Cardiotoxicity. risk assessment and early diagnosis

Cardiotoxicity. Risk & Early DiagnosisCardiotoxicity. Risk & Early Diagnosis

Jose López-SendónJose López-SendónHospital Universitario La Paz. MadridHospital Universitario La Paz. Madrid

CardiotoxicityCardiotoxicityRisk Assessment and Early DiagnosisRisk Assessment and Early Diagnosis


Disclosure Information for this presentation: noneDisclosure Information for this presentation: none


•• Cardio-vascular-toxicity. The full windowCardio-vascular-toxicity. The full window

•• PrevalencePrevalence

•• Risk factors Risk factors

•• Diagnostic criteria. HF / ALVD Diagnostic criteria. HF / ALVD

•• Early diagnosis important? Early diagnosis important?

•• Tools for diagnosis Tools for diagnosis

•• Need of local protocols Need of local protocols










Cancer Therapy Related Cardiovascular ProblemsCancer Therapy Related Cardiovascular Problems•• Acute vs subacute Acute vs subacute vs vs long termlong term•• Systolic & diastolic left ventricular dysfunction Systolic & diastolic left ventricular dysfunction•• Heart failure Heart failure•• Arrhythmias Arrhythmias•• Myocardial Ischemia Myocardial Ischemia•• Hypotension / hypertension Hypotension / hypertension•• Myocarditis / Pericarditis Myocarditis / Pericarditis•• Valvular disease Valvular disease•• Peripheral Vascular Disease Peripheral Vascular Disease•• Thrombosis Thrombosis




•• Risk factorsRisk factors






Cancer Therapy Related Cardiac DysfunctionCancer Therapy Related Cardiac Dysfunction

Cardinale et al. Circulation June 2016Cardinale et al. Circulation June 2016


2y after chemotherapy for brest cancer


Classic risk factors for heart failureClassic risk factors for heart failure

Framingham Framingham JAMA 1996;275:1557JAMA 1996;275:1557

Cardiotoxicity. Risk & Early DiagnosisCardiotoxicity. Risk & Early DiagnosisLong-term survivors of childhood cancerLong-term survivors of childhood cancer

Comparison with siblingsComparison with siblings

Oeffinger;NEJM 2006;355:1572Oeffinger;NEJM 2006;355:1572


Long term!Long term!

••Cancer patients live longer … and …Cancer patients live longer … and …

••Cardiac risk increased 2 Cardiac risk increased 2 -- 25 times! 25 times!


CARDIOTOX database, n= 350 patients 1 year follow-upCARDIOTOX database, n= 350 patients 1 year follow-up

Heart Rate and CardiotoxicityHeart Rate and Cardiotoxicity

Heart RateHeart Rate % patients% patients Cardiac dysfuntion Cardiac dysfuntion at 1 yearat 1 year

< 80 l/min 30% 6%

> 80 l/min 70% 36%

> 90 l/min 38% 40%




•• Risk factorsRisk factors






Cardiotoxicity Risk FactorsCardiotoxicity Risk Factors••Drug typeDrug type••High, cumulative doseHigh, cumulative dose••Rapid infusionRapid infusion••Combination of drugsCombination of drugs••Older ageOlder age••Chest radiotherapyChest radiotherapy••Heart failure LVDHeart failure LVD••Pregnancy / Delivery?Pregnancy / Delivery?•• … …

Risk factors for CV diseaseRisk factors for CV disease••Known CV disease!Known CV disease!••AgeAge••GendreGendre••GenesGenes••SmokingSmoking••SedentarismSedentarism••DietDiet••HypertensionHypertension••HypercholeterolemiaHypercholeterolemia••DiabetesDiabetes••ObesityObesity••Dental healthDental health••……

Risk factors for Heart FailureRisk factors for Heart Failure••Previous MIPrevious MI••HypertensionHypertension••Vascular diseaseVascular disease••AnginaAngina••DiabetesDiabetes••……


AlientoCardiologist


Cardiotoxic ProblemsCardiotoxic Problems•• Acute vs subacute Acute vs subacute vs vs long termlong term•• Hypertension Hypertension•• Hypercholesterolemia Hypercholesterolemia•• Diabetes Diabetes•• Life syle Life syle






•• Early diagnosis important?Early diagnosis important?




Diagnostic criteriaDiagnostic criteria

•• Evolving concept! Changing definition! Evolving concept! Changing definition!

•• ASE & EACI 2015ASE & EACI 2015

•• LVEF > 10 points LVEF > 10 points

•• to a value of LVEF < 53%to a value of LVEF < 53%

•• confirmed in a repeated study after 2-3 wconfirmed in a repeated study after 2-3 w

Eur heart J 2014;15.1063








•• Need of local protocolsNeed of local protocols


Echo Imaging techniques. LVEF gold standard?Imaging techniques. LVEF gold standard?

MUGA

NMR

CT



Imaging techniques. Direct identification of myocardial damage?Imaging techniques. Direct identification of myocardial damage?

36 y old lady Successful chemotherapy

7 y: Heart failure LVEF 25%

9 y: NYHA class ILVEF 30%

10 y: Chest pain x > 20 hTroponin +Non diagnostic ECGNormal coronary arteriesSuspected myocarditis








•• Tools for diagnosisTools for diagnosis



JACC2010;55:213


Baseline 21 D 3 M 6 M

hs-cTnT 8,3 % 17,2 % 53,5 % 36,9 %

c-TnI 0 % 3,1 % 25 % 19,2 %

Spanish congress of cardiology 2014










Eur heart J 2014;15.1063Annals of Oncology 2012; 23:156-166


ECHO basal and every 3 mothsECHO basal and every 3 moths

1000 patients / year 5000 ECHOs / year1000 patients / year 5000 ECHOs / year





ConclusionsConclusions

•• High prevalence of CTRCD ( High prevalence of CTRCD (Cancer Therapy Related Cardiac Dysfunction)Cancer Therapy Related Cardiac Dysfunction)

•• Risk factors known Risk factors known

•• Explosion of diagnostic tools Explosion of diagnostic tools (not all available)(not all available)

•• Early diagnosis important Early diagnosis important

•• Need for local protocols, now! Need for local protocols, now!

•• Extraordinary opportunity for team work and research Extraordinary opportunity for team work and research

Health & Medicine

Cardiotoxicity. risk assessment and early diagnosis