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Oommen SG, Man RK, Talluri K, Nizam M, Kohir T, Aviles MA, Nino M, Jaisankar LG, Jaura J, Wannakuwatte RA, Tom L, Abraham J, Siddiqui HF. Heart Failure With Improved Ejection Fraction: Prevalence, Predictors, and Guideline-Directed Medical Therapy. Cureus 2024; 16:e61790. [PMID: 38975458 PMCID: PMC11227107 DOI: 10.7759/cureus.61790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
Recently, a new category of heart failure with improved ejection fraction (HFimpEF) has emerged in the classification system. This is defined as the subgroup of patients with heart failure with reduced ejection fraction (HFrEF) whose left ventricular ejection fraction has recovered partially or completely, with no specific cut-off values established yet in the guidelines. In our review, we aim to provide an overview of prevalence, predictors, mechanism of remodeling, and management strategies regarding HFimpEF. These patients constitute a sizeable cohort among patients with reduced ejection fraction. Certain patient characteristics including younger age and female gender, absence of comorbid conditions, low levels of biomarkers, and non-ischemic etiology were identified as positive predictors. The heart undergoes significant maladaptive changes post failure leading to adverse remodeling influenced etiology and duration. Goal-directed medical therapy including beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin II receptor blockers (ARBs) have notably improved cardiac function by inducing reverse remodeling. Despite a more favorable prognosis compared to HFrEF, patients with improved ejection fraction (EF) still face clinical events and reduced quality of life, and remain at risk of adverse outcomes. Although the evidence is scarce, it is advisable to continue treatment modalities despite improvement in EF, including device therapies, to prevent relapse and clinical deterioration. It is imperative to conduct further research to understand the mechanism leading to EF amelioration and establish guidelines to identify and direct management strategies.
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Affiliation(s)
- Sheethal G Oommen
- Psychiatry, Grigore T. Popa University of Medicine and Pharmacy, Iași, ROU
| | - Ruzhual K Man
- Research, Lady Hardinge Medical College, Mumbai, IND
| | - Keerthi Talluri
- Department of Medicine, Ganni Subba Lakshmi Medical College, Rajahmundry, IND
| | - Maryam Nizam
- Emergency Department, Valaichennai Base Hospital, Valaichennai, LKA
| | - Tejashwini Kohir
- Department of Medicine, Ganni Subba Lakshmi Medical College, Rajahmundry, IND
| | | | | | | | - Jashan Jaura
- General Practice, Max Super Speciality Hospital, Bathinda, Bathinda, IND
| | | | - Leo Tom
- Internal Medicine, Kowdoor Sadananda Hegde Medical Academy, Mangalore, IND
| | - Jeby Abraham
- General Medicine, Yenepoya Medical College, Mangalore, IND
| | - Humza F Siddiqui
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Zou JH, Hua BT, Shao XX, Wang C, Li H, Lu YN, Tian X, Li ZX, Pu LJ, Wang J. Redefining left bundle branch block from high-density electroanatomical mapping. Int J Cardiol 2024; 402:131830. [PMID: 38320669 DOI: 10.1016/j.ijcard.2024.131830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/13/2024] [Accepted: 02/01/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The existing ECG criteria for diagnosing left bundle branch block (LBBB) are insufficient to distinguish between true and false blocks accurately. METHODS We hypothesized that the notch width of the QRS complex in the lateral leads (I, avL, V5, V6) on the LBBB-like ECG could further confirm the diagnosis of true complete left bundle branch block (t-LBBB). We conducted high-density, three-dimensional electroanatomical mapping in the cardiac chambers of 37 patients scheduled to undergo CRT. These patients' preoperative electrocardiograms met the ACC/AHA/HRS guidelines for the diagnosis of complete LBBB. If the left bundle branch potential could be mapped from the base of the heart to the apex on the left ventricular septum, it was defined as a false complete left bundle branch block (f-LBBB). Otherwise, it was categorized as a t-LBBB. We conducted a comparative analysis between the two groups, considering the clinical characteristics, real-time correspondence between the spread of ventricular electrical excitation and the QRS wave, QRS notch width of the lateral leads (I, avL, V5, V6), and the notch width/left ventricular end-diastolic diameter (Nw/LVd) ratio. We performed the ROC correlation analysis of Nw/LVd and t-LBBB to determine the sensitivity and specificity