Cardiovascular Health of Patients With Cancer and Cancer Survivors: A Roadmap to the Next Level

Laterality of Radiation Therapy in Breast Cancer is Not Associated With Increased Risk of Coronary Artery Disease in the Contemporary Era

Purpose

External beam radiation therapy (EBRT) is a critical component of breast cancer (BC) therapy. Given the improvement in technology in the contemporary era, we hypothesized that there is no difference in the development of or worsening of existing coronary artery disease (CAD) in patients with BC receiving left versus right-sided radiation.

Methods and Materials

For the meta-analysis portion of our study, we searched PubMed, Web of Science, and Scopus and included studies from January 1999 to September 2022. CAD was identified using a homogenous metric across multiple studies included. We computed the risk ratio (RR) for included studies using a random effects model. For the institutional cohort portion of our study, we selected high cardiovascular-risk patients who received diagnoses of BC between 2010 and 2022 if they met our inclusion criteria. We performed a Cox proportional hazards model with stepwise adjustment.

Results

A pooled random effects model with 9 studies showed that patients with left-sided BC receiving EBRT had a 10% increased risk of CAD when compared with patients with right-sided BC receiving EBRT (RR, 1.10; 95% CI, 1.02-1.18; P = .01). However, subgroup analysis of 6 studies that included patients diagnosed after 1980 did not show a significant difference in CAD based on BC laterality (RR, 1.07; 95% CI, 0.95-1.20; P = .27). For the institutional cohort portion of the study, we found that patients with left-sided BC who received EBRT did not have a significantly higher risk of CAD when compared with their right-sided counterparts (hazard ratios [HR], 0.73; 95% CI, 0.34-1.54; P = .402).

Conclusions

Our study suggests a historical trend of increased CAD in BC patients receiving left-sided EBRT. Data from patients diagnosed after 2010 in our institutional cohort did not show a significant difference, emphasizing that modern EBRT regimens are safe, and laterality of BC does not affect CAD outcomes in the short term after a BC diagnosis.

Cancer history and physical function in patients with cardiovascular disease

Both cancer and cardiovascular disease (CVD) cause skeletal muscle mass loss, thereby increasing the likelihood of a poor prognosis. We investigated the association between cancer history and physical function and their combined association with prognosis in patients with CVD. We retrospectively reviewed 3,796 patients with CVD (median age: 70 years; interquartile range [IQR]: 61-77 years) who had undergone physical function tests (gait speed and 6-minute walk distance [6MWD]) at discharge. We performed multiple linear regression analyses to assess potential associations between cancer history and physical function. Moreover, Kaplan-Meier curves and Cox regression analyses were used to evaluate prognostic associations in four groups of patients categorized by the absence or presence of cancer history and of high or low physical function. Multiple regression analyses showed that cancer history was significantly and independently associated with a lower gait speed and 6MWD performance. A total of 610 deaths occurred during the follow-up period (median: 3.1 years; IQR: 1.4-5.4 years). The coexistence of low physical function and cancer history in patients with CVD was associated with a significantly higher mortality risk, even after adjusting for covariates (cancer history/low gait speed, hazard ratio [HR]: 1.93, P < 0.001; and cancer history/low 6MWD, HR: 1.61, P = 0.002). Cancer history is associated with low physical function in patients with CVD, and the combination of both factors is associated with a poor prognosis.

Reducing the impact of cardiovascular disease in older people with cancer: a qualitative study of healthcare providers

PURPOSE

Cancer survivors are at greater risk of cardiovascular disease (CVD) than cancer-free controls. Despite evidence-based guidelines recommending CVD risk factor assessment, surveillance and risk-reduction, many people with cancer do not receive adequate CVD care. To address potential barriers and enablers of care, we examined healthcare professionals' (HCPs) perceptions and experiences of CVD risk assessment and management in people with cancer.

METHODS

We conducted one focus group and 12 individual interviews to examine HCPs' perceptions and experiences of CVD care in care. We used reflexive thematic analysis to collect and analyse the qualitative data to construct and understand themes.

RESULTS

Twenty-one HCPs participated (8 oncologists, 5 nurses, 3 general practitioners, 2 dietitians, 1 cardiologist, 1 haematologist and 1 physiotherapist). Majority of HCPs were aware of CVD risk in cancer but were concerned they could not deliver CVD care alone due to system-level barriers including lack of time and training. HCPs also perceived patient-level barriers including socioeconomic disadvantage and fatalistic outlook. Despite barriers, HCPs suggested diverse solutions for improving CVD care in cancer including new models-of-care, clinical pathways, risk assessment/management tools and education.

CONCLUSIONS

The diversity of perceived barriers and suggested solutions identified by HCPs suggests the need for a multilevel approach tailored to context. Future research involving people with cancer is needed to co-design acceptable interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Improved understanding of HCP's perceptions can inform the development of new interventions to deliver CVD care to people with cancer to reduce morbidity and mortality.

Health Literacy, Individual and Community Engagement, and Cardiovascular Risks and Disparities: JACC: CardioOncology State-of-the-Art Review

Cardiovascular and cancer outcomes intersect within the realm of cardio-oncology survivorship care, marked by disparities across ethnic, racial, social, and geographical landscapes. Although the clinical community is increasingly aware of this complex issue, effective solutions are trailing. To attain substantial public health impact, examinations of cancer types and cardiovascular risk mitigation require complementary approaches that elicit the patient's perspective, scale it to a population level, and focus on actionable population health interventions. Adopting such a multidisciplinary approach will deepen our understanding of patient awareness, motivation, health literacy, and community resources for addressing the unique challenges of cardio-oncology. Geospatial analysis aids in identifying key communities in need within both granular and broader contexts. In this review, we delineate a pathway that navigates barriers from individual to community levels. Data gleaned from these perspectives are critical in informing interventions that empower individuals within diverse communities and improve cardio-oncology survivorship.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature

BACKGROUND

Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research.

METHODS

Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460.

RESULTS

Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities.

CONCLUSIONS

Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

Using the consolidated framework for implementation research (CFIR) to guide implementation of cardio-oncology services

Introduction

Cardio-oncology focuses on diagnosing and preventing adverse cardiovascular outcomes in cancer patients. Interdisciplinary cardio-oncology services address the spectrum of prevention, detection, monitoring, and treatment of cancer patients at risk of cardio-toxicity and aim to improve the continuum of cardiac care for oncology patients. The goal of this study was to engage clinician and administrative stakeholders to assess multilevel needs, barriers, and expectations regarding cardio oncology services.

Methods

We interviewed clinicians and administrators at an academic medical center using the Consolidated Framework for Implementation Research (CFIR) to understand multilevel determinants influencing cardio-oncology service implementation. We also conducted a web-based survey to assess the knowledge, attitude, and perceptions of cardio-oncology services held by local and regional clinicians who may refer cardio-oncology patients to the study site.

