Cancer Treatment Important for those at risk for or having heart disease

Assessing Patients Undergoing Cancer Treatment

Cleveland Clinic

Important for those at risk for or having heart disease

Apr. 9, 2015 / Heart & Vascular / Technology & Treatments

By Balaji Tamarappoo, MD, PhD

New chemotherapy agents have improved cancer survival, yet some may cause lasting damage to the heart. This is particularly concerning for patients who are at risk for or have existing heart disease. Although cardiotoxicity does not affect all patients, detecting problems early on provides the opportunity for proactive treatment. The goal is to help patients complete their cancer treatment without incurring damage to the heart.

Prior to starting chemotherapy, we advise obtaining an echocardiogram to determine baseline heart function. This will serve as a point of reference for any changes that may occur during or following completion of therapy.

Anthracyclines in general, and doxorubicin in particular, are among the most common chemotherapeutic agents known to be cardiotoxic. Cumulative doses of 400-500 mg per meter2 of body surface area can cause heart failure or cardiomyopathy at any time up to several years after treatment ends.

When a patient has received around 250 mg per meter2 of body surface area, we begin to become concerned about toxicity. We obtain a second echocardiogram at this point and compare it to the baseline echo. If all is well, the patient may continue treatment. If any abnormalities of heart function are seen, we may be able to add beta-blockers and ACE inhibitors to prevent further damage during treatment. This also provides an opportunity for the oncologist to consider alternative chemotherapy.

After treatment has been completed, we look again. If no disturbing changes have taken place, we have the patient return at one year. From this point on, a repeat echo is only necessary if the patient experiences symptoms of a heart problem.

Trastuzumab is an agent known to cause heart failure and arrhythmias during treatment. Although these side effects are reversible, and long-term effects are rare, they need to be addressed. The drug is usually given for one year, so echocardiograms at baseline, 6 months and end of treatment are advised. Treatment with tyrokinase inhibitors may cause hypertension that needs appropriate treatment.

Patients taking beta-blockers or ACE inhibitors may find that their oncologist discontinues these medications if they experience side effects from chemotherapy. It is wise to follow these patients closely to ensure the medications are restarted after the cancer has been addressed.

While chemotherapy agents can affect the heart muscle, radiation therapy tends to primarily affect the valves. Pre- and post-radiation echos are reasonable to evaluate valve function. If calcifications are seen, the patient should be followed every couple of years to monitor the development of valve disease.

Because heart damage can develop within the first year after therapy, and even several years after therapy, it is important for cancer patients to be followed by a cardiologist or cardio-oncologist, who can be alert for the development of symptoms including weakness, fatigue, swelling of the legs and feet, chest pain, arrhythmias or dizziness and provide immediate evaluation and early treatment, if needed.

A cardio-oncologist is also warranted when a patient with a prior history of cancer develops new cardiac problems or heart failure requiring advanced treatment.

Although echocardiography provides a cost-effective method of monitoring these patients, the addition of strain imaging provides a superior method of visualizing myocardial deformation. In the Cardio-Oncology Center at Cleveland Clinic, we are focusing our research on the value of strain imaging. Currently, we are assessing whether abnormal strain measurements on a clinically stable patient signify a bad prognosis later in life.

Government panel backs preventive statin use by adults 40 and over

(Reuters Health) - Aligning with heart health groups and other experts, a U.S. government-backed panel now suggests that adults as young as 40 without a previous heart attack or stroke may need to start on a low or moderate dose of cholesterol-lowering drugs.

People ages 40 to 75 with at least one risk factor for cardiovascular disease and a 10 percent or greater risk of heart attack or stroke over the next decade should take statin drugs, the U.S. Preventive Services Task Force recommends.

Doctors may also consider prescribing the drugs for people in this age group with a 7.5 percent to 10 percent risk of heart attack or stroke based on the American Heart Association and American College of Cardiology risk calculator (www.cvriskcalculator.com).

"In addition to a healthy lifestyle, statins are useful for people at an elevated risk for cardiovascular disease," said Dr. Douglas Owens, of Stanford University in California and a member of the USPSTF.

Risk factors for cardiovascular disease include high total cholesterol or triglycerides - known as dyslipidemia, high blood pressure, diabetes and smoking. Ten-year risk of heart attack and stroke is calculated based on these and additional factors like sex and ancestry.

Heart disease, stroke and other cardiovascular diseases killed almost 787,000 people in the U.S in 2011, according to the American Heart Association.

Cholesterol, a type of fat in the blood, can build up in arteries and increase the risk of heart attacks, strokes and other cardiovascular problems. Statins lower cholesterol by blocking its production in the liver.

This is the first time the USPSTF is making a recommendation on the use of statins. It's based on analysis of existing data from 18 randomized controlled trials comparing statin use among people without previous heart attacks and strokes to people taking dummy pills or nothing at all.

Compared to those who are not on treatment, statin use was tied to a 17 percent reduced risk of death from any cause, and a 36 percent reduced risk of death from cardiovascular disease.

People taking statins were also 28 percent less likely to have strokes, 37 percent less likely to have heart attacks and 31 percent less likely to have other cardiovascular problems.

The benefits of statins were consistent in people with different risk factors, the panel found. And serious side effects like muscle or liver problems and diabetes were not significantly increased according to the analysis.

"We feel the benefits outweigh any potential harms," Owens told Reuters Health.

Owen also said, however, that people who have the highest cardiovascular risk will benefit the most from statins.

The new recommendation isn't surprising and is consistent with 2013 recommendations from the American Heart Association and American College of Cardiology, according to Dr. Sekar Kathiresan, who wasn't involved with the new recommendation but is director of preventive cardiology at Massachusetts General Hospital in Boston.

Those organizations recommended statins for people ages 40 to 75 with diabetes or a 7.5 percent or greater risk of heart attack or stroke over the next decade, people with a previous heart attack or stroke and young people with very high LDL ("bad") cholesterol.

Currently, 36 million Americans take statins, according to the USPSTF.

Cholesterol and Triglycerides Among Children

In another recommendation published online on Monday, the USPSTF proposed an update to its advice on testing children and teens for dyslipidemia, that is, high cholesterol level from any cause, including the inherited condition known as familial high cholesterol.

As it had in 2007, the panel said there is still not enough evidence to recommend for or against screening people younger than age 20 for either high cholesterol in general, which affects roughly seven of every 100 children and teens in the U.S., or familial hypercholesterolemia, which affects one in every 200 to 500 people across North America and Europe.

The statement is in line with the advice of the UK National Screening Committee and the American Academy of Family Physicians.

Owens said this is an area for future research, because it's an important topic.

"We’d say if you have concerns or any concern of elevated risk, it would be time to have a conversation with a child’s clinician," he said.

The panel also points out that the American Academy or Pediatrics (AAP) and the National Heart, Lung, and Blood Institute endorse universal screening for all children before ages nine and 11, and again between puberty and adulthood. Earlier testing is recommended for children at an increased risk of the condition.

"I actually tend to err on the side of AAP here, because it’s quite common and treatable," Kathiresan told Reuters Health.

"I think it’s appropriate for a national body to say we don’t have definitive evidence," he said, but he added that the problem is that finding the condition when a person is young is an incredible opportunity to modify risks in those people.

He said it's likely a discussion for a parent to have with their child's pediatrician.

Both recommendations are available for public comment on the USPSTF's website until January 25, 2016.

SOURCE: bit.ly/1euI2Rl U.S. Preventive Services Task Force, online December 21, 2015.

(Corrects paras 17 and 18 (after subhead) to clarify data on dyslipidemia in children.)