for diagnostic authenticity. RESULTS Twenty-five patients were included in the t-LBBB group, while 12 patients were assigned to the f-LBBB group. Within the t-LBBB group, the first peak of the QRS notch correlated with the depolarization of the right ventricle and septum, the trough corresponded to the depolarization of the left ventricle across the left ventricle, and the second peak aligned with the depolarization of the left ventricular free wall. In contrast, within the f-LBBB group, the first peak coincided with the depolarization of the right ventricle and a majority of the left ventricle, the second peak occurred due to the depolarization of the latest, locally-activated myocardium in the left ventricle, and the trough was a result of delayed activation of the left ventricle that did not align with the usual peak timing. The QRS notch width (45.2 ± 12.3 ms vs. 52.5 ± 9.2 ms, P < 0.05) and the Nw/LVd ratio (0.65 ± 0.19 ms/mm vs. 0.81 ± 0.17 ms/mm, P < 0.05) were compared between the two groups. After conducting the ROC correlation analysis, a sensitivity of 56% and a specificity of 91.7% for diagnosing t-LBBB using Nw/LVd were obtained. CONCLUSION By utilizing the current diagnostic criteria for LBBB, an increased Nw/LVd value can enhance the effectiveness of diagnosing LBBB.
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Affiliation(s)
- Jun-Hua Zou
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Bao-Tong Hua
- The third Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiao-Xia Shao
- The third Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Chao Wang
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Hao Li
- The third Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ya-Nan Lu
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xin Tian
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhi-Xuan Li
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Li-Jin Pu
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
| | - Jing Wang
- The first Department of Cardiology, the First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
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Derakhshan S, Ghaderi B, Roshani D. Left ventricular mechanical dyssynchrony after chemotherapy in breast cancer patients with normal rest gated SPECT-MPI. Ann Nucl Med 2024; 38:272-277. [PMID: 38244106 DOI: 10.1007/s12149-023-01897-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/24/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Early diagnosis of chemotherapy-induced cardiotoxicity plays an important role in preventing heart failure. The main aim of our study was to assess left ventricular (LV) dyssynchrony measured by phase analysis of gated single-photon emission computed tomography (SPECT) as an early sign of cardiotoxicity after breast cancer chemotherapy. METHODS This cross-sectional study was conducted on patients with stage ≤ 3 breast cancer and no history of cardiovascular disease or diabetes. After mastectomy, the patients underwent rest gated SPECT myocardial perfusion imaging (MPI). Sixty patients with normal gated SPECT-MPI were selected and the imaging was performed after chemotherapy with doxorubicin, cyclophosphamide and paclitaxel. LV function and contractility parameters were extracted by QGS software and the results were compared with the t test method. The abnormality of at least one of the three phase analysis indices was considered as left ventricular dyssynchrony (LVD). RESULTS The average LV end-systolic volume and ejection fraction (LVEF) before and after chemotherapy were (16.2 ± 8.0 ml and 21.6 ± 11.6 ml) and (73.4 ± 7.9% and 67.5 ± 9.2%) respectively, which showed a significant decrease (P < 0.05). In 2 patients (3.3%), the LVEF decreased to less than 50% after chemotherapy. The average parameters of left ventricular contractility before and after chemotherapy were, respectively, as follows: PHB (24.1 ± 7.5 and 33.8 ± 16.4), PSD (9.4 ± 6.1 and 5.7 ± 1.9) and entropy (28.9 ± 7.1 and 35.6 ± 9.7), which showed a significant increase (P < 0.05). LVD was observed in 14 patients (23.4%) after chemotherapy and prevalence of LVD was significantly higher in patients who had received a cumulative dose of doxorubicin of more than 400 mg/m2 (P = 0.005). There was no relationship between age and body mass index with the incidence of LVD after chemotherapy (P > 0.05). CONCLUSION Using phase analysis of gated SPECT-MPI, chemotherapy-induced LVD was seen in a significant number of patients with breast cancer, especially with a high cumulative dose of doxorubicin. LVD might indicate chemotherapy-induced cardiotoxicity before LVEF becomes abnormal.
