Different manifestation of irradiation induced coronary artery disease detected with coronary computed tomography compared with matched non-irradiated controls

Left Anterior Descending Artery Dissection in a Female Patient With History of Chest Radiation Treatment and Separate Ostia of the Left Coronary Arteries

Obstructive and flow limiting coronary artery dissections can be a catastrophic clinical scenario, requiring urgent treatment and tailored approach for each case. A 55-year-old female patient, with a history of breast cancer, chest radiation treatments and hypertension presented with episodes of angina and significant area of reversible ischemia on single-photon emission computerized tomography (SPECT). Coronary angiogram revealed separate ostia of the left coronary arteries and three-vessel disease (SYNTAX (Synergy between percutaneous coronary intervention (PCI) with Taxus and Cardiac Surgery) = 15); subsequent full revascularization was achieved successfully with two drug-eluting stents (DES) (mid left anterior descending artery (LAD), left circumflex coronary artery (LCx)) and one drug-coated balloon (posterior descending artery (PDA)). However, after a few hours the patient underwent an urgent second angiography due to ongoing chest pain and electrocardiogram (ECG) changes. Proximal complete occlusion of the anomalous LAD was displayed and a long dissection attributable to an intimal tear following first stent implantation was recorded (well expanded and apposed stent (proximal stent edges were implanted in an unhealthy vessel area infiltrated with fibrotic and calcified plaque) not detectable by conventional angiography). A second 3.5 × 38 mm DES was implanted optimally in the proximal LAD segment and overlapped with the first one, with immediate restoration of the flow and relief of the patient's symptoms. The patient was discharged symptom free and with recommendation for optimal medical treatment for secondary coronary artery disease (CAD) prevention. Conventional coronary angiography in patients with history of chest radiation treatment might not detect accurately the extent and characteristics of the underlying CAD. Appropriate use of intravascular imaging in these cases secures a safe approach for ambiguous lesions and facilitates treatment of iatrogenic coronary dissections following PCI.

Clinical Utility and Prognostic Value of Coronary Computed Tomography Angiography in Patients With Cancer

There is growing interest in the role of coronary computed tomography angiography (CTA) in cardio-oncology. However, there is a paucity of real-world experience and outcome data for patients with cancer. This study sought to determine the clinical utility and prognostic value of coronary CTA in patients with cancer. In this prospective, single-center study, we recruited patients with cancer who underwent coronary CTA. Coronary artery disease (CAD) extent was classified as normal, nonobstructive (1% to 49% stenosis), and potentially obstructive (≥50% stenosis). Patients were followed up for a median of 9 months (interquartile range 3 to 30 months) for cancer-related deaths and major adverse cardiovascular events (MACEs) defined as nonfatal myocardial infarction, urgent unplanned revascularization, or cardiovascular death. The mean age of patients (n = 113) was 61 ± 12 years, and 68 were female (60%). The most common underlying cancers were breast (29%) and lymphoma (13%). A total of 25 patients had potentially obstructive CAD, most commonly of the left anterior descending artery. After coronary CTA, 88% statin-naive patients with potentially obstructive CAD were initiated on statin therapy. A total of 28/32 patients who were taking fluoropyrimidine chemotherapy (5-fluorouracil or capecitabine) continued therapy, of whom none had MACEs. Overall, there were no episodes of MACEs in this cohort and 11% had cancer-related deaths. Coronary CTA has an important role in the clinical decision-making in patients with cancer to detect CAD, initiate primary preventative therapy, and guide coronary revascularization. No MACEs occurred. Using this coronary CTA-guided approach, preventative therapy was initiated, and most patients continued prognostically important cancer therapy.

