Γυναίκα 67 ετών 2 η μετεγχειρητική ημέρα μετά αφαίρεση μονήρους πνευμονικού όγκου στον άνω λοβό του αριστερού πνεύμονα Οξύ πρόσθιο STEMI Οικογενειακό ιστορικό νεοπλασιών: αρνητικό Σύντομο ατομικό ιστορικό: Καρκίνος αριστερού μαστού πριν 30 έτη: χειρουργική αφαίρεση (μαστεκτομή συν λεμφαδενικός καθαρισμός) και συμπληρωματική ακτινοθεραπεία - Σακχαρώδης διαβήτης τύπου 2 - Αρτηριακή υπέρταση - ΧΑΠ - Τέως καπνίστρια (διακοπή προ 3ετίας) - Υποθυρεοειδισμός
Cardio-oncologist s goals: To recognize and treat optimally the preexisting CV risk factors To avoid the possibility that pre-existing cardiac disease be a barrier and lead to a reduction in the therapeutic opportunities of the patient To protect the patient from developing cardiac disease because of cancer therapy
1. CV assessment should be performed at the time of cancer diagnosis BEFORE any treatment! 2. CV assessment should be SYSTEMATIC and not random! 3. CV follow up is LIFELONG in cancer survivors!
The same imaging modality and/or biomarker assay should be used for continued screening throughout the treatment pathway. Switching between modalities or assays is strongly discouraged. Modalities and tests with the best reproducibility are preferred. Imaging modalities that provide additional relevant clinical information are preferred (e.g. right ventricular function, pulmonary pressures, valvular function, pericardial evaluation). High quality radiation-free imaging is preferred, if available.
Systolic Function Diastolic Function RV function Valvular Disease Pericardium
Decrease in LVEF more than 10 percentage points to a value below 50% >15% relative percentage reduction of GLS from baseline
Risum N et al. J Am Soc Echocardiogr 2012;25:1195-203.
Systolic Function Diastolic Function RV function Valvular Disease Pericardium
Asymptomatic cancer survivors often present echocardiographic indices of diastolic dysfunction characterized by altered relaxation or restrictive pattern (stiffness). Cancer survivors are more susceptible to develop comorbidities that induce or aggravate diastolic dysfunction (hypertension, diabetes, dyslipidemia). Multiple hits hypothesis Global LV diastolic dysfunction precedes global LV systolic dysfunction. (?) Diastolic dysfunction is an important contributor for the decreased physical performance in cancer patients. Monitoring of the left ventricular diastolic function on the basis of the E/e' ratio at baseline or 3 months after is unlikely to predict LVEF decline in patients who receive trastuzumab. Fluctuations of E and e in cardio-oncology pts could be a consequence of loading conditions (nausea, vomiting and diarrhea) and not a real change of LV performance. Altena R et al., Br J Cancer 100:1861 1866.
Systolic Function Diastolic Function RV function Valvular Disease Pericardium
Qualitative and quantitative assessment of RV function
Strain is more sensitive to identify subtle RV dysfunction Recovery of LV function is lower in patients who had concomitant RV dysfunction at the time of cardiotoxicity compared to those who did not
Pulmonary hypertension - Chemotherapy: Dasatinib, Carfilzomib, cyclophosphamide - Stem cell bone marrow transplantation Complications of metastatic cancer : thrombotic pulmonary tumor microangiopathy
Systolic Function Diastolic Function RV function Valvular Disease Pericardium
Radiotherapy Infective endocarditis Remodeling of LV and RV Tumor infiltration Aortic and mitral valve mostly affected Stenotic or regurgitant lesions
Systolic Function Diastolic Function RV function Valvular Disease Pericardium
Pericardial effusion Pericardial constriction Pericarditis Radiation Metastatic cancer Chemotherapy: - anthracyclines - cyclophosphamide - bleomycin
Reduced contractile reserve after chemotherapy, despite normal LVEF and GLS. Decreased cardiac reserve during chemotherapy is predictive of subsequent decline in LVEF. In patients with intermediate or high pre-test probability of CAD who are undergoing or who have completed regimens that may be associated with ischemia (fluorouracil, bevacizumab, sorafenib, and sunitinib). In case of the development of cardiotoxicity, the transient recovery of LV function during stress echo may also predict a better outcome. Plana JC et al. European Heart Journal: Cardiovascular Imaging 15 1063 1093. Civelli M et al. International Journal of Cardiology 111 120 126. Yeh ETH et al. J Am Coll Cardiol 2009;53:2231-47. Grosu A et al. Eur Heart J 2005;26:2404-12.
No routine cardiac imaging after completion of chemotherapy if LVEF and GLS are normal 6 months after and there are no additional factors increasing the patient s risk. Assessment of cardiac function 4 and 10 years after completion of anthracycline therapy if >240mg/m 2 of doxorubin or >360mg/m 2 of epirubicin. In type 2 agents, echo at completion of therapy and after 6 months ESMO guidelines, 2012.
5-year survival rates approach 80% childhood cancer survivors are at a 15-fold increased risk of developing CHF at 7-fold higher risk of premature death due to cardiac causes
Risk of cumulative incidence of cardiac events in childhood cancer survivors (www.cancer.gov)
surveillance should begin no later than 2 years after completion of cardiotoxic therapy continue for a minimum of every 5 years thereafter cardiomyopathy surveillance is reasonable prior to pregnancy or in the first trimester for all female survivors treated with anthracyclines and/or chest radiation (moderate recommendation).