSP 43 mmHg, LAE- 44, Mild global LV dysfunction, EF 48%

– 6/1/07: Cardiac Cath: moderate to severe MR, RVSP 43 mmHg, no obstructive CAD, normal LV function.

– Clearance for Dr. Chitwood in Greenville, NC

•6/22/07: Pt admitted to Pitt County Memorial Hospital. Minimally invasive mitral valve repair with placement of #29 ATS ring. Postop uncomplicated. Discharged on postop day #4.

Case Study 2

2007 s/p MVRepair:•7/2/07: Echo- NSR, LAE, Trace PI, Trace TR, Mild diffusely diminished LV function, EF 49%.•CXR reveals small to moderate right pleural effusion

– 7/13/07: f/u CXR no change

•Pt begins cardiac rehab •Possible post cardiotomy syndrome

– Increase ASA 325 mg to TID x 3 weeks

•12/10/07: Pt c/o decreased ROM right arm– PT ordered– Continue Atenolol 50 mg qd. Pt desires generic BP drug Diovan switched to

Cozaar 100 mg qd (Office visit BP 140/72)

Case Study 2

2008:•4/7/08: Memorial Hospital- Patient not taking any BP med due to miscommunication with PCP. Now pt c/o SOB walking a few steps. EKG: no change. No edema. Chest clear. •Echo: NSR, LAE 46, s/p MVRepair, Global LV dysfunction, EF 26%, Trace MR, Trace TR, Trace AR, RVSP 45 mmHg.•DC Atenolol 25 mg qd, Restart Diovan 80 mg qd, Start Coreg 12.5 mg BID and Digoxin 0.125 mg qd

Case Study 2• 4/24/08: Pt states SOB with walking improved. Can walk into lunch room without panting.

C/O of blurry vision when driving. – Change digoxin to 0.125 mg qod, Coreg 25 mg BID

• 5/28/08: Blurry vision continues when driving. Office BP 138/90 – Increase Diovan to 160 mg qd.

• 6/18/08: C/O palpitations 2-3x week at night, night sweats, resolves with raising head off bed. Orthopnea. No improvement with increased Diovan.

– Add Aldactone 25 mg qd.

• 8/25/08: Echo- NSR, Diffuse significant LV dysfunction, EF 20%, LAE 43, s/p MVR, 2+ MR, 2+ TR, RVSP 33 mmHg.

– Decrease Diovan to half- 40 mg qd. Contact Dr. Auerbach regarding chemotherapy treatments.

• 8/29/08: MRI- EF 39%, thinning of LV apex• 9/05/08: TEE- No mitral valve vegetation, or other abnormalities. 2+ MR, LAE, LV

contractility appeared moderately reduced. • 9/22/08: SOB and fatigue better. BNP 38

– Decrease aldactone 12.5 mg qd

Case Study 2• 8/11/09: NSR, Normal LV Contractility, EF

56%, Normal chamber sizes, Trace PR, 1+ TR, s/p MVR

• Drop in BP’s changed meds:– Hold Diovan, decrease Coreg to half, continue

Digoxin

• 4/13/10: NSR, Normal LV contractility, EF 60%, NO LAE, 1+ PR, 1+ TR, RVSP not measured, difficult to assess MR- out of plane.

• 4/26/11: NSR, Normal LV contractility, EF 73%, difficult to quantify MR- out of plane, RVSP 30 mmHg, MAC, 1+ TR

• 2012: Hypotension. Stop Digoxin

Anthracyclines and HF

CHF/Cardiac Toxicity

Cardiac Toxicity

Hundley, 2012

Cardiac Toxicity

Cardiac Toxicity

Cardiac Toxicity

• SEER-Medicare database in the USA showed a cohort treated from 2002-2007 to have a 5 year incidence of heart failure of 18%

• For early stage breast cancer, a patient is more likely to die of heart disease than cancer.

Cardiac Toxicity

Strain Imaging

Cleveland Clinic

Elevated values according to MD Anderson: Trop >0.05BNP >125Strain < 19%

Elevated values according to MD Anderson: Trop >0.05BNP >125Strain < 19%

Markers and Images

Markers and Images

Cardinale, 2012

Markers and Images

Cardinale, 2012

Treatment

Cardinale, 2012

Treatment

Treatment

Recovery of LV dysfunction with standard HF therapy

• Jensen, et al. Annals of Oncology. 2002. 13:499-709.

Jensen, et al. Annals of Oncology. 2002. 13:499-709.

Treatment

Durand, 2012

It is unknown when you stop these treatments- panel said they stay conservative and treat them on low dose ACEI or BB forever. Unless females become pregnant, switch ACE to BB.

It is unknown when you stop these treatments- panel said they stay conservative and treat them on low dose ACEI or BB forever. Unless females become pregnant, switch ACE to BB.

Treatment

Early detection of Type II toxicity during F/U using

Algorithms

Starting ACE-I for Troponin I positive patients

Algorithms

Proposal• Our protocol:

– Strain Surveillance During Chemotherapy for Improving Cardiovascular Outcomes (SUCCOUR) Study

• PI: Tom Marwick from Royal Hobart Hospital, Hobart Australia

• US Study Center: Cardiac Care Critique with Florida Cancer Specialists

Proposal

• International study centers:– Australia: Royal Hobart Hospital, Royal Brisbane Hospital, Princess

Alexandra Hospital, Queen Elizabeth Hospital, Canberra Hospital– Belgium: Cardiovascular Center Aalst, KUL, University of Liege, UCL– Bulgaria: National Cardiovascular Hospital– Canada: Universite de Montreal, University of Toronto– Germany: Wuerzburg, Leipzig, Mainz– Italy: Padua– Japan: Sapporo– Korea: Yonsei University, Seoul University, Ulsan University– Norway: Oslo University Hospital– Romania: Carol Davila University, Bucharest Hospital– Spain: University Hospital

Proposal 120 patients with increased risk of cardiotoxicity from medications

N=20

Control n=10 Strain n=10EF alone EF + GLS

A: EF drop >5% to <55% Strain+ With Symptoms Start BB&ACEStart BB&ACE

B: Asx drop >10% to <55%Start BB&ACE

Observing: 24 month follow-up

ProposalPilot Project:•Control group: Standard of care, remote locations•Case group

– Baseline: • Complete 3D echo with strain• hsTnI• BNP

– Established intervals• Limited 3D and 2D echo with strain for LVEF• hsTnI• BNP• Cardiac follow-up

Florida Cancer Specialists Locations

Group B

Group ACardiac Care

Critique

Radiation

“

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Cardiac Toxicity

Radiation Algorithm

Thank you!ICOS holds case presentation webinars, 2nd Thursday of every

month, 9 am EST.

We have a Bike-a-Thon coming up in August from Waynesville, NC to Grove Park Inn in Asheville, NC

North America 501(3)(c)