Cancer survivorship at heart: a multidisciplinary cardio-oncology roadmap for healthcare professionals

In cancer, a patient is considered a survivor from the time of initial diagnosis until the end of life. With improvements in early diagnosis and treatment, the number of cancer survivors (CS) has grown considerably and includes: (1) Patients cured and free from cancer who may be at risk of late-onset cancer therapy-related cardiovascular toxicity (CTR-CVT); (2) Patients with long-term control of not-curable cancers in whom CTR-CVT may need to be addressed. This paper highlights the importance of the cancer care continuum, of a patient-centered approach and of a prevention-oriented policy. The ultimate goal is a personalized care of CS, achievable only through a multidisciplinary-guided survivorship care plan, one that replaces the fragmented management of current healthcare systems. Collaboration between oncologists and cardiologists is the pillar of a framework in which primary care providers and other specialists must be engaged and in which familial, social and environmental factors are also taken into account.

Plaque Rupture in a Hodgkin Lymphoma Survivor without Cardiovascular Risk Factors 20 Years after Thoracic Radiotherapy: A Case Report

BACKGROUND

Major improvements in cancer therapies have significantly contributed to increased survival rates of Hodgkin lymphoma (HL) survivors, outweighing cardiovascular side effects and the risks of radiation-induced heart disease. Non-invasive screening for coronary artery disease (CAD) starting five years after irradiation is recommended, as plaque development and morphology may differ in this high-risk population. Due to rapid plaque progression and a possibly higher incidence of non-calcified plaques, coronary artery calcium scoring may not be sufficient as a screening modality in HL survivors treated with thoracic radiotherapy.

CASE SUMMARY

A 42-year-old man with a history of HL treated with thoracic radiotherapy presented at the emergency department 20 years after cancer treatment with an ST-elevation myocardial infarction, in the absence of cardiovascular risk factors, for which primary percutaneous coronary intervention of the left anterior descending artery was performed. Four months prior to acute myocardial infarction, invasive coronary angiography only showed wall irregularities. Two years earlier, the Agatston calcium score was zero.

DISCUSSION

In HL survivors treated with thoracic radiotherapy, a calcium score of zero may not give the same warranty period for cardiac event-free survival compared to the general population. Coronary computed tomography angiography can be a proper diagnostic tool to detect CAD at an early stage after mediastinal irradiation, as performing calcium scoring may not be sufficient in this population to detect non-calcified plaques, which may show rapid progression and lead to acute coronary syndrome. Also, intensive lipid-lowering therapy should be considered in the presence of atherosclerosis in this patient population.

Role of Real-World Data in Assessing Cardiac Toxicity After Lung Cancer Radiotherapy

Radiation-induced heart disease (RIHD) is a recent concern in patients with lung cancer after being treated with radiotherapy. Most of information we have in the field of cardiac toxicity comes from studies utilizing real-world data (RWD) as randomized controlled trials (RCTs) are generally not practical in this field. This article is a narrative review of the literature using RWD to study RIHD in patients with lung cancer following radiotherapy, summarizing heart dosimetric factors associated with outcome, strength, and limitations of the RWD studies, and how RWD can be used to assess a change to cardiac dose constraints.

Coronary Atherosclerosis and Aortic Valve Disease as Long-Term Sequelae of Radiation Therapy in Childhood

Coronary atherosclerosis and valvular heart disease are rare, but potentially severe sequelae following mediastinal radiation therapy. We present a case of premature ischemic heart disease and severe aortic stenosis in a 40-year-old woman following radiation therapy in childhood. We stress the awareness of prior mediastinal radiation therapy as an important risk factor for premature coronary atherosclerosis and valvular heart disease, particularly in younger patients without classical risk factors for coronary artery disease.

Radiation-Induced Cardiovascular Disease: Review of an Underrecognized Pathology

Radiation therapy demonstrates a clear survival benefit in the treatment of several malignancies. However, cancer survivors can develop a wide array of cardiotoxic complications related to radiation. This pathology is often underrecognized by clinicians and there is little known on how to manage this population. Radiation causes fibrosis of all components of the heart and significantly increases the risk of coronary artery disease, cardiomyopathy, valvulopathy, arrhythmias, and pericardial disease. Physicians should treat other cardiovascular risk factors aggressively in this population and guidelines suggest obtaining regular imaging once symptomatology is established. Patients with radiation‐induced cardiovascular disease tend to do worse than their traditional counterparts for the same interventions. However, there is a trend toward fewer complications and lower mortality with catheter‐based rather than surgical approaches, likely because radiation makes these patients poor surgical candidates. When appropriate, these patients should be referred for percutaneous management of valvulopathy and coronary disease.

