ISCHEMIC HEART DISEASE IN THE CANCER PATIENT: THOMAS M. SUTER MD UNIVERSITY HOSPITAL BERN, SWITZERLAND
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1 UNIVERSITÄTSKLINIK FÜR KARDIOLOGIE ZENTRUM FÜR HERZINSUFFIZIENZ KARDIO-ONKOLOGIE ISCHEMIC HEART DISEASE IN THE CANCER PATIENT: CONSIDERATIONS BEYOND CONVENTIONAL ARTERIOSCLEROSIS CARDIAC TOXICITIES ARISING FROM CANCER THERAPIES THOMAS M. SUTER MD UNIVERSITY HOSPITAL BERN, SWITZERLAND
2 DECLARATION OF INTEREST I have nothing to declare Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 2
3 ISCHEMIC HEART DISEASE IN THE CANCER PATIENT: CONSIDERATIONS BEYOND CONVENTIONAL ARTERIOSCLEROSIS MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS Disease Related Treatment Related Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 3
4 ISCHEMIC HEART DISEASE IN THE CANCER PATIENT: CONSIDERATIONS BEYOND CONVENTIONAL ARTERIOSCLEROSIS MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS Disease Related Treatment Related Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 4
5 MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS DISEASE RELATED Leukemia - Acute myeloid leukemia(aml) - leukostasis, thrombotic abnormalities AML & Myocardial Infarcation Squamous Cell Type Cancer - Lung - Head and Neck Urothelial Tract Cancer Ogawa A. et al. J Med 1995 Bloodjournal;120:21:4321 Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 5
6 MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS DISEASE RELATED Leukemia - Acute myeloid leukemia(aml) - leukostasis, thrombotic abnormalities Platelet Inhibition Anthracycline Cardiotoxicity Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 6
7 ISCHEMIC HEART DISEASE IN THE CANCER PATIENT: CONSIDERATIONS BEYOND CONVENTIONAL ARTERIOSCLEROSIS MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS Disease Related Treatment Related Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 7
8 ISCHEMIC HEART DISEASE IN THE CANCER PATIENT TREATMENT-RELATED MECHANISMS ARTERIOSCLEROSIS ENDOTHELIAL TOXICITY; ENDOTHELIAL DYSFUNCTION VASOSPASMS THROMBOSIS Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 8
9 Kardio-Onkologie Wichtiges für den Internisten 9
10 COMMON ROLES OF CARDIO-ONCOLOGY SERVICES Prior RX Preexisting CV Problems Identification Optimization Guideline-directed Therapy Preoperative evaluation Risk Assessment Optimization Interdisciplinary Approach Optimized Cancer Therapy During RX Cancer Rx related CV Problems Identification Treatment Interdisciplinary Approach Interruption/Stop Cancer Rx After RX Cancer Survivor CV Complications Surveillance/Identification Preventive Therapy Treatment Secondary Cancers CV Risk Assessment for Cancer RX CV Optimization for Cancer Rx Multidisciplinary Approach Lancelotti P, Suter TM et al. Cardio-Oncology Services: Rationale, Organization, and Implementation; EHJ 2018 in press Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 10
11 MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS Prior RX Preexisting CV Problems Identification Optimization Guideline-directed Therapy Preoperative evaluation Risk Assessment Optimization Interdisciplinary Approach Optimized Cancer Therapy During RX Cancer Rx related CV Problems Identification Treatment Interdisciplinary Approach Interruption/Stop Cancer Rx After RX Cancer Survivor CV Complications Surveillance/Identification Preventive Therapy Treatment Secondary Cancers CV Risk Assessment for Cancer RX CV Optimization for Cancer Rx Multidisciplinary Approach Lancelotti P, Suter TM et al. Cardio-Oncology Services: Rationale, Organization, and Implementation; EHJ 2018 in press Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 11
12 CANCER DRUGS WITH ENDOTHELIAL TOXICITY Drug Incidence Prevention Alkylating Agents - Cisplatin 2%? VEGF Inhibitors Variabel? Fluoropyrimidines Zamorano, J. L., Suter T. M. et al. Guidelines, E. S. C. C. f. P. (2016) Eur Heart J. doi: /eurheartj/ehw211 Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 12