Results

Multiple facilitators to cardio-oncology service implementation emerged. Interview participants believed cardio-oncology services could benefit patients and the organization by providing a competitive advantage. A majority (74%) of clinicians surveyed thought a cardio-oncology service would significantly improve cancer patients' prognoses. Implementation barriers discussed included costs and a siloed organizational structure that complicated cross-service collaboration. In the clinician survey, differences in the views toward cardio-oncology services held by cardiology versus oncology providers would need to be negotiated in future cardio-oncology service development. For example, while most providers accepted similar risk of cardio-toxicity when consenting patients for cancer therapy in a curative setting, cardiologists accepted significantly higher levels of risk than oncologists in an incurable setting: 75% of oncologists accepted 1-5% risk; 77% of cardiologists accepted ≥5% risk).

Conclusions

Participants supported implementation and development of cardio-oncology services. Respondents also noted multi-level barriers that could be addressed to maximize the potential for success. Engaging administrators and clinicians from cardiology and oncology disciplines in the future development of such services can help ensure maximal relevance and uptake.

Heartbreaker: Detection and prevention of cardiotoxicity in hematological malignancies

Cancer survivors are at significant risk of cardiovascular (CV) morbidity and mortality; patients with hematologic malignancies have a higher rate of death due to heart failure compared to all other cancer subtypes. The majority of conventional hematologic cancer treatments is associated with increased risk of acute and long-term CV toxicity. The incidence of cancer therapy induced CV toxicity depends on the combination of patient characteristics and on the type, dose, and duration of the therapy. Early diagnosis of CV toxicity, appropriate referral, more specific cardiac monitoring follow-up and timely interventions in target patients can decrease the risk of CV adverse events, the interruption of oncological therapy, and improve the patient's prognosis. Herein, we summarize the CV effects of conventional treatments used in hematologic malignancies with a focus on definitions and incidence of the most common CV toxicities, guideline recommended early detection approaches, and preventive strategies before and during cancer treatments.

Advancing the care of individuals with cancer through innovation & technology: Proceedings from the cardiology oncology innovation summit 2020 and 2021

As cancer therapies increase in effectiveness and patients' life expectancies improve, balancing oncologic efficacy while reducing acute and long-term cardiovascular toxicities has become of paramount importance. To address this pressing need, the Cardiology Oncology Innovation Network (COIN) was formed to bring together domain experts with the overarching goal of collaboratively investigating, applying, and educating widely on various forms of innovation to improve the quality of life and cardiovascular healthcare of patients undergoing and surviving cancer therapies. The COIN mission pillars of innovation, collaboration, and education have been implemented with cross-collaboration among academic institutions, private and public establishments, and industry and technology companies. In this report, we summarize proceedings from the first two annual COIN summits (inaugural in 2020 and subsequent in 2021) including educational sessions on technological innovations for establishing best practices and aligning resources. Herein, we highlight emerging areas for innovation and defining unmet needs to further improve the outcome for cancer patients and survivors of all ages. Additionally, we provide actionable suggestions for advancing innovation, collaboration, and education in cardio-oncology in the digital era.

Health position paper and redox perspectives on reactive oxygen species as signals and targets of cardioprotection

The present review summarizes the beneficial and detrimental roles of reactive oxygen species in myocardial ischemia/reperfusion injury and cardioprotection. In the first part, the continued need for cardioprotection beyond that by rapid reperfusion of acute myocardial infarction is emphasized. Then, pathomechanisms of myocardial ischemia/reperfusion to the myocardium and the coronary circulation and the different modes of cell death in myocardial infarction are characterized. Different mechanical and pharmacological interventions to protect the ischemic/reperfused myocardium in elective percutaneous coronary interventions and coronary artery bypass grafting, in acute myocardial infarction and in cardiotoxicity from cancer therapy are detailed. The second part keeps the focus on ROS providing a comprehensive overview of molecular and cellular mechanisms involved in ischemia/reperfusion injury. Starting from mitochondria as the main sources and targets of ROS in ischemic/reperfused myocardium, a complex network of cellular and extracellular processes is discussed, including relationships with Ca2+ homeostasis, thiol group redox balance, hydrogen sulfide modulation, cross-talk with NAPDH oxidases, exosomes, cytokines and growth factors. While mechanistic insights are needed to improve our current therapeutic approaches, advancements in knowledge of ROS-mediated processes indicate that detrimental facets of oxidative stress are opposed by ROS requirement for physiological and protective reactions. This inevitable contrast is likely to underlie unsuccessful clinical trials and limits the development of novel cardioprotective interventions simply based upon ROS removal.

Developing a Clinical Cardio-Oncology Program and the Building Blocks for Success: JACC: CardioOncology How To

•Cardio-oncology programs are necessary to provide optimal cardiovascular care to cancer patients and survivors.•Focus on developing a clear vision and mission-successful programs must be tailored to an organization's unique landscape.•Fostering partnerships with cardiologists and oncologists to provide high-quality patient-centered care is crucial.•Patience is essential-program development takes time, but success can be achieved.

Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review

Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.

Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations

It is well known that patients with cancer have a significantly higher cardiovascular mortality risk than the general population. Cardio-oncology has emerged to focus on these issues including risk reduction, detection, monitoring, and treatment of cardiovascular disease or complications in patients with cancer. The rapid advances in early detection and drug development in oncology, along with socioeconomic differences, racial inequities, lack of support, and barriers to accessing quality medical care, have created disparities in various marginalized populations. In this review, we will discuss the factors contributing to disparities in cardio-oncologic care in distinct populations, including Hispanic/Latinx, Black, Asian and Pacific Islander, indigenous populations, sex and gender minorities, and immigrants. Some factors that contribute to differences in outcomes in cardio-oncology include the prevalence of cancer screening rates, genetic cardiac/oncologic risk factors, cultural stressors, tobacco exposure rates, and physical inactivity. We will also discuss the barriers to cardio-oncologic care in these communities from the racial and socioeconomic context. Appropriate and timely cardiovascular and cancer care in minority groups is a critical component in addressing these disparities, and there need to be urgent efforts to address this widening gap.