Cardiac computed tomography in cardio-oncology: an update on recent clinical applications

Chemotherapy and radiotherapy have drastically improved cancer survival, but they can result in significant short- and long-term cardiovascular complications, most commonly heart failure from chemotherapy, whilst radiotherapy increases the risk of premature coronary artery disease (CAD), valve, and pericardial diseases. Cardiac computed tomography (CT) with calcium scoring has a role in screening asymptomatic patients for premature CAD, cardiac CT angiography (CTCA) allows the identification of significant CAD, also in the acute settings where concerns exist towards invasive angiography. CTCA integrates the diagnostic work-up and guides surgical/percutaneous management of valvular heart diseases and allows the assessment of pericardial conditions, including detection of effusion and pericardial calcification. It is a widely available and fast imaging modality that allows a one-step evaluation of CAD, myocardial, valvular, and pericardial disease. This review aims to provide an update on its current use and accompanying evidence-base for cardiac CT in the management of cardio-oncology patients.

18-Year Follow-Up After Coronary Stenting for Left Main Coronary Artery Lesions

The current treatment of radiation-induced coronary artery disease (RCAD) is comparable to that of generic coronary artery disease (CAD); however, the outcomes of these treatment measures have not been fully examined in RCAD. A 33-year-old woman, without conventional cardiovascular risk factors, presented with left main coronary artery (LMCA) lesions. At the age of 26, she received mediastinal radiation therapy (RT) to treat mixed cellularity Hodgkin lymphoma. One BiodivYsio 3.5 × 18 mm stent was implanted at the LMCA site. At the age of 38, the patient was treated by balloon dilatation because of approximately 50% in-stent stenosis. At the last follow-up in February 2018, when the patient was 51 years old, she no longer complained of chest pain. Coronary angiography showed no de novo or in-stenosis lesions, although optical coherence tomography showed mild neointimal proliferation, calcific plaque, small ruptured intima, and several uncovered struts. The experience of treating this case may shed some light on coronary stenting in coronary lesions caused by RCAD.

Contemporary Understandings of Cardiovascular Disease After Cancer Radiotherapy: a Focus on Ischemic Heart Disease

PURPOSE OF REVIEW

Radiation-induced cardiovascular disease, including coronary artery disease, is a well-known sequela of radiation therapy and represents a significant source of morbidity and mortality for cancer survivors. This review examines current literature and guidelines to care for this growing population of cancer survivors.

RECENT FINDINGS

The development of radiation-induced ischemic heart disease following radiation can lead even to early cardiotoxicities, inclusive of coronary artery disease, which limit cancer treatment outcomes. These coronary lesions tend to be diffuse, complex, and proximal. Early detection with multimodality imaging and targeted intervention is required to minimize these risks. Early awareness, detection, and management of radiation-induced cardiovascular disease are paramount as cancer survivorship continues to grow.

Chemotherapy-Related Anatomical Coronary-Artery Disease in Lung Cancer Patients Evaluated by Coronary-Angiography SYNTAX Score

Fundamento

A doença arterial coronariana (DAC) associada à quimioterapia está se tornando um tema emergente na prática clínica. Contudo, o mecanismo subjacente da quimioterapia associada à DAC permanence incerto.

Objetivos

O estudo investigou a associação entre a quimioterapia e as anomalias anatômicas ateroscleróticas das artérias coronárias dentre pacientes com cancer de pulmão.

Métodos

Foram incluídos pacientes submetidos à angiografia coronária (AGC), entre 2010 e 2017, com câncer de pulmão prévio. Os fatores de risco associados à DAC e os dados sobre o câncer de pulmão foram avaliados. Avaliamos as anomalias das artérias coronárias de acordo com o escore SYNTAX (SXescore) calculado à AGC. Na análise de regressão logística, o escore SYNTAX foi classificado como alto (SXescoreALTO) se ≥22. Os dados foram analisados através de estatística descritiva e análise de regressão.

