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Cardio OncologyNeeds and Opportunities
Charleston, SC
November 23rd, 2019
William B. Ellison, Jr MD FACC
• What is it ?
• Why are we here?
• Why does it matter?
• How many people are affected ?
• What types of cardiovascular pathology are we talking about?
• What strategies are effective in reducing the incidence of the problems and/or mitigating the effects ?
Cardio Oncology
Cardiovascular Complications of Cancer Therapy
Forms of Cardiotoxicity
L.F. Nhola, H.R. Villarraga / Rev Esp Cardiol. 2017;70(7):583–589
Mechanisms of Coronary Artery Disease in Cancer Therapy
Cancer Treatment Induced Cardiac Arrhythmias
(Circ Arrhythm Electrophysiol. 2017;10:e005443. DOI: 10.1161/CIRCEP.117.005443
Radiation Induced Heart Disease
Time Course of ToxicityTime frame Agent CV Toxicity
Minutes Paclitaxel Bradycardia
Days
VEGF inhibitors(bevacizumab, lenvatinib, aflibercept, sunitimib)
Hypertension
Tyrosine Kinase Inhibitors (sunitinib, vandetanib)
QT prolongation
Weeks
Checkpoint Inhibitors(nivolumab, pembrolizumab)
Myocarditis
Proteasome inhibitors(carfilzomib)
Heart Failure (HFpEF)
Months
Trastuzumab Heart Failure (HFrEF)
Tyrosine Kinase Inhibitors(nilotinib, ponatinib)
Peripheral Arterial Disease (PAD)
YearsAnthracyclines(doxorubicin)
Heart Failure (HFrEF)
Decades Radiation Restrictive cardiomyopathy
Common Risk Factors
Clonal Hematopoiesis of Indeterminate Potential (CHIP)
• Prevention of CV complications
• Optimization of CV health for CV patients and the facilitation of anticancer treatment
• Early identification of CV complications
• Surveillance for late complications
Who Needs a Cardiologist?
European Heart Journal (2018) 00, 1-8
•63 y.o. male with metastatic rectal cancer treated with FOLFOX beginning June 2018-last dose 9/24/2018
• FOL- folinic acid (leucovorin)
• F- 5-fluorouracil
•OX- oxiliplatin
FOLFOX
Admitted 9/26 with abdominal and chest pain thought to represent indigestion. trop 0.039
Repeat EKG after pain resolution. Discharged on antacids
Admitted to hospital in another city 11.2018with anterior MI
FOLFOX restarted 1.9.2019- stopped 1.23.2019. Readmitted to Roper 1.25 with chest pain and trop of 0.052. Cath showed patent stents in LAD and D1
Cardio Oncology Team
Cardio Oncology Team
• What protocols are helpful in cardiovascular care?
• Role of biomarkers
• Echo and other determinants of EF• How often
• What if it drops
• When to resume
• What medications if any are useful for cardioprotection?• ACEs, beta blockers, aspirin, statins
• What cardiac surveillance is appropriate before, during, and after treatment and for how long?
• What do we do about survivors of childhood cancers in our system?
Cardio Oncology Team