Racial and Ethnic Differences in Cardiac Surveillance Evaluation of Patients Treated With Anthracycline-Based Chemotherapy

Background Anthracyclines remain a key treatment for many malignancies but can increase the risk of heart failure or cardiomyopathy. Specific guidelines recommend echocardiography and serum cardiac biomarkers such as BNP (B-type natriuretic peptide) or NT-proBNP (N-terminal proBNP) evaluation before and 6 to 12 months after treatment. Our objective was to evaluate associations between racial and ethnic groups in cardiac surveillance of survivors of cancer after exposure to anthracyclines. Methods and Results Adult patients in the OneFlorida Consortium without prior cardiovascular disease who received at least 2 cycles of anthracyclines were included in the analysis. Multivariable logistic regression was performed to estimate the odds ratios (ORs) and 95% CIs for receiving cardiac surveillance at baseline before anthracycline therapy, 6 months after, and 12 months after anthracycline exposure among different racial and ethnic groups. Among the entire cohort of 5430 patients, 63.4% had a baseline echocardiogram, with 22.3% receiving an echocardiogram at 6 months and 25% at 12 months. Non-Hispanic Black (NHB) patients had a lower likelihood of receiving a baseline echocardiogram than Non-Hispanic White (NHW) patients (OR, 0.75 [95% CI, 0.63-0.88]; P=0.0006) or any baseline cardiac surveillance (OR, 0.76 [95% CI, 0.64-0.89]; P=0.001). Compared with NHW patients, Hispanic patients received significantly less cardiac surveillance at the 6-month (OR, 0.84 [95% CI, 0.72-0.98]; P=0.03) and 12-month (OR, 0.85 [95% CI, 0.74-0.98]; P=0.03) time points, respectively. Conclusions There were significant racial and ethnic differences in cardiac surveillance among survivors of cancer at baseline and following anthracycline-based treatment in NHB and Hispanic cohorts. Health care providers need to be cognizant of these social inequities and initiate efforts to ensure recommended cardiac surveillance occurs following anthracyclines.

Preexisting hypertension and cancer therapy: evidence, pathophysiology, and management recommendation

Cancer is considered one of the leading causes of mortality worldwide. At the same time, hypertension is recognized as one of the most common comorbidities in cancer patients. Antineoplastic therapies, mainly tyrosine kinase and vascular endothelial growth factor inhibitors, have been associated with new-onset hypertension by activation of different pathophysiological pathways. However, the role of preexisting hypertension in cancer patients under treatment has not been thoroughly studied. According to this review, preexisting hypertension is an independent risk factor for increased blood pressure during anticancer therapy. Therefore, physicians should recognize hypertension and its phenotypes (i.e., masked hypertension) as an important modifiable risk factor that should be properly managed prior to the initiation of cancer therapy to avoid premature chemotherapy cessation. The development of onco-hypertension will help establish specific guidelines for managing hypertension in cancer patients.

Cancer and Postradiotherapy Cardiotoxicity: How to Face Damage in Women’s Hearts?

Cancer and cardiovascular disease are the two main causes of death worldwide in both men and women. In the past decades, survival rate in cancer patients has substantially improved due to new treatments and developments in radiation therapy (RT). In women, breast cancer (BC) is the leading cause of cancer death and thoracic RT is a main component of the treatment in many cases. Nevertheless, despite new techniques that limit the area receiving RT, cardiac damage is still an important concern in BC patients. In this review, the following aspects will be addressed: pathophysiology of postradiotherapy heart damage in women with BC; mechanisms, diagnosis and prevention/management of heart damage; and future areas of potential research for radiotherapy injury in women.

Comparison of American and European guidelines for cardio-oncology of heart failure

Heart failure is a complex clinical syndrome, whose signs and symptoms are caused by functional or structural impairment of ventricular filling or ejection of blood. Due to the interaction among anticancer treatment, patients' cardiovascular background, including coexisting cardiovascular diseases and risk factors, and cancer itself, cancer patients develop heart failure. Some drugs for cancer treatment may cause heart failure directly through cardiotoxicity or indirectly through other mechanisms. Heart failure in turn may make patients lose effective anticancer treatment, thus affecting the prognosis of cancer. Some epidemiological and experimental evidence shows that there is a further interaction between cancer and heart failure. Here, we compared the cardio-oncology recommendations among heart failure patients of the recent 2022 American guidelines, 2021 European guidelines, and 2022 European guidelines. Each guideline acknowledges the role of multidisciplinary (cardio-oncology) discussion before and during scheduled anticancer therapy.

Incidence and risk factors of cardiovascular mortality in patients with gastrointestinal adenocarcinoma

BACKGROUND

Gastrointestinal (GI) cancers are common and fatal. Improved cancer-directed therapies, with thier substantial role in improving cancer-specific survival, may increase non-cancer mortality-including cardiovascular mortality-in these patients.

AIM

To identify the risk factors of cardiovascular mortality in GI adenocarcinoma patients.

METHODS

Data of GI adenocarcinoma patients were gathered from the Surveillance, Epidemiology, and End Results database. We used Pearson's chi-square test to assess the relationships between categorical variables. We used the Kaplan-Meyer test in the univariate analysis and Cox regression test for the multivariate analysis.

RESULTS

Among 556,350 included patients, 275,118 (49.6%) died due to adenocarcinoma, 64,079 (11.5%) died due to cardiovascular causes, and 83,161 (14.9%) died due to other causes. Higher rates of cardiovascular mortality were found in patients ≥ 50 years (HR, 8.476; 95% CI, 7.91-9.083), separated (HR, 1.27; 95% CI, 1.184-1.361) and widowed (HR, 1.867; 95% CI, 1.812-1.924), patients with gastric (HR, 1.18; 95% CI, 1.1-1.265) or colorectal AC (HR, 1.123; 95% CI, 1.053-1.198), and patients not undergone surgery (HR, 2.04; 95% CI, 1.958-2.126). Lower risk patients include females (HR, 0.729; 95% CI, 0.717-0.742), blacks (HR, 0.95; 95% CI, 0.924-0.978), married (HR, 0.77; 95% CI, 0.749-0.792), divorced (HR, 0.841; 95% CI, 0.807-0.877), patients with pancreatic AC (HR, 0.83; 95% CI, 0.757-0.91), and patients treated with chemotherapy (HR, 0.416; 95% CI, 0.406-0.427).

CONCLUSIONS

Risk factors for cardiovascular mortality in GI adenocarcinoma include advanced age, males, whites, separated and widowed, gastric or colorectal adenocarcinoma, advanced grade or advanced stage of the disease, no chemotherapy, and no surgery. Married and divorced, and patients with pancreatic adenocarcinoma have a lower risk.

Patient similarity and other artificial intelligence machine learning algorithms in clinical decision aid for shared decision-making in the Prevention of Cardiovascular Toxicity (PACT): a feasibility trial design

BACKGROUND

The many improvements in cancer therapies have led to an increased number of survivors, which comes with a greater risk of consequent/subsequent cardiovascular disease. Identifying effective management strategies that can mitigate this risk of cardiovascular complications is vital. Therefore, developing computer-driven and personalized clinical decision aid interventions that can provide early detection of patients at risk, stratify that risk, and recommend specific cardio-oncology management guidelines and expert consensus recommendations is critically important.

OBJECTIVES

To assess the feasibility, acceptability, and utility of the use of an artificial intelligence (AI)-powered clinical decision aid tool in shared decision making between the cancer survivor patient and the cardiologist regarding prevention of cardiovascular disease.