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Affiliation(s)
- Siamak Derakhshan
- Department of Radiotherapy, Faculty of Paramedical Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| | - Bayazid Ghaderi
- Cancer and Immunology Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Daem Roshani
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Zhu Y, Zhang Z, Ma J, Zhang Y, Zhu S, Liu M, Zhang Z, Wu C, Xu C, Wu A, Sun C, Yang X, Wang Y, Ma C, Cheng J, Ni D, Wang J, Xie M, Xue W, Zhang L. Assessment of left ventricular ejection fraction in artificial intelligence based on left ventricular opacification. Digit Health 2024; 10:20552076241260557. [PMID: 38882253 PMCID: PMC11179548 DOI: 10.1177/20552076241260557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 05/23/2024] [Indexed: 06/18/2024] Open
Abstract
Background Left ventricular opacification (LVO) improves the accuracy of left ventricular ejection fraction (LVEF) by enhancing the visualization of the endocardium. Manual delineation of the endocardium by sonographers has observer variability. Artificial intelligence (AI) has the potential to improve the reproducibility of LVO to assess LVEF. Objectives The aim was to develop an AI model and evaluate the feasibility and reproducibility of LVO in the assessment of LVEF. Methods This retrospective study included 1305 echocardiography of 797 patients who had LVO at the Department of Ultrasound Medicine, Union Hospital, Huazhong University of Science and Technology from 2013 to 2021. The AI model was developed by 5-fold cross validation. The validation datasets included 50 patients prospectively collected in our center and 42 patients retrospectively collected in the external institution. To evaluate the differences between LV function determined by AI and sonographers, the median absolute error (MAE), spearman correlation coefficient, and intraclass correlation coefficient (ICC) were calculated. Results In LVO, the MAE of LVEF between AI and manual measurements was 2.6% in the development cohort, 2.5% in the internal validation cohort, and 2.7% in the external validation cohort. Compared with two-dimensional echocardiography (2DE), the left ventricular (LV) volumes and LVEF of LVO measured by AI correlated significantly with manual measurements. AI model provided excellent reliability for the LV parameters of LVO (ICC > 0.95). Conclusions AI-assisted LVO enables more accurate identification of the LV endocardium and reduces observer variability, providing a more reliable way for assessing LV function.
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Affiliation(s)
- Ye Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Zisang Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Junqiang Ma
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Shenzhen, China
| | - Yiwei Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Manwei Liu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ziming Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chunyan Xu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Anjun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chenchen Sun
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xin Yang
- Electronics and Information Engineering Department, Huazhong University of Science and Technology, Wuhan, China
| | - Yonghuai Wang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Chunyan Ma
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shenyang, Liaoning, China
- Clinical Medical Research Center of Imaging in Liaoning Province, Shenyang, Liaoning, China
| | - Jun Cheng
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Shenzhen, China
| | - Dong Ni
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Shenzhen, China
| | - Jing Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wufeng Xue
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, China
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Shenzhen, China
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Das B. Pharmacotherapy for Cancer Treatment-Related Cardiac Dysfunction and Heart Failure in Childhood Cancer Survivors. Paediatr Drugs 2023; 25:695-707. [PMID: 37639193 DOI: 10.1007/s40272-023-00585-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/29/2023]
Abstract
The number of childhood cancer survivors is increasing rapidly. According to American Association for Cancer Research, there are more than 750,000 childhood cancer survivors in the United States and Europe. As the number of childhood cancer survivors increases, so does cancer treatment-related cardiac dysfunction (CTRCD), leading to heart failure (HF). It has been reported that childhood cancer survivors who received anthracyclines are 15 times more likely to have late cancer treatment-related HF and have a 5-fold higher risk of death from cardiovascular (CV) disease than the general population. CV disease is the leading cause of death in childhood cancer survivors. The increasing need to manage cancer survivor patients has led to the rapid creation and adaptation of cardio-oncology. Cardio-oncology is a multidisciplinary science that monitors, treats, and prevents CTRCD. Many guidelines and position statements have been published to help diagnose and manage CTRCD, including those from the American Society of Clinical Oncology, the European Society of Cardiology, the Canadian Cardiovascular Society, the European Society of Medical Oncology, the International Late Effects of Childhood Cancer Guideline Harmonization Group, and many others. However, there remains a gap in identifying high-risk patients likely to develop cardiomyopathy and HF in later life, thus reducing primary and secondary measures being instituted, and when to start treatment when there is echocardiographic evidence of left ventricular (LV) dysfunctions without symptoms of HF. There are no randomized controlled clinical trials for treatment for CTRCD leading to HF in childhood cancer survivors. The treatment of HF due to cancer treatment is similar to the guidelines for general HF. This review describes the latest pharmacologic therapy for preventing and treating LV dysfunction and HF in childhood cancer survivors based on expert consensus guidelines and extrapolating data from adult HF trials.
