Evaluation and management of patients with heart disease and cancer: cardio-oncology

Abstract

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.

Figure 1

Outline of a general Cardio-Oncology algorithm. CAD = coronary artery disease; CXR = chest x-ray; ECG = electrocardiogram; HTN = hypertension.

Figure 2

Outline of a putative risk assessment, monitoring, and management model for patients undergoing chemotherapy. The central concept is that patient- and medication-related risk factors can be used to generate an overall risk score that can then be used to determine monitoring intervals and thresholds for preventive strategies. Such models need to be accounted for the fact that not all chemotherapeutics and patient-related risk factors weigh the same, and hence the ultimate prediction models will need to be more stratified and will need to be verified. ACE-I = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; CAD = coronary artery disease; cTn = cardiac troponin; CXR = chest x-ray; ECG = electrocardiogram; HTN = hypertension; IFN-α = interferon-alpha; TTE = transthoracic echocardiogram.

Figure 3

Illustration of the percentage of patients with improvement of left ventricular ejection fraction (LVEF) to >50% depending on the timing of initiation of heart failure therapy after diagnosis of anthracycline-induced cardiomyopathy (upper panel) and survival free of cardiac events for patients with improvement of LVEF below (partial responders) or above 50% (responders) (From Journal of the American College of Cardiology, with permission).

Figure 4

Established algorithm for the monitoring of patients undergoing anthracycline-based chemotherapy (Adapted from The American Journal of Medicine, with permission. A variation to this algorithm is the reassessment prior to each cycle after 250-300 mg/kg² in those at high risk. ECG = electrocardiogram; LVEF = left-ventricular ejection fraction; RNA = radionuclide angiography; TTE = transthoracic echocardiogram.

Figure 5

Algorithm for the monitoring of patients undergoing Herceptin chemotherapy (Adapted from The Oncologist, with permission). ECG = electrocardiogram; EF = left-ventricular ejection fraction; RNA = radionuclide angiography (MUGA); TTE = transthoracic echocardiogram.

Figure 6

Monitoring algorithm of patients after radiation therapy (From J Am Soc Echocardiogr, with permission). US = ultrasound.