DESIGN

This is a single-center, double-arm, open-label, randomized interventional feasibility study. Our cardio-oncology cohort of > 4000 individuals from our Clinical Research Data Warehouse will be queried to identify at least 200 adult cancer survivors who meet the eligibility criteria. Study participants will be randomized into either the Clinical Decision Aid Group (where patients will use the clinical decision aid in addition to current practice) or the Control Group (current practice). The primary endpoint of this study is to assess for each patient encounter whether cardiovascular medications and imaging pursued were consistent with current medical society recommendations. Additionally, the perceptions of using the clinical decision tool will be evaluated based on patient and physician feedback through surveys and focus groups. This trial will determine whether a clinical decision aid tool improves cancer survivors' medication use and imaging surveillance recommendations aligned with current medical guidelines.

TRIAL REGISTRATION

ClinicalTrials.Gov Identifier: NCT05377320.

Clinical response to lifestyle counseling for dyslipidemia and elevated blood pressure in childhood cancer survivors

BACKGROUND

Childhood cancer survivors (CCS) have increased risk of premature cardiovascular disease. Whether they respond similarly to lifestyle changes for elevated blood pressure (BP), body mass index (BMI), and dyslipidemia to those without history of childhood cancer is unknown.

PROCEDURE

This retrospective cohort study included CCS and 3:1 age- and sex-matched controls treated at Boston Children's Hospital Preventive Cardiology (2010-2019) using lifestyle management based on National Heart, Lung, and Blood Institute (NHLBI) guidelines. Change in BMI, BP, and lipids were analyzed.

RESULTS

We included 52 CCS and 162 controls with a median age of approximately 16 years. More CCS (84.3%) had elevated baseline fasting triglycerides (TG) than controls (49.4%) (p < .001). More CCS (62.5%) also had abnormal baseline high-density lipoprotein cholesterol (HDL-C) compared to controls (35.2%) (p = .001). Baseline BMI, BP, total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) were similar between groups. Over 15 weeks [IQR: 10.5-26], CCS had greater decrease in TG than controls (72.5 vs. 17 mg/dl decrease, p = .095). BP improved in 5% of CCS versus 38% of controls (p = .008). For both, BMI, TC, LDL-C, and HDL-C remained stable. CCS with stem cell transplantation (SCT) had a TC increase of 5% (6 mg/dl) compared to a decrease of 9% (19 mg/dl) among CCS without SCT (p = .02).

CONCLUSIONS

CCS demonstrated similar improvement in lipids, but impaired BP lowering in response to lifestyle management compared to controls. Further prospective studies are needed to determine if earlier pharmaceutical treatment is warranted in this higher risk population and for the long-term risk reductions of these approaches.

Coronary vasomotor dysfunction portends worse outcomes in patients with breast cancer

BACKGROUND

Impaired MFR in the absence of flow-limiting CAD is associated with adverse events. Cardiovascular disease is an important cause of morbidity and mortality in patients with breast cancer. We sought to test the utility of MFR to predict outcomes in a cohort of patients with breast cancer.

METHODS

We retrospectively studied consecutive patients with breast cancer or breast cancer survivors who underwent cardiac stress PET imaging from 2006 to 2017 at Brigham and Women's Hospital. Patients with a history of clinically overt CAD, LVEF < 45%, or abnormal myocardial perfusion were excluded. Subjects were followed from time of PET to the occurrence of a first major adverse cardiovascular event (MACE) and all-cause death.

RESULTS

The final cohort included 87 patients (median age 69.0 years, 98.9% female, mean MFR 2.05). Over a median follow-up of 7.6 years after PET, the lowest MFR tertile was associated with higher cumulative incidence of MACE (adjusted subdistribution hazard ratio 4.91; 95% CI 1.68-14.38; p = 0.004) when compared with the highest MFR tertile.

CONCLUSIONS

In patients with breast cancer, coronary vasomotor dysfunction was associated with incident cardiovascular events. MFR may have potential as a risk stratification biomarker among patients with/survivors of breast cancer.

County-level geographic disparities in cardiovascular disease mortality among US breast cancer survivors, 2000-2018

BACKGROUND

Disparities in cardiovascular disease mortality among breast cancer survivors are documented, but geographic factors by county-level socioeconomic status (SES) and rurality are not well described.

METHODS

We analyzed 724 518 women diagnosed with localized or regional stage breast cancer between 2000 and 2017 within Surveillance, Epidemiology, and End Results Program-18 with follow-up until 2018. We calculated relative risks (RRs) of cardiovascular disease mortality using Poisson regression, accounting for age- and race-specific rates in the general population, according to county-level quintiles of SES (measured by Yost index), median income, and rurality at breast cancer diagnosis. We also calculated 10-year cumulative mortality risk of cardiovascular disease accounting for competing risks.

RESULTS

Cardiovascular disease mortality was 41% higher among breast cancer survivors living in the lowest SES (RR = 1.41, 95% confidence interval [CI] = 1.36 to 1.46, Ptrend < .001) and poorest (RR = 1.41, 95% CI = 1.36 to 1.47, Ptrend < .001) counties compared with the highest SES and wealthiest counties, and 24% higher for most rural relative to most urban counties (RR = 1.24, 95% CI = 1.17 to 1.30, Ptrend < .001). Disparities for the lowest SES relative to highest SES counties were greatest among younger women aged 18-49 years (RR = 2.32, 95% CI = 1.90 to 2.83) and aged 50-59 years (RR = 2.01, 95% CI = 1.77 to 2.28) and within the first 5 years of breast cancer diagnosis (RR = 1.53, 95% CI = 1.44 to 1.64). In absolute terms, however, disparities were widest for women aged 60+ years, with approximately 2% higher 10-year cumulative cardiovascular disease mortality risk in the poorest compared with wealthiest counties.

CONCLUSIONS

Geographic factors at breast cancer diagnosis were associated with increased cardiovascular disease mortality risk. Studies with individual- and county-level information are needed to inform public health interventions and reduce disparities among breast cancer survivors.

The impact of greenspace or nature-based interventions on cardiovascular health or cancer-related outcomes: A systematic review of experimental studies

SIGNIFICANCE

Globally, cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality. While having different etiologies, CVD and cancer are linked by multiple shared risk factors, the presence of which exacerbate adverse outcomes for individuals with either disease. For both pathologies, factors such as poverty, lack of physical activity (PA), poor dietary intake, and climate change increase risk of adverse outcomes. Prior research has shown that greenspaces and other nature-based interventions (NBIs) contribute to improved health outcomes and climate change resilience.

OBJECTIVE

To summarize evidence on the impact of greenspaces or NBIs on cardiovascular health and/or cancer-related outcomes and identify knowledge gaps to inform future research.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and Peer Review of Electronic Search Strategies (PRESS) guidelines, we searched five databases: Web of Science, Scopus, Medline, PsycINFO and GreenFile. Two blinded reviewers used Rayyan AI and a predefined criteria for article inclusion and exclusion. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). This review is registered with PROSPERO, ID # CRD42021231619.