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Affiliation(s)
- Bibhuti Das
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor Scott and White McLane Children's Medical Center, Temple, TX, 76502, USA.
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6
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Shehram M, Khalid H, Shafique HM, Umer B, Zafar A, Ullah A, Zaidi SMJ, Basit J, Mehmoodi A, Malik J. Efficacy and safety of cardiac resynchronization therapy in chemotherapy-induced cardiomyopathy: A systematic review. Ann Noninvasive Electrocardiol 2023; 28:e13070. [PMID: 37435629 PMCID: PMC10475884 DOI: 10.1111/anec.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/12/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVE The aim of the study was to assess the efficacy of cardiac resynchronization therapy (CRT) in patients with chemotherapy-induced cardiomyopathy (CIC). METHODS With the increasing incidence of CIC, the association of CRT with improvement in clinical outcomes, echocardiographic parameters, and New York Heart Classification (NYHA) class was assessed through this qualitative systematic review. RESULTS The five studies included a total of 169 patients who underwent CRT after CIC, and of these, 61 (36.1%) patients were males. All studies showed an improvement in left ventricular ejection fraction (LVEF), among other echocardiographic parameters of LV volume. However, these findings are limited by short follow-up periods, small sample sizes, and the absence of a control group. CONCLUSION CRT was associated with improvement in all patient parameters with CIC.
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Affiliation(s)
- Muhammad Shehram
- Department of CardiologyMufti Mehmood Memorial Teaching HospitalDI KhanPakistan
| | - Hiba Khalid
- Department of DermatologyBenazir Bhutto HospitalRawalpindiPakistan
| | - Hafiz Muhammad Shafique
- Department of Interventional CardiologyArmed Forces Institute of CardiologyRawalpindiPakistan
| | - Bakht Umer
- Department of Interventional CardiologyArmed Forces Institute of CardiologyRawalpindiPakistan
| | - Awais Zafar
- Department of MedicineSahiwal Medical CollegeSahiwalPakistan
| | - Asif Ullah
- Department of CardiologyKhyber Medical University Institute of Medical SciencesKohatPakistan
| | | | - Jawad Basit
- Department of Cardiovascular MedicineCardiovascular Analytics GroupCanterburyUK
| | - Amin Mehmoodi
- Department of MedicineIbn e Seen HospitalKabulAfghanistan
| | - Jahanzeb Malik
- Department of Cardiovascular MedicineCardiovascular Analytics GroupCanterburyUK
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Agarwal MA, Sridharan A, Pimentel RC, Markowitz SM, Rosenfeld LE, Fradley MG, Yang EH. Ventricular Arrhythmia in Cancer Patients: Mechanisms, Treatment Strategies and Future Avenues. Arrhythm Electrophysiol Rev 2023; 12:e16. [PMID: 37457438 PMCID: PMC10345968 DOI: 10.15420/aer.2023.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/12/2023] [Indexed: 07/18/2023] Open
Abstract
Cardiovascular disease and cancer are the leading causes of morbidity and mortality in the US. Despite the significant progress made in cancer treatment leading to improved prognosis and survival, ventricular arrhythmias (VA) remain a known cardiovascular complication either exacerbated or induced by the direct and indirect effects of both traditional and novel cancer treatments. Although interruption of cancer treatment because of VA is rarely required, knowledge surrounding this issue is essential for optimising the overall care of patients with cancer. The mechanisms of cancer-therapeutic-induced VA are poorly understood. This review will discuss the ventricular conduction (QRS) and repolarisation abnormalities (QTc prolongation), and VAs associated with cancer therapies, as well as existing strategies for the identification, prevention and management of cancer-treatment-induced VAs.