Resultados

Ao todo, 94 pacientes foram incluídos no estudo. O SXescore foi mais alto no grupo com quimioterapia quando comparado com o grupo sem quimioterapia (25,25, IIQ [4,50–30,00] versus 16,50, IIQ [5,00–22,00]; p = 0,0195). A taxa do SXescoreALTO foi maior no grupo com quimioterapia do que no no grupo sem quimioterapia (58,33% versus 25,86; p = 0,0016). Tanto a análise de regressão logística univariada (OR: 4,013; 95% IC:1,655–9,731) quanto a multivariada (OR: 5,868; 95% IC:1,778–19,367) revelaram que a quimioterapia aumentou o risco de uma maior taxa do SXescoreALTO. A análise multivariada de regressão logística Stepwise mostrou que o risco para DAC anatômica mais grave aumenta com a quimioterapia como um todo em 5.323 vezes (95% IC: 2,002–14,152), e com o regime à base de platina em 5,850 vezes (95% IC: 2,027–16,879).

Conclusões

A quimioterapia está associada com a complexidade e gravidade anatômica da DAC, o que pode explicar, em parte, o maior risco de DAC associada à quimioterapia dentre pacientes com câncer de pulmão. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Prognosis of acute coronary syndromes after radiotherapy for breast cancer

BACKGROUND AND PURPOSE

Breast cancer patients treated with radiotherapy are at increased risk of subsequent acute coronary syndromes (ACS). We aimed to study if radiotherapy also influences the prognosis of these ACS.

MATERIALS AND METHODS

We included all 398 patients diagnosed with ACS following radiotherapy from our hospital-based cohort of early breast cancer patients aged <71 years, treated 1970-2009. Cardiovascular disease incidence and cause of death were acquired through questionnaires to general practitioners and cardiologists. Internal mammary chain (IMC) irradiation delivers the highest heart doses in breast cancer radiotherapy. Hence, we compared ACS prognosis between patients treated with/without IMC-irradiation. ACS prognosis was assessed through cardiac death, death due to ACS and cardiovascular disease incidence, using multivariable Cox proportional hazard models and by estimating cumulative incidence.

RESULTS

In total, 62% of patients with ACS had received IMC-irradiation and 38% did not (median age at ACS diagnosis, 67 years). Median time between breast cancer and ACS was 15 years. After ACS, ten-year cumulative risk of cardiac death was 35% for patients who had IMC-irradiation (95% confidence interval [95%CI] 29-41) compared to 24% (95%CI 17-31) for patients without IMC-irradiation (p = 0.04). After correction for confounders, IMC-irradiation remained associated with a less favourable prognosis of ACS compared to no IMC-irradiation (hazard ratio cardiac death = 1.7, 95%CI 1.1-2.5).

CONCLUSION

Our results suggest that radiotherapy, in case of substantial heart doses,may worsen ACS prognosis. This is an important, novel finding that may impact upon the risk-based care for breast cancer survivors with ACS.

Cardiotoxicity of mediastinal radiotherapy

Aim

To explore available recent literature related to cardiotoxicity following mediastinal radiation.

Background

Radiotherapy-related heart injury is well documented, with no apparent safety threshold dose. The number of long-term cancer survivors exposed to mediastinal radiotherapy at some point of their treatment is increasing. Heart dosimetric parameters are of great importance in developing a treatment plan, but few data are available regarding radiosensitivity and dose-volume constraints for specific heart structures.

Materials and Methods

In October 2018, we identified articles published after 1990 through a PubMed/MEDLINE database search. The authors examined rough search results and manuscripts not relevant for the topic were excluded. We extracted clinical outcomes following mediastinal radiotherapy of childhood cancers, lymphoma, medulloblastoma, thymic cancers and hematopoietic cell transplantation survivors and evaluated treatment planning data, whenever available.