RESULTS & DISCUSSION

Of 2565 articles retrieved, 31 articles met the inclusion criteria, and overall had a low risk of bias. 26 articles studied cardiovascular related outcomes and 5 studied cancer-related outcomes. Interventions were coded into 4 categories: forest bathing, green exercise, gardening, and nature viewing. Outcomes included blood pressure (BP), cancer-related quality of life (QoL) and (more infrequently) biomarkers of CVD risk. Descriptions of findings are presented as well as visual presentations of trends across the findings using RAW graphs. Overall studies included have a low risk of bias; and alluvial chart trends indicated that NBIs may have beneficial effects on CVD and cancer-related outcomes.

CONCLUSIONS & IMPLICATIONS

(1) Clinical implication: Healthcare providers should consider the promotion of nature-based programs to improve health outcomes. (2) Policy implication: There is a need for investment in equitable greenspaces to improve health outcomes and build climate resilient neighborhoods. (3) Research or academic implication: Research partnerships with community-based organizations for a comprehensive study of benefits associated with NBIs should be encouraged to reduce health disparities and ensure intergenerational health equity. There is a need for investigation of the mechanisms by which NBIs impact CVD and exploration of the role of CVD biological markers of inflammation among cancer survivors.

Risk of cardiovascular diseases in cancer patients: A nationwide representative cohort study in Taiwan

BACKGROUND

The associations with cancer and cardiovascular diseases (CVD) had inconsistent results. The study aimed to investigate the risk of cardiovascular diseases (CVD) between populations with and without cancer.

METHODS

Patients with common cancers in Taiwan were enrolled in the study between 2007 and 2018 using the Taiwan Cancer Registry. We focused on colorectal cancer, women's breast cancer, lung cancer, liver cancer, oral cancer, prostate cancer, and thyroid cancers. The study endpoint was fatal and non-fatal CVD, which was defined as ischemic heart disease and ischemic stroke according to the National Health Insurance Research Database. We compared the risk of CVD between patients with cancer and age- and sex-matched (1:1 ratio) participants who did not have cancer or CVD. Multivariable adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained from Cox regression analysis. To evaluate the chronological trend, we estimated the HRs and 95% CI yearly since the diagnosis.

RESULTS

Among the 552,485 cancer patients (mean age, 60.6 years; women, 47.7%) during the median follow-up period of 4.1 years, 32,634 cases of fatal and non-fatal CVD were identified. Compared with that noted in the non-cancer population, the overall fully adjusted HR with 95% CI was 1.28 (1.25, 1.30) in the cancer population. The CVD risk was the highest in the first year, the adjusted HR with 95% CI was 2.31 (2.23, 2.40), and this risk decreased yearly.

CONCLUSIONS

Patients with cancer had a significantly higher risk of fatal or non-fatal CVD. The risk was the highest in the first year since diagnosis and decreased yearly.

Cardio oncology: Digital innovations, precision medicine and health equity

The rapid emergence of cardio-oncology has resulted in a rapid growth of cardio-oncology programs, dedicated professional societies sections and committees, and multiple collaborative networks that emerged to amplify the access to care in this new subspecialty. However, most existing data, position statements and guidelines are limited by the lack of availability of large clinical trials to support these recommendations. Furthermore, there are significant challenges regarding proper access to cardio-oncology care and treatment, particularly in marginalized and minority populations. The emergence and evolution of personalized medicine, artificial intelligence (AI), and machine learning in medicine and in cardio-oncology provides an opportunity for a more targeted, personalized approach to cardiovascular complications of cancer treatment. The proper implementation of these new modalities may facilitate a more equitable approach to adequate and universal access to cardio-oncology care, improve health related outcomes, and enable health care systems to eliminate the digital divide. This article reviews and analyzes the current status on these important issues.

Cardio-oncology: Implications for Clinical Practice for Women

PURPOSE OF REVIEW

Clinical cardio-oncology considerations specific to women span across many areas and are particularly relevant for management of patients with sex-specific cancers, such as breast cancer.

RECENT FINDINGS

Major improvement in breast cancer survivorship over the last decade and the recognition of CV disease as the second leading cause of death among survivors point to the relevance of long-term cardiovascular (CV) safety. This review summarizes the CV effects associated with multimodality breast cancer treatments and contemporary approach to CV risk stratification, prevention, early detection, monitoring, and management at the time of cancer diagnosis, during and after completion of treatment. We highlight the growing role of a multidisciplinary, team-based approach for comprehensive CV and oncology care through the entire cancer treatment continuum, from diagnosis through survivorship.

Left Ventricular Assist Device Implantation in Cancer-Therapy-Related Heart Failure

Objectives: Cancer-therapy-related heart failure (CTrHF) due to cardiotoxic drugs or radiation is a growing cause of end-stage heart failure. Limited knowledge is available concerning the use of continuous-flow left-ventricular-assist devices (cfLVAD) in this setting. Methods: The files of all 1334 patients who underwent cfLVAD implantation between December 2008 and December 2020 were screened for the cause of heart failure. All patients with CTrHF were included in the analysis. Results: A total of 32 patients with a median age of 58 years (IQR: 46–65) were included in the study; 15 (47%) were male. The median time from the first diagnosis of heart failure (HF) to cfLVAD implantation was 6 months (IQR 2–24), and from cancer treatment to cfLVAD implantation 40 months (IQR 5–144). Malignancies comprised non-Hodgkin lymphoma (n = 12, 37%), breast cancer (n = 9, 28%), sarcoma (n = 5, 16%), leukemia (n = 5, 16%), and others (n = 1, 3%). In 24 patients, chemotherapy included anthracyclines (others n = 2, unknown n = 6). Chest radiation was performed in 13 patients (39%). Moreover, 71% were classified as INTERMACS profile 1 or 2. The 30-day survival rate after LVAD implantation was 88%. Rethoracotomy was necessary in nine (29%), and a temporary right ventricular assist device in seven (21%) patients. The median survival was 29 months. There was no significant difference in survival or right HF between patients with CTrHF and a matched control group. Conclusions: CfLVAD implantation is feasible in high-risk patients with CTrHF with or without prior chest radiation.

The Impact of Exercise on Cardiotoxicity in Pediatric and Adolescent Cancer Survivors: A Scoping Review

Childhood and adolescent cancer survivors are disproportionately more likely to develop cardiovascular diseases from the late effects of cardiotoxic therapies (e.g., anthracycline-based chemotherapy and chest-directed radiotherapy). Currently, dexrazoxane is the only approved drug for preventing cancer treatment-related cardiac damage. While animal models highlight the beneficial effects of exercise cancer treatment-related cardiac dysfunction, few clinical studies have been conducted. Thus, the objective of this scoping review was to explore the designs and impact of exercise-based interventions for managing cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors. Reviewers used Joanna Briggs Institute’s methodology to identify relevant literature. Then, 4616 studies were screened, and three reviewers extracted relevant data from six reports. Reviewers found that exercise interventions to prevent cancer treatment-related cardiac dysfunction in childhood and adolescent cancer survivors vary regarding frequency, intensity, time, and type of exercise intervention. Further, the review suggests that exercise promotes positive effects on managing cancer treatment-related cardiac dysfunction across numerous indices of heart health. However, the few clinical studies employing exercise interventions for childhood and adolescent cancer survivors highlight the necessity for more research in this area.

