Abstract
Background: Cardio-oncology is a young sub-specialty that addresses the needs of cancer patients at risk of, or who have experienced cancer therapy related cardiac dysfunction (CTRCD). This study assessed clinicians' understanding of cardio-oncology, opinions towards current practice, and approach to diagnosing and managing CTRCD.
Methods: A 45-question survey was administered online via Survey Monkey and WeChat to health care providers (HCPs) comprising of cardiologists, oncologists, and others from September 2017 to March 2018. Implementation of the survey followed a modified Dillman's Total Design Method.
Results: In total, 160 responses were collected from 22 countries; majority were from cardiologists (53.8%) and oncologists (32.5%). The remaining 13.7% identified themselves as "others," including general internists, cardio-oncologists, pediatric oncologists, radiation oncologists, cardiac rehabilitation therapists, nurse practitioners, research students, and pharmacists. In the setting of metastatic cancer, there was a difference in risk tolerance for cardiotoxicity between subspecialties. In this case, more cardiologists (36.7%) accepted a 5-10% risk of cardiotoxicity compared to oncologists (20.0%). Majority of cardiologists felt that cardiotoxicity should be monitored, even in asymptomatic cancer patients (55.8%). Only 12% of oncologists selected this response. In contrast, 50.0% of oncologists reported that cardiologists should be involved only when patients develop cardiotoxicity. In comparison, 6.5% of cardiologists selected this response. Majority of cardiologists stated that cardio-oncology clinics would significantly improve cancer patients' prognosis (88.3%); only 45.8% of oncologists shared this opinion. Of all respondents, 66.9% stated they were familiar with a variety of international guidelines for managing cardiotoxicity. Of all oncologists, 65.3% indicated that they referred to these guidelines for clinical decision making.
Conclusions: Despite the growth of cardio-oncology clinics, there are significant knowledge gaps regarding prevention and treatment strategies for CTRCD among health care providers. Knowledge translation from guidelines and collaboration between cardiologists and oncologists are needed to improve cardiovascular outcomes of cancer patients.
PMID: 32154018 [PubMed]
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Early markers of cardiovascular injury in childhood leukaemia survivors treated with anthracycline chemotherapy.
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Early markers of cardiovascular injury in childhood leukaemia survivors treated with anthracycline chemotherapy.
Cardiooncology. 2019;5:11
Authors: Long TM, Marsh CE, Dembo LG, Watson P, Wallman KE, Walwyn TS, Choong CS, Naylor LH
Abstract
Background: Cardiovascular disease (CVD) is the leading non-malignant cause of death in childhood cancer survivors. Heightened risk of CVD is often attributable to treatment with anthracycline chemotherapy. Anthracycline-mediated cardiac injury may lie latent for years following cessation of treatment and is therefore often not detected until disease is advanced and aggressive therapy is required. Symptomatic CVD may be preceded by subclinical cardiac and vascular dysfunction. This study aimed to determine whether such dysfunction could be detected in healthy, anthracycline-treated survivors of childhood leukaemia.
Methods: Cardiac magnetic resonance imaging (cMRI) with late gadolinium enhancement and endothelial function were used to characterise pre-clinical stages of CVD. Twenty-two long-term (>5 years survival; age 21 ± 3 years) childhood leukaemia survivors were assessed. All survivors were asymptomatic and had normal resting echocardiography. To exclude potential confounding effects of radiotherapy, no survivors had received this treatment. Twenty-two similarly aged (25 ± 3 years) gender-matched controls were recruited for comparison.
Results: Left ventricular ejection fraction was lower in the survivors (55.0 ± 4.6%) compared to the controls (59.4 ± 6.2%; p = 0.010). Further, five survivors (23%) had clinically reduced (<50%)
Conclusions: We detected subclinical changes in cardiovascular structure and function indicative of early disease in anthracycline-treated childhood leukaemia survivors with normal echocardiography. Early detection and characterisation of underlying disease allows for timely intervention and improved outcomes in this at-risk population.
PMID: 32154017 [PubMed]
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Concomitant use of renin-angiotensin-aldosterone system inhibitors prevent trastuzumab-induced cardiotoxicity in HER2+ breast cancer patients: an institutional retrospective study.
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Concomitant use of renin-angiotensin-aldosterone system inhibitors prevent trastuzumab-induced cardiotoxicity in HER2+ breast cancer patients: an institutional retrospective study.
Cardiooncology. 2019;5:9
Authors: Moey MYY, Liles DK, Carabello BA
Abstract
Background: Cardiotoxicity is an adverse effect of trastuzumab (TRA) in the treatment of human epidermal growth factor 2 positive (HER2+) breast cancer. Current literature on the cardioprotective effects of agents targeted against the renin-angiotensin-aldosterone system (RAAS) and beta-blockers (BB) in TRA-treated HER2+ breast cancer patients is conflicting. We hypothesized that concurrent use of RAAS inhibitors would prevent TRA-induced cardiotoxicity (TIC).
Methods and materials: Surveillance ejection fraction (EF) at 3-month intervals up to 36 months obtained from echocardiogram or multigated acquisition (MUGA) scans were retrospectively compared to baseline EF in TRA-treated HER2+ breast cancer patients between 2011 to 2016 at a tertiary cancer center. TIC was defined as a decrease of EF by more than 15 EF percentage points from baseline on surveillance imaging. Cardiac medications and comorbidities were compared between patients with reduced EF secondary to TIC (rEF) and patients who did not experience TIC (pEF). A published clinical risk score (CRS) was applied to the patient population with calculated sensitivity analyses to determine if the CRS could predict TIC.