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Affiliation(s)
- Manyoo A Agarwal
- Heart, Vascular and Thoracic Institute, Cardio-Oncology Program, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Aadhavi Sridharan
- Section of Electrophysiology, Division of Cardiology, Department of Medicine, Banner Health, University of Arizona – Tucson, Tucson, AZ, US
| | - Rhea C Pimentel
- Department of Cardiovascular Medicine, University of Kansas Health System, Kansas City, KS, US
| | - Steven M Markowitz
- Division of Cardiovascular Medicine, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, US
| | - Lynda E Rosenfeld
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, US
| | - Michael G Fradley
- Thalheimer Center for Cardio-Oncology, Division of Cardiology, Department of Medicine, University of Pennsylvania, PA, US
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, US
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Itzhaki Ben Zadok O, Nardi Agmon I, Neiman V, Eisen A, Golovchiner G, Bental T, Schamroth-Pravda N, Kadmon E, Goldenberg GR, Erez A, Kornowski R, Barsheshet A. Implantable Cardioverter Defibrillator for the Primary Prevention of Sudden Cardiac Death among Patients With Cancer. Am J Cardiol 2023; 191:32-38. [PMID: 36634547 DOI: 10.1016/j.amjcard.2022.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 01/12/2023]
Abstract
Data are limited regarding the characteristics and outcomes of patients with cancer who are found eligible for primary defibrillator therapy. We performed a single-center retrospective analysis of patients with preexisting cancer diagnoses who become eligible for a primary prevention implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) defibrillator. Multicenter Automatic Defibrillator Implantation Trial-ICD (MADIT-ICD) benefit scores were calculated. The study included 75 cancer patients at a median age of 73 (interquartile range 64, 81) years at heart failure diagnosis. Active cancer was present in 51%. Overall, 55% of the cohort had coronary artery disease and 37% were CRT eligible. We found that 48%, 49%, and 3% of cohorts had low, intermediate, and high MADIT-ICD Benefit scores, respectively. Only 27% of patients underwent primary defibrillator implantation. Using multivariate analysis, indication for CRT and intermediate/high MADIT-ICD Benefit categories were found as independent predictors for implantation (odds ratio 8.42 p <0.001 and odds ratio 3.74 p = 0.040, respectively). During a median follow-up of 5.3 (interquartile range 4.5, 7.2) years, one patient (5%) with a defibrillator had appropriate shock therapy and 2 patients (10%) had bacteremia. Of 13 patients with CRT defibrillator-implants, one patient was admitted for heart failure exacerbation (8%). Using a time-varying covariate model, we did not observe statistically significant differences in the survival of patients with cancer implanted versus those not implanted with primary defibrillators (hazard ratio 0.521, p = 0.127). In conclusion, although primary defibrillator therapy is underutilized in patients with cancer, its relative benefit is limited because of competing risk of nonarrhythmic mortality. These findings highlight the need for personalized cardiologic and oncologic coevaluation.