Cardiovascular Magnetic Resonance Imaging in the Early Detection of Cardiotoxicity Induced by Cancer Therapies

The significant progress in cancer treatment, including chemotherapy, immunotherapy, radiotherapy, and combination therapies, has led to higher long-term survival rates in cancer patients, while the cardiotoxicity caused by cancer treatment has become increasingly prominent. Cardiovascular magnetic resonance (CMR) is a non-invasive comprehensive imaging modality that provides not only anatomical information, but also tissue characteristics and cardiometabolic and energetic assessment, leading to its increased use in the early identification of cardiotoxicity, and is of major importance in improving the survival rate of cancer patients. This review focused on CMR techniques, including myocardial strain analysis, T1 mapping, T2 mapping, and extracellular volume fraction (ECV) calculation in the detection of early myocardial injury induced by cancer therapies. We summarized the existing studies and ongoing clinical trials using CMR for the assessment of subclinical ventricular dysfunction and myocardial changes at the tissue level. The main focus was to explore the potential of clinical and preclinical CMR techniques for continuous non-invasive monitoring of myocardial toxicity associated with cancer therapy.

Mechanisms of Myocardial Ischemia in Cancer Patients: A State-of-the-Art Review of Obstructive Versus Non-Obstructive Causes

In patients with cancer, myocardial infarction (MI) has distinct features and mechanisms compared to the non-oncology population. Triggers of myocardial ischemia specific to the oncology population have been increasingly identified. Coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary oxygen supply-demand mismatch are all causes of MI that have been shown to have specific triggers related to either the treatments or complications of cancer. MI can occur in the presence or absence of atherosclerotic coronary artery disease (CAD). MI with nonobstructive CAD (MINOCA) is a heterogeneous syndrome that has distinct pathophysiology and different epidemiology from MI with significant CAD (MI-CAD). Recognition and differentiation of MI-CAD and MINOCA is essential in the oncology population, due to unique etiology and impact on diagnosis, management, and overall outcomes. There are currently no reports in the literature concerning MINOCA as a unified syndrome in oncology patients. The purpose of this review is to analyze the literature for studies related to known triggers of myocardial ischemia in cancer patients, with a focus on MINOCA. We propose that certain cancer treatments can induce MINOCA-like states, and further research is warranted to investigate mechanisms that may be unique to certain cancer states and types of treatment.

Disparities in Cardio-oncology: Effects On Outcomes and Opportunities for Improvement

Purpose of Review

The purpose of this article is to provide a comprehensive review of available data on health disparities and the interconnected social determinants of health (SDOH) in cardio-oncology. We identify the gaps in the literature and suggest areas for future research. In addition, we propose strategies to address these disparities at various levels.

Recent Findings

There has been increasing recognition of health disparities and the role of SODH on an individual’s access to health care, quality of care, and outcomes of the illness. There is growing evidence of sex and race-based differences in cancer therapy-related cardiotoxicity. Recent studies have shown how access and quality of health care are affected by financial stability and rurality. Our recent study utilizing the social vulnerability index (SVI) and county-level patient data found graded increase in county-level cardio-oncology mortality with greater social vulnerability. The incremental impact of social vulnerability was higher for cardio-oncology mortality than for mortality related to either cancer or CVD alone. The mortality rates in these patients were higher in rural areas compared to urban areas regardless of social vulnerability. Additionally, for those within the counties within highest social vulnerability, Black individuals had significantly higher cardio-oncology mortality compared with White individuals.

Summary

Disparities in the cardio-oncology population are deep-rooted and widespread, leading to poor quality of life and increased mortality. It is crucial to integrate SDOH, not only in clinical care delivery but also in future research, and registry data to improve our understanding and the outcomes in our unique subset of cardio-oncology patients.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Cardiac computed tomography-derived myocardial tissue characterization after anthracycline treatment

AIMS

Understanding cardiac function after anthracycline administration is very important from the perspective of preventing the onset of heart failure. Although cardiac magnetic resonance and echocardiography are recognized as the 'gold standard' for detecting cardiotoxicity, they have many shortcomings. We aimed to investigate whether cardiac computed tomography (CCT) could replace these techniques, assessing serial changes in cardiac tissue characteristics as determined by CCT after anthracycline administration.

METHODS AND RESULTS

We prospectively investigated 15 consecutive breast cancer patients who were scheduled to receive anthracycline therapy. We performed echocardiography and CCT before and 3, 6, and 12 months after anthracycline treatment. The mean cumulative administered anthracycline dose was 269.9 ± 14.6 mg/m² (doxorubicin-converted dose). Of the 15 enrolled patients who received anthracycline treatment for breast cancer, none met the definition of cardiotoxicity. The CCT-derived extracellular volume fraction tended to continue to increase after anthracycline treatment and had relatively similar dynamics to the left ventricular ejection fraction and global longitudinal strain as determined by echocardiography.

CONCLUSIONS

Our findings indicated that CCT could provide adequate information about the characteristics of myocardial tissue after anthracycline administration. CCT may improve the understanding of cardiotoxicity by compensating for the weaknesses of echocardiography. This technique could be useful for understanding cardiac tissue characterization as a 'one-stop shop' evaluation, providing new insight into cardiooncology.

Cardiovascular Event Reporting in Modern Cancer Radiation Therapy Trials

Purpose

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in cancer survivors, particularly after chest radiation therapy (RT). However, the extent to which CVD events are consistently reported in contemporary prospective trials is unknown.

Methods and Materials

From 10 high-impact RT, oncology, and medicine journals, we identified all latter phase trials from 2000 to 2019 enrolling patients with breast, lung, lymphoma, mesothelioma, or esophageal cancer wherein chest-RT was delivered. The primary outcome was the report of major adverse cardiac events (MACEs), defined as incident myocardial infarction, heart failure, coronary revascularization, arrhythmia, stroke, or CVD death across treatment arms. The secondary outcome was the report of any CVD event. Multivariable regression was used to identify factors associated with CVD reporting. Pooled annualized incidence rates of MACEs across RT trials were compared with contemporary population rates using relative risks (RRs).