13 CANCER DRUGS - VASOSPASM Drug Incidence Prevention Fluoropyrimidines - 5-fluorouracil (5-FU) - Capecitabine - Gemcitabine Up to 10%? Zamorano, J. L., Suter T. M. et al. Guidelines, E. S. C. C. f. P. (2016) Eur Heart J. doi: /eurheartj/ehw211 Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 13
14 CANCER DRUGS WITH ENDOTHELIAL TOXICITY Drug Incidence Prevention VEGF Inhibitors 1.5 4%? Zamorano, J. L., Suter T. M. et al. Guidelines, E. S. C. C. f. P. (2016) Eur Heart J. doi: /eurheartj/ehw211 Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 14
15 MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS Prior RX Preexisting CV Problems Identification Optimization Guideline-directed Therapy Preoperative evaluation Risk Assessment Optimization Interdisciplinary Approach Optimized Cancer Therapy During RX Cancer Rx related CV Problems Identification Treatment Interdisciplinary Approach Interruption/Stop Cancer Rx After RX Cancer Survivor CV Complications Surveillance/Identification Preventive Therapy Treatment Secondary Cancers CV Risk Assessment for Cancer RX CV Optimization for Cancer Rx Multidisciplinary Approach Lancelotti P, Suter TM et al. Cardio-Oncology Services: Rationale, Organization, and Implementation; EHJ 2018 in press Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 15
16 MYOCARDIAL ISCHEMIA IN ONCOLOGY PATIENTS Drug Incidence Prevention Alkylating Agent - Cisplatin Risk Factors Zamorano, J. L., Suter T. M. et al. Guidelines, E. S. C. C. f. P. (2016) Eur Heart J. doi: /eurheartj/ehw211 Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 16
17 TESTICULAR CANCER LONG-TERM CARDIOTOXICITY Coronary Artery Disease Arteriosclerotic Disease cisplatin, vinblastine, bleomycin bleomycin, etoposide, cisplatin van den Belt-Dusebout, A. W., R. de Wit, et al J Clin Oncol 25: Haugnes, H. S., T. Wethal, et al J Clin Oncol 28: Heart Failure in Cancer Patients thomas.suter@insel.ch 17
18 CARDIOVASCULAR SIDE EFFECTS OF RADIATION THERAPY Valvular Disease Cardiac Dysfunction Pericardial Disease Heart Failure in Cancer Patients Coronary Artery Dz Conduction Disease 18
19 SPATIAL DISTRIBUTION OF RADIATION DOSE IN THE HEART FROM BREAST CANCER REGIMENS Taylor C et al. J Clin Oncol May 23 Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 19
20 BREAST CANCER - RISK OF ISCHEMIC HEART DISEASE Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 15
21 HODGKIN DISEASE SURVIVORS LONG-TERM RISK OF CARDIOVASCULAR DISEASE van Nimwegen FA et al. JAMA Intern Med. 2015; 175: 1007 Salz T et al. JCO 2017;35 Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland 21
22 HODGKIN SURVIVOR LONG-TERM CARDIAC COMPLICATIONS 50 y/o male Oncological History 1983 Hodgkin Lymphoma IIA 06-10/1983 Radiation Therapy 46 Gy med & abdominal 2014 Non-Hodgkin-Lymphoma I E : 6 Zyklen R-CHOP and 2 x Rituximab mono Cardiac History 10/2002 AVR (AS), CABG x3, Pace Maker Endocarditis x2 07/12 PTCA VG RCA 04/14 Mitral Valve Valvuloplasty 08/14 Moderate Mitral Stenosis 12/14 Heart Failure Class IV; Severe MS, rest. CMP 12/14 Transcatheter Mitral Valve Replacement Ischemic Heart Disease in the Cancer Patient thomas.suter@insel.ch Bern University Hospital, Cardiology, Bern Switzerland
23 ISCHEMIC HEART DISEASE IN THE CANCER PATIENT Prior RX During RX After RX Preexisting CV Problems Identification Optimization Guideline-directed Therapy Preoperative evaluation Risk Assessment Optimization Disease Related Leukemia Treatment Related Cancer Survivor Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 23
24 CARDIO-ONCOLOGY SERVICE UNIVERSITY HOSPITAL BERN ADULT CARDIO-ONCOLOGY PEDIATRIC CARDIO-ONCOLOGY CANCER SURVIVOR PROJECT BASIC RESEARCH Ischemic Heart Disease in the Cancer Patient Bern University Hospital, Cardiology, Bern Switzerland 24
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