Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association

Abstract

Cardiovascular disease (CVD) remains the leading cause of mortality in women, yet many people perceive breast cancer to be the number one threat to women's health. CVD and breast cancer have several overlapping risk factors, such as obesity and smoking. Additionally, current breast cancer treatments can have a negative impact on cardiovascular health (eg, left ventricular dysfunction, accelerated CVD), and for women with pre-existing CVD, this might influence cancer treatment decisions by both the patient and the provider. Improvements in early detection and treatment of breast cancer have led to an increasing number of breast cancer survivors who are at risk of long-term cardiac complications from cancer treatments. For older women, CVD poses a greater mortality threat than breast cancer itself. This is the first scientific statement from the American Heart Association on CVD and breast cancer. This document will provide a comprehensive overview of the prevalence of these diseases, shared risk factors, the cardiotoxic effects of therapy, and the prevention and treatment of CVD in breast cancer patients.

Keywords: AHA Scientific Statement; breast cancer; cardiotoxicity; cardiovascular disease; oncology; prevention; risk factors.

Figure 1.. Rates of cardiovascular disease and breast cancer in women.

Age-adjusted mortality rates of coronary heart disease (CHD) and stroke are higher than that of breast cancer. Death rates are higher in NH black women than in NH white and Hispanic women for CHD, stroke, and breast cancer. NH indicates non-Hispanic. Reprinted from Benjamin et al. Copyright © 2017, American Heart Association, Inc.

Figure 2.. Risk factors for cardiovascular disease (CVD) and breast cancer.

CVD and breast cancer have shared and separate risk factors.^,–

Figure 3.. Factors associated with developing CVD and breast cancer.

Impact of these factors in a positive (green downward arrow, reduced risk) or negative (red upward arrow, increased risk) on developing CVD or breast cancer.^,– CVD indicates cardiovascular disease.

Figure 4.. Simplified depiction of detection, prevention, and treatment of left ventricular systolic dysfunction in breast cancer.

Schematic of the continuum of breast cancer treatment in relation to subsequent cardiac toxicity and heart failure. ACC indicates American College of Cardiology; ACE, angiotensin-converting enzyme; AHA, American Heart Association; CV, cardiovascular; LVEF, left ventricular ejection fraction; and MUGA, multigated acquisition. Modified from Khouri et al. Copyright © 2012, American Heart Association, Inc.

Figure 5.. Echocardiographic surveillance during and after treatment with anthracycline therapy or HER2-directed therapy.

At any time during the course of surveillance imaging, if the ejection fraction is <53%, then cardiology consultation is recommended. If cardiac imaging is suboptimal, then cardiac magnetic resonance imaging should be considered. After completion of therapy, patients should undergo annual cardiovascular assessments by a provider; however, cardiac imaging should be at the discretion of the provider based on the history and physical examination. HER2 indicates human epidermal growth factor receptor 2. This Figure is based on recommendations from the consensus document for multimodality imaging in adult cancer patients prepared by the American Society of Echocardiography and the European Association of Cardiovascular Imaging.