Results

The 108 trials that met criteria enrolled 59,070 patients (mean age, 58.0 ± 10.2 years; 46.0% female), with 273,587 person-years of available follow-up. During a median follow-up of 48 months, 468 MACEs were reported (including 96 heart failures, 75 acute coronary syndrome, 1 revascularization, 94 arrhythmias, 28 strokes, and 20 CVD deaths; 307 occurred in the intervention arms vs 144 in the control arms; RR, 1.96; P < .001). Altogether, 50.0% of trials did not report MACEs, and 37.0% did not report any CVD. The overall weighted-trial incidence was 376 events per 100,000 person-years compared with 1408 events per 100,000 person-years in similar nontrial patients (RR, 0.27; P < .001). There were no RT factors associated with CVD reporting.

Conclusion

In contemporary chest RT–based clinical trials, reported CVD rates were lower than expected population rates.

Greenspace, Inflammation, Cardiovascular Health, and Cancer: A Review and Conceptual Framework for Greenspace in Cardio-Oncology Research

Cardiovascular disease (CVD) is a leading cause of global morbidity and mortality. Cancer survivors have significantly elevated risk of poor cardiovascular (CV) health outcomes due to close co-morbid linkages and shared risk factors between CVD and cancer, as well as adverse effects of cancer treatment-related cardiotoxicity. CVD and cancer-related outcomes are exacerbated by increased risk of inflammation. Results from different pharmacological interventions aimed at reducing inflammation and risk of major adverse cardiovascular events (MACEs) have been largely mixed to date. Greenspaces have been shown to reduce inflammation and have been associated with CV health benefits, including reduced CVD behavioral risk factors and overall improvement in CV outcomes. Greenspace may, thus, serve to alleviate the CVD burden among cancer survivors. To understand pathways through which greenspace can prevent or reduce adverse CV outcomes among cancer survivors, we review the state of knowledge on associations among inflammation, CVD, cancer, and existing pharmacological interventions. We then discuss greenspace benefits for CV health from ecological to multilevel studies and a few existing experimental studies. Furthermore, we review the relationship between greenspace and inflammation, and we highlight forest bathing in Asian-based studies while presenting existing research gaps in the US literature. Then, we use the socioecological model of health to present an expanded conceptual framework to help fill this US literature gap. Lastly, we present a way forward, including implications for translational science and a brief discussion on necessities for virtual nature and/or exposure to nature images due to the increasing human-nature disconnect; we also offer guidance for greenspace research in cardio-oncology to improve CV health outcomes among cancer survivors.

Current State of Pediatric Cardio-Oncology: A Review

The landscape of pediatric oncology has dramatically changed over the course of the past several decades with five-year survival rates surpassing 80%. Anthracycline therapy has been the cornerstone of many chemotherapy regimens for pediatric patients since its introduction in the 1960s, and recent improved survival has been in large part due to advancements in chemotherapy, refinement of supportive care treatments, and development of novel therapeutics such as small molecule inhibitors, chimeric antigen receptor T-cell therapy, and immune checkpoint inhibitors. Unfortunately, many cancer-targeted therapies can lead to acute and chronic cardiovascular pathologies. The range of cardiotoxicity can vary but includes symptomatic or asymptotic heart failure, arrhythmias, coronary artery disease, valvar disease, pericardial disease, hypertension, and peripheral vascular disease. There is lack of data guiding primary prevention and treatment strategies in the pediatric population, which leads to substantial practice variability. Several important future research directions have been identified, including as they relate to cardiac disease, prevention strategies, management of cardiovascular risk factors, risk prediction, early detection, and the role of genetic susceptibility in development of cardiotoxicity. Continued collaborative research will be key in advancing the field. The ideal model for pediatric cardio-oncology is a proactive partnership between pediatric cardiologists and oncologists in order to better understand, treat, and ideally prevent cardiac disease in pediatric oncology patients.

Perceptions of the Cardiologists and Oncologists: Initial Step for Establishing Cardio-Oncology Service

Background: Over the last years, there was no established cardio-oncology service in Iraq and no firm data about the incidence of cardiovascular disease (CVD) among patients with cancer. As an initial step, we decided to conduct a national cardio-oncology online survey for cardiologists, oncologists, and their residents which would help us to understand the expected prevalence, problems, and readiness for collaboration between the two specialties.

Objectives: For evaluating the current national practice in the cardiology and oncology specialty fields and to identify the hidden gaps associated with the development or worsening of CVD among patients with cancer.

Methods: An online survey including 19-question for cardiologists/cardiology residents (CCRs) and 30-question for oncologists/oncology residents (OORs) about cardio-oncology service was sent to them including all Iraqi cities using Google document form during December 2020.

Results: The total number of responses was 164, mainly 62.2% from CCRs while 37.8% from OORs. Hypertension was the main baseline risk factor (71%). A 77.5% of CCRs prescribe cardiovascular drugs vs. 35.5% by OORs. About 76.5% of CCRs and 79% of OORs are facing difficulties in the management of patients with cancer with established CVD. CVD was the leading cause of both hospitalization (30.7%) and mortality (48.4%). About 62.8% of CCRs and 64.5% of OORs have an interest to work in cardio-oncology service.

Conclusion: Based on the perception of cardiologists and oncologists, CVD is the main cause of hospitalization and mortality among patients with cancer. High interest among CCRs and OORs to work in cardio-oncology service. Positive initiatives are available to take the action plan in this emerging field.

Pediatric Cardio-Oncology Medicine: A New Approach in Cardiovascular Care

Survival for pediatric patients diagnosed with cancer has improved significantly. This achievement has been made possible due to new treatment modalities and the incorporation of a systematic multidisciplinary approach for supportive care. Understanding the distinctive cardiovascular characteristics of children undergoing cancer therapies has set the underpinnings to provide comprehensive care before, during, and after the management of cancer. Nonetheless, we acknowledge the challenge to understand the rapid expansion of oncology disciplines. The limited guidelines in pediatric cardio-oncology have motivated us to develop risk-stratification systems to institute surveillance and therapeutic support for this patient population. Here, we describe a collaborative approach to provide wide-ranging cardiovascular care to children and young adults with oncology diseases. Promoting collaboration in pediatric cardio-oncology medicine will ultimately provide excellent quality of care for future generations of patients.

Associations of cardiovascular risk factors with survival outcomes in a cancer registration: Findings from the KUMAMON registry

Although the relationship between cardiovascular diseases and malignant diseases has recently attracted attention, the associations of cardiovascular risk factors and clinical outcomes in cancer patients remain to be elucidated. We performed a retrospective, observational study that explored the clinical outcomes of patients with cancer or with a history of cancer.We enrolled 30,706 consecutive adult cancer patients from Kumamoto University Hospital. We investigated mortality and morbidity, including cardiovascular conditions (dyslipidemia [DL]/diabetes mellitus [DM]/hypertension [HT]). The primary endpoint was all-cause mortality.Of the enrolled patients, 9032 patients (29.4%) died within the follow-up period. The Kaplan-Meier analysis demonstrated that in the groups classified according to the number of DL/DM/HT (LDH) factors, the LDH1 and LDH2 groups had a significantly higher probability of the primary endpoint than the LDH0 group (P < .001 and P < .001, respectively), whereas there were no significant differences between the LDH0 group and LDH3 group (P = .963). Univariate Cox proportional hazards regression analyses of mortality complemented by the multiple imputation method including various factors demonstrated that the presence of DL in cancer patients was a significant negative predictor of mortality (hazard ratio = 0.79, P < .01).The all-cause mortality rate did not always increase as the number of LDH factors increased. The present study revealed that the presence of DL is a negative risk factor for all-cause mortality in cancer patients.