Results

A total of 1311 manuscripts were identified in our first-round search. Of these manuscripts, only 115 articles, matching our selection criteria, were included.

Conclusions

Studies uniformly show a linear radiation dose-response relationship between mean absorbed dose to the heart (heart-D_mean) and the risk of dying as a result of cardiac disease, particularly when heart-D_mean exceeds 5 Gy. Limited data are available regarding dose-volume predictors for heart substructures and the risk of subsequent cardiac toxicity. An individual patient's cardiotoxicity risk can be modified with advanced treatment planning techniques, including deep inspiration breath hold. Proton therapy is currently showing advantages in improving treatment planning parameters when compared to advanced photon techniques in lymphoma, thymic malignancies, malignant mesothelioma and craniospinal irradiation.

Percutaneous Coronary Intervention and Outcomes in Patients With Lymphoma in the United States (Nationwide Inpatient Sample [NIS] Analysis)

Characteristics and outcomes of patients with lymphoma undergoing percutaneous coronary intervention (PCI) are unknown. Therefore, we analyzed clinical characteristics and outcomes in patients that underwent PCI and had a concomitant diagnosis of Hodgkin's (HL) or non-Hodgkin's (NHL) lymphoma. We analyzed patients with and without lymphoma diagnosis from the Nationwide Inpatient Sample in the United States who underwent PCI procedure during 2004 to 2014. Multivariable regression analysis was performed to examine the association between lymphoma diagnosis and clinical outcomes post-PCI including short-term complications and in-hospital mortality. A total of 7,119,539 PCI procedures were included in the analysis and 18,052 patients had a diagnosis of lymphoma (0.25%). These patients were likely to experience in-hospital mortality (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.25 to 1.54), stroke or transient ischemic attack (OR 1.75, 95% CI 1.61 to 1.90), and any in-hospital complication (OR 1.31, 95% CI 1.25 to 1.37), following PCI. In the lymphoma subtype-analysis, diagnosis of HL was associated with an increased odds of in-hospital death (OR 1.40, 95% CI 1.24 to 1.56), any in-hospital complication (OR 1.31, 95% CI 1.25 to 1.38), bleeding complications (OR 1.12 95% CI 1.05 to 1.20), and vascular complications (OR 1.13 95% CI 1.06 to 1.20) whereas these odds were not significantly associated with non-Hodgkin's diagnosis. Finally, both types of lymphoma were associated with increased odds of stroke/transient ischemic attack following PCI (OR 1.82, 95% CI 1.67 to 1.99 and OR 1.31, 95% CI 1.05 to 1.63, respectively). In conclusion, while the prevalence of lymphoma in the observed PCI cohort was low, a diagnosis of lymphoma was associated with an adverse prognosis following PCI, primarily in patients with the HL diagnosis.

Treatment for lymphoma and late cardiovascular disease risk: A systematic review and meta-analysis

BACKGROUND AND AIMS

Lymphoma patients are frequently treated with cancer therapies that may increase the risk of adverse health outcomes later in life, including cardiovascular disease (CVD) mortality. We sought to investigate the long-term risk of CVD incidence in this survivor population relative to the general population to quantify this health burden.

METHODS

A systematic review and meta-analysis was conducted using EMBASE, MEDLINE, and CINAHL databases, from date of inception to November 2016, with additional searches completed through June 2018. Included reports were observational studies assessing CVD incidence in patients of either Hodgkin or non-Hodgkin lymphoma (HL, NHL) who survived for at least 5 years from the time of diagnosis or if the study had a median follow-up of 10 years. Meta-analyses were performed using random effects models, and subgroup analyses were conducted to determine the incidence of specific CVD subtypes (coronary heart disease, pericardial disease, valvular heart disease, myocardial disease, cardiac dysrhythmia, and cerebrovascular disease). Heterogeneity was assessed using I 2 statistics and prediction intervals.