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Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Inbar Nardi Agmon
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victoria Neiman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Alon Eisen
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gregory Golovchiner
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamir Bental
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nili Schamroth-Pravda
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Kadmon
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gustavo Ruben Goldenberg
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Erez
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Barsheshet
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Brala D, Thevathasan T, Grahl S, Barrow S, Violano M, Bergs H, Golpour A, Suwalski P, Poller W, Skurk C, Landmesser U, Heidecker B. Application of Magnetocardiography to Screen for Inflammatory Cardiomyopathy and Monitor Treatment Response. J Am Heart Assoc 2023; 12:e027619. [PMID: 36744683 PMCID: PMC10111485 DOI: 10.1161/jaha.122.027619] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Inflammatory cardiomyopathy is one of the most common causes of sudden cardiac death in young adults. Diagnosis of inflammatory cardiomyopathy remains challenging, and better monitoring tools are needed. We present magnetocardiography as a method to diagnose myocardial inflammation and monitor treatment response. Methods and Results A total of 233 patients were enrolled, with a mean age of 45 (±18) years, and 105 (45%) were women. The primary analysis included 209 adult subjects, of whom 66 (32%) were diagnosed with inflammatory cardiomyopathy, 17 (8%) were diagnosed with cardiac amyloidosis, and 35 (17%) were diagnosed with other types of nonischemic cardiomyopathy; 91 (44%) did not have cardiomyopathy. The second analysis included 13 patients with inflammatory cardiomyopathy who underwent immunosuppressive therapy after baseline magnetocardiography measurement. Finally, diagnostic accuracy of magnetocardiography was tested in 3 independent cohorts (total n=23) and 1 patient, who developed vaccine-related myocarditis. First, we identified a magnetocardiography vector to differentiate between patients with cardiomyopathy versus patients without cardiomyopathy (vector of ≥0.051; sensitivity, 0.59; specificity, 0.95; positive predictive value, 93%; and negative predictive value, 64%). All patients with inflammatory cardiomyopathy, including a patient with mRNA vaccine-related myocarditis, had a magnetocardiography vector ≥0.051. Second, we evaluated the ability of the magnetocardiography vector to reflect treatment response. We observed a decrease of the pathologic magnetocardiography vector toward normal in all 13 patients who were clinically improving under immunosuppressive therapy. Magnetocardiography detected treatment response as early as day 7, whereas echocardiographic detection of treatment response occurred after 1 month. The magnetocardiography vector decreased from 0.10 at baseline to 0.07 within 7 days (P=0.010) and to 0.03 within 30 days (P<0.001). After 30 days, left ventricular ejection fraction improved from 42.2% at baseline to 53.8% (P<0.001). Conclusions Magnetocardiography has the potential to be used for diagnostic screening and to monitor early treatment response. The method is valuable in inflammatory cardiomyopathy, where there is a major unmet need for early diagnosis and monitoring response to immunosuppressive therapy.
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Affiliation(s)
- Debora Brala
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Tharusan Thevathasan
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Simon Grahl
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Steve Barrow
- Division of Instrumentation at Space Telescope Science Institute Baltimore MD
| | - Michele Violano
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Hendrikje Bergs
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Ainoosh Golpour
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Phillip Suwalski
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Wolfgang Poller
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Carsten Skurk
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Ulf Landmesser
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany.,Berlin Institute of Health at Charité Berlin Germany
| | - Bettina Heidecker
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
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10
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Pothineni NVK, Van Besien H, Fradley MG. Arrhythmic Complications Associated with Cancer Therapies. Heart Fail Clin 2022; 18:375-383. [PMID: 35718413 DOI: 10.1016/j.hfc.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Over the last several decades, advancements in cancer screening and treatment have significantly improved cancer mortality and overall quality of life. Unfortunately, non-cancer-related side effects, including cardiovascular toxicities can impact the continued delivery of these treatments. Arrhythmias are an increasingly recognized class of cardiotoxicity that can occur as a direct consequence of the treatment or secondary to another type of toxicity such as heart failure, myocarditis, or ischemia. Atrial arrhythmias, particularly atrial fibrillation (AF) are most commonly encountered, however, ventricular- and bradyarrhythmias can also occur, albeit at lower rates. Treatment strategies tailored to patients with cancer are essential to allow for the safe delivery of the cancer treatment without affecting short- or long-term oncologic or cardiovascular outcomes.