The Importance of Primary Care in Cardio-Oncology

OPINION STATEMENT

There is significant interplay between cancer and cardiovascular disease involving shared risk factors, cross disease communication where cardiovascular events can influence cancer recurrence, and mortality rates and cardiotoxicity from cancer treatments with resultant increased cardiovascular mortality and morbidity in cancer patients. This is a major cause of death in many long-term cancer survivors. As a result, cardio-oncology, which involves the prevention, early detection, and optimal treatment of cardiovascular disease in patients treated for cancer, is expanding globally. However, there is still limited awareness of its importance and limited application of the lessons already learnt. Primary care physicians, and their clinical teams, especially nursing colleagues, have a foundation role in the management of all patients, and this paper outlines areas where they can lead in the cardio-oncology management of cancer patients. Although there is currently a lack of an adequate clinical framework or shared care plan, primary care physicians have a role to play in the various phases of cancer treatment: pre-therapy, during therapy, and survivorship.

Current status and future perspectives of onco-cardiology: Importance of early detection and intervention for cardiotoxicity, and cardiovascular complication of novel cancer treatment

The prognosis has improved remarkably in recent years with the development of cancer treatment. With the increase in the number of cancer survivors, complications of cardiovascular disease have become a problem. Therefore, the field of onco-cardiology has been attracting attention. The field of onco-cardiology covers a wide range of areas. In the past, cardiac dysfunction caused by cardiotoxic drug therapies such as doxorubicin (Adriamycin) was the most common cause of cardiac dysfunction, but nowadays, cardiovascular complications caused by aging cancer survivors, atherosclerotic disease in cardiovascular risk carriers, thromboembolism, and new drugs (e.g., myocarditis caused by immune checkpoint inhibitors and hypertension caused by angiogenesis) are becoming more common. In this review, we summarize the latest findings of cardiotoxicity of cancer therapy, appropriate treatment and prevention, and cardiovascular complications of novel chemotherapy, which will increase in demand in the near future.

Cardio-Oncology Educational Program: National Survey as the First Step to Start

Aim: The collaboration of cardiologists, general practitioners (GPs), and oncologists is crucial in cancer patient management. We carried out a national-based survey-The Ukrainian National Survey (UkrNatSurv)-on behalf of the Cardio-Oncology (CO) Working Group (WG) of the Ukrainian Society of Cardiology to analyze the level of knowledge in cardio-oncology. Methods: A short questionnaire was presented to specialists involved in the management of cancer patients across the country. The questionnaire was made up of eight questions concerning referred cancer patient number, CV complications of cancer therapy, diagnostic methods to detect cardiotoxicity, and drugs used for its treatment. Results: A total of 426 questionnaires of medical specialists from different regions of Ukraine were collected and analyzed; the majority of respondents were cardiologists (190), followed by GPs (177), 40 oncologists (mainly chemotherapists and hematologists), other -19 (imaging specialists, neurologists, endocrinologists, etc.). All responders were equally involved in the management of cancer patients. However, less than half of the patients have been seen before the start of cancer therapy. GPs observe the majority of patients after the end of treatment. All doctors are sufficiently aware of cancer therapy-associated CV complications. However, the necessary diagnostic tools, mostly biomarkers, are not used widely by different specialists. The criteria for cardiotoxicity, in particular, the level of reduction of the left ventricular ejection fraction (LVEF) as a marker of LV dysfunction, are not clearly understood. The specific knowledge in the management of CV complications in cancer is required. Conclusion: UkrNatSurv is the first survey in Ukraine to investigate the awareness of CO care provided to cancer patients with CV diseases (CVD) or developed CV complications. Providing such surveys among doctors involved in CO is an excellent tool to investigate the knowledge gaps in clinical practice. Therefore, the primary task is to develop a national educational CO program.

Cardiac risk stratification of breast cancer patients in a cardio-oncology clinic

PURPOSE

The field of cardio-oncology aims to optimize the cardiac health of cancer patients. The goals of this study are to (1) describe the demographics of a cardio-oncology clinic and (2) apply the American Society of Clinical Oncology (ASCO) cardiac risk stratification guidelines among breast cancer patients to assess the development of cardiovascular events, primarily heart failure (HF).

METHODS

We performed a retrospective chart review on 203 consecutive cardio-oncology patients who were seen between January 2019 and March 2020. Mean follow-up for the cohort was 29.2 ± 3.1 months (range 0-113). We applied the ASCO guidelines to the breast cancer subgroup.

RESULTS

The plurality of patients 82/203 (40%) referred to clinic had breast cancer. The most common reason for referral was asymptomatic left ventricular (LV) dysfunction or HF (40%). Only 36/203 (18%) of patients were referred for a pre-chemotherapy evaluation. In breast cancer patients, there was a trend toward significance in up-titrating or initiating beta-blockers in the high vs. low risk ASCO groups [46/69 (67%) vs. 5/13 (38%), p = 0.054]. Approximately 13/82 (16%) of breast cancer patients required alterations to their anti-cancer therapy. HF events occurred in 1/36 (3%) of cancer treatment naïve patients and 14/167 (8%) of those with prior therapy, specifically 9% of the breast cancer subset.

CONCLUSION

Our study provides insight into referral practices, interventions, and outcomes at a cardio-oncology clinic. Furthermore, breast cancer patients continue to have high rates of HF. These findings suggest a need to shift referral practices upstream for a pre-chemotherapy evaluation to optimize cardiovascular health.

The EACVI survey on cardiac imaging in cardio-oncology

Early and late cardiovascular (CV) toxicities related to many cancer treatments may complicate the clinical course of patients, offsetting therapeutic benefits, and altering prognosis. The early detection, monitoring, and treatment of cardiotoxicity have therefore become essential parts of cancer patient care. CV imaging is a cornerstone of every cardio-oncology unit, but its use may vary across Europe because of the non-uniform availability of advanced imaging techniques and differences in the organization and logistics of cardio-oncology services. The purpose of this EACVI survey in cardio-oncology is to obtain real-world data on the current usage of cardiac imaging in cancer patients. Data from 104 centres and 35 different countries confirmed that cardiac imaging plays a pivotal role in the detection and monitoring of cardiac toxicity in oncology patients in Europe and beyond. However, it also revealed gaps between guidelines recommendations and everyday clinical practice, highlighting some of the challenges that need to be overcome in this rapidly advancing field.