The prevention of cardiovascular disease in cancer survivors

Abstract

The number of cancer survivors in the United States has exceeded 12 million and is increasing. After secondary malignancies, cardiovascular disease is the leading cause of late morbidity and death among cancer survivors. The cardiovascular needs of cancer survivors have not been described. We describe the clinical characteristics of 53 patients seen during the first year of our Cardiovascular Prevention in Cancer Survivors clinic. The mean age of the patients was 40.1 ± 13.7 years. The mean survival since cancer diagnosis was 13.9 years. A history of chemotherapy-induced cardiomyopathy was present in 21%, and 5.7% had known atherosclerotic disease. One fourth had hypertension; 32.1%, dyslipidemia; and 13%, diabetes mellitus. Three quarters had received anthracycline chemotherapy, while half had received radiation. Half had an abnormal echocardiogram (55%), and 11 of 18 had an abnormal carotid ultrasonogram. The mean Framingham risk score for patients older than 30 years (n=37) was 8.4, yielding a 10-year risk of cardiovascular disease of 7.6%. The mean vascular age was 54.3 years, and the mean chronological age was 46.3 years. The mean follow-up duration was 566 ± 213 days. There were significant improvements in serum triglycerides and high-density lipoprotein levels, as well as trends toward improved blood pressure control. Cardiovascular risk factors are prevalent in cancer survivors. There is an immediate need for the widespread availability of cardiovascular preventive services to reduce the late adverse effects of chemotherapy and radiation. Early intervention might help to improve the cardiovascular risk profile.

Keywords: Anthracyclines/adverse effects; antineoplastic agents/adverse effects; atherosclerosis; calcinosis/etiology; cancer; cardiomyopathies/etiology/prevention & control; cardiotoxins; cardiovascular diseases/chemically induced/prevention & control; carotid artery diseases; disease progression; heart failure/etiology; heart/drug effects; heart/radiation effects; monitoring, physiologic; radiation injuries; risk factors; survivorship.

Fig. 1 Cardiovascular Prevention in Cancer Survivors protocol for the monitoring and treatment of patients exposed to chemotherapy associated with left ventricular dysfunction. ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = brain natriuretic peptide; CHF = congestive heart failure; ECG = electrocardiogram; echo = transthoracic echocardiogram; F/U = follow up; HTN = hypertension; LV = left ventricular; LVEF = left ventricular ejection fraction; LVH = left ventricular hypertrophy

Fig. 2 Cardiovascular Prevention in Cancer Survivors protocol for monitoring and treatment of patients with high-risk radiation therapy exposure. ACEI = angiotensin converting enzyme inhibitor; ASA = aspirin; BB = β-blockers; CIMT = carotid intima–medial thickness; ECG = electrocardiogram; echo = transthoracic echocardiogram; LDL = low-density-lipoprotein cholesterol; RT = radiation therapy