Results: Of 127 patients with TRA-treated HER2+ breast cancer, 11% developed cardiotoxicity resulting in discontinuation of TRA. Cardiotoxicity with reduced EF was seen as early as 3 months and at subsequent 3-month follow up intervals up to the 15-month follow-up. Co-existing arrhythmia, coronary artery disease (CAD), hypertension (HTN) and diabetes mellitus (DM) tended to infer an increased risk for cardiotoxicity. Patients with pEF were found to be concurrently on a RAAS inhibitor more than the rEF group (OR of 0.24, 95% CI 0.05-1.11, p 0.06). The CRS high-risk cut-off had a sensitivity of 0.17 (95% CI 0.03-0.49), specificity of 0.89 (95% CI 0.82-0.94), positive predictive value of 0.14 (95% CI 0.03-0.44) and negative predictive value of 0.91 (95% CI 0.84-0.95).
Conclusion: Our data suggest that the concurrent use of a RAAS inhibitors during TRA treatment may provide a protective effect against TIC and warrants further investigation. The low sensitivity and positive predictive value demonstrated that the CRS has minimal utility as a screening tool for prediction of patients at high risk for TIC. Therefore, closer surveillance of patients receiving TRA is warranted for early detection of TIC.
PMID: 32154015 [PubMed]
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Spontaneously occurring cardiovascular lesions in commonly used laboratory animals.
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Spontaneously occurring cardiovascular lesions in commonly used laboratory animals.
Cardiooncology. 2019;5:6
Authors: Herman E, Eldridge S
Abstract
The search for new chemical entities which are clinically effective and do not adversely affect the cardiovascular system is an ongoing objective. In vivo studies designed to detect potential drug-induced cardiovascular toxicity typically utilize both rodent and non-rodent species. An important component of such studies includes the microscopic evaluation of tissues for histopathologic changes. A factor which could potentially complicate this type of evaluation relates to the potential for laboratory animals to develop natural or spontaneous pathological cardiovascular lesions. Some types of these naturally occurring alterations are similar to those induced by chemical compounds and thus could confound accurate interpretation. Accurate morphologic analysis becomes contingent upon the ability to distinguish spontaneous cardiovascular changes from actual drug-induced lesions. A summary of some of the more frequently reported spontaneous cardiovascular alterations in commonly-used laboratory animals is presented below. Special emphasis is given to the spectrum of spontaneous background myocardial pathology that might be encountered during preclinical studies conducted to identify potential cardiotoxic actions of anticancer agents.
PMID: 32154013 [PubMed]
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NT-proBNP correlates with LVEF decline in HER2-positive breast cancer patients treated with trastuzumab.
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NT-proBNP correlates with LVEF decline in HER2-positive breast cancer patients treated with trastuzumab.
Cardiooncology. 2019;5:4
Authors: Bouwer NI, Liesting C, Kofflard MJM, Sprangers-van Campen SM, Brugts JJ, Kitzen JJEM, Fouraux MA, Levin MD, Boersma E
Abstract
Background: Early identification of cardiac dysfunction by non-invasive imaging in HER2-positive breast cancer patients treated with trastuzumab is challenging. In particular multigated acquisition (MUGA) scan, which is most widely used, is unable to detect subclinical cardiac changes. The use of N-terminal pro-brain natriuretic peptide (NT-proBNP), a serum biomarker of myocardial stress, might improve timely diagnosis.
Methods: This prospective, single-center, cohort study included patients with HER2-positive breast cancer who started trastuzumab therapy. Echocardiography was scheduled at regular intervals every 3 months during one year follow-up for cardiac function monitoring. For research purposes, NT-proBNP was determined at the same time points. Trastuzumab-induced cardiotoxicity (TIC) was the primary study endpoint, defined as a left ventricular ejection fraction (LVEF) < 45%,10% since inclusion, and/or the incidence of a clinical cardiac event.
Results: A total of 135 patients were enrolled between April 2008 and June 2016, with a median age of 54 years (IQR: 47-61). By three-dimensional echocardiography (3DE), the median LVEF at baseline was 62% (IQR: 58-65). At a median of 6 months (IQR: 5-11), 45 patients (33%) reached the study endpoint of TIC. Patients with TIC had a mean change of - 9.5% in LVEF (95% CI -7.2 to - 11.7; p = 0.001) during 1 year of trastuzumab treatment. Both NT-proBNP at baseline (HR 1.04, 95% CI 1.02-1.07; p = 0.003) and LVEF decline during anthracycline treatment prior to the start of trastuzumab (HR 1.16, 95% CI 1.07-1.25; p < 0.001)
Conclusions: NT-proBNP cannot be used as a surrogate monitoring tool for trastuzumab-induced cardiotoxicity in HER2-positive breast cancer patients during the first year of treatment. Patients showing an LVEF decline during anthracycline pre-treatment appeared vulnerable for trastuzumab-induced cardiotoxicity.
PMID: 32154011 [PubMed]
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How progressive cancer endangers the heart: an intriguing and underestimated problem.
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How progressive cancer endangers the heart: an intriguing and underestimated problem.
Cancer Metastasis Rev. 2020 Mar 09;:
Authors: Ausoni S, Calamelli S, Saccà S, Az
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