RESULTS

Of the 7734 studies identified, 22 studies were included in this review, representing 32 438 HL and NHL survivors. Relative to the general population, lymphoma survivors had statistically significant two to threefold increases in the risk for nearly all subtypes of CVD examined. Lymphoma survivors appeared to be particularly susceptible to pericardial diseases (HL: 10.67, 95% confidence interval (CI), 7.75-14.69; NHL: 4.70, 95% CI, 2.08-10.61) and valvular diseases (HL: 13.10, 95% CI, 7.41-23.16; NHL: 3.76, 95% CI, 2.12-6.66). Although the 95% CIs were suggestive of increased risks, the 95% prediction intervals often included the null, reflecting the high heterogeneity of the estimates.

CONCLUSION

Given the suggested increased risks of cardiovascular outcomes in lymphoma survivor populations relative to the general population, tailored screening and prevention programmes may be warranted to offset the future burden of disease.

Is the Importance of Heart Dose Overstated in the Treatment of Non-Small Cell Lung Cancer? A Systematic Review of the Literature

PURPOSE

Some recent studies have suggested a relationship between cardiac dose and mortality in non-small cell lung cancer (NSCLC), but others have reported conflicting data. The goal of this study was to conduct a systematic review and meta-analysis to provide an evidence-based estimate of the relationship between cardiac dose and mortality in these patients.

METHODS AND MATERIALS

A systematic review of MEDLINE (PubMed) and Embase databases (inception to January 2018) was performed according to PRISMA guidelines. Studies that evaluated cardiac dosimetric factors in patients with NSCLC and included outcomes of cardiac events, cardiac mortality, and/or overall survival were identified.

RESULTS

From 5614 patients across 22 studies, a total of 214 cardiac dosimetric parameters (94 unique) were assessed as possible predictors of cardiac toxicity or death. Assessed predictors included general (eg, mean heart dose [MHD]), threshold-based (eg, heart V5), and anatomic-based (eg, atria, ventricles) dosimetric factors. The most commonly analyzed parameters were MHD, heart V5, and V30. Most studies did not make corrections for multiplicity of testing. For overall survival, V5 was found to be significant on multivariable analysis (MVA) in 1 of 11 studies and V30 in 2 of 12 studies; MHD was not significant in any of 8 studies. For cardiac events, V5 was found to be significant on multivariable analysis in 1 of 2 studies, V30 in 1 of 3 studies, and MHD in 2 of 4 studies. A meta-analysis of the data could not be performed because most negative studies did not report effect estimates.

CONCLUSIONS

Consistent heart dose-volume parameters associated with overall survival of patients with NSCLC were not identified. Multiplicity of testing is a major issue and likely inflates the overall risk of type I errors in the literature. Future studies should specify predictors a priori, correct for multiplicity of testing, and report effect estimates for nonsignificant variables.

How to prevent and manage radiation-induced coronary artery disease

Radiation-induced coronary heart disease (RICHD) is the second most common cause of morbidity and mortality in patients treated with radiotherapy for breast cancer, Hodgkin's lymphoma and other prevalent mediastinal malignancies. The risk of RICHD increases with radiation dose. Exposed patients may present decades after treatment with manifestations ranging from asymptomatic myocardial perfusion defects to ostial, triple-vessel disease and sudden cardiac death. RICHD is insidious, with a long latency and a tendency to remain silent late into the disease course. Vessel involvement is often diffuse and is preferentially proximal. The pathophysiology is similar to that of accelerated atherosclerosis, characterised by the formation of inflammatory plaque with high collagen and fibrin content. The presence of conventional risk factors potentiates RICHD, and aggressive risk factor management should ideally be initiated prior to radiation therapy. Stress echocardiography is more sensitive and specific than myocardial perfusion imaging in the detection of RICHD, and CT coronary angiography shows promise in risk stratification. Coronary artery bypass grafting is associated with higher risks of graft failure, perioperative complications and all-cause mortality in patients with RICHD. In most cases, the use of drug-eluting stents is preferable to surgical intervention, bare metal stenting or balloon-angioplasty alone.