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Affiliation(s)
| | - Herman Van Besien
- Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael G Fradley
- Division of Cardiology, Department of Medicine, Cardio-Oncology Center of Excellence, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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11
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Lalario A, Del Mestre E, Lo Casto M, Nuzzi V, Manca P, Bromage DI, Barbati G, Merlo M, Sinagra G, Cannatà A. Clinical characterization and natural history of chemotherapy-induced dilated cardiomyopathy. ESC Heart Fail 2022; 9:3052-3059. [PMID: 35735911 DOI: 10.1002/ehf2.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/11/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Chemotherapy-induced dilated cardiomyopathy (CI-DCM) is a well-recognized phenotype of non-ischemic dilated cardiomyopathy (DCM), characterized by poor outcomes. However, a detailed comparison between idiopathic DCM (iDCM) and CI-DCM is still lacking. METHODS AND RESULTS All consecutive DCM patients enrolled in the Trieste Muscle Heart Disease Registry were analysed. CI-DCM and iDCM were defined according to current recommendations. The primary study outcome measure was all-mortality death and secondary outcomes were a) a composite of cardiovascular death/heart-transplantation/ventricular-assist-device implantation, and b) major ventricular arrhythmias. The study included 551 patients (499 iDCM and 52 CI-DCM). At enrolment, compared with iDCM, CI-DCM patients were older (51 ± 14 years vs. 58 ± 3 years, respectively, P < 0.001) and had a higher left ventricular ejection fraction (32% ± 9 vs. 35% ± 10, respectively, P = 0.03). Over a median follow-up of 90 months (IQR 54-140 months), CI-DCM patients had a higher incidence of all-cause mortality compared with iDCM (36.5% vs. 8.4% in CI-DCM and iDCM respectively, P < 0.001), while the incidence of major ventricular arrhythmias was higher in the iDCM group compared with CI-DCM (4% vs. 0%, in CI-DCM and iDCM respectively, P = 0.03). The risk of the composite outcome was comparable between the two groups (P = 0.91). At Cox multivariable analysis, the diagnosis of CI-DCM emerged as independently associated to primary outcome (HR 6.42, 95% C.I. 2.52-16.31, P < 0.001). CONCLUSIONS In a well-selected DCM cohort, patients with a chemotherapy-induced aetiology had a higher incidence of all-cause mortality compared with iDCM. Conversely, the incidence of life-threatening ventricular arrhythmic events was higher among patients with iDCM.
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Affiliation(s)
- Andrea Lalario
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Eva Del Mestre
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Michele Lo Casto
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Vincenzo Nuzzi
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Paolo Manca
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniel I Bromage
- Department of Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Giulia Barbati
- Biostatistic Unit, University of Trieste, Trieste, Italy
| | - Marco Merlo
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Antonio Cannatà
- Department of Cardiology, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy.,Department of Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
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12
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Vuong JT, Stein-Merlob AF, Cheng RK, Yang EH. Novel Therapeutics for Anthracycline Induced Cardiotoxicity. Front Cardiovasc Med 2022; 9:863314. [PMID: 35528842 PMCID: PMC9072636 DOI: 10.3389/fcvm.2022.863314] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/14/2022] [Indexed: 01/04/2023] Open
Abstract
Anthracyclines remain an essential component of the treatment of many hematologic and solid organ malignancies, but has important implications on cardiovascular disease. Anthracycline induced cardiotoxicity (AIC) ranges from asymptomatic LV dysfunction to highly morbid end- stage heart failure. As cancer survivorship improves, the detection and treatment of AIC becomes more crucial to improve patient outcomes. Current treatment modalities for AIC have been largely extrapolated from treatment of conventional heart failure, but developing effective therapies specific to AIC is an area of growing research interest. This review summarizes the current evidence behind the use of neurohormonal agents, dexrazoxane, and resynchronization therapy in AIC, evaluates the clinical outcomes of advanced therapy and heart transplantation in AIC, and explores future horizons for treatment utilizing gene therapy, stem cell therapy, and mechanism-specific targets.
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Affiliation(s)
- Jacqueline T. Vuong
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Ashley F. Stein-Merlob
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Richard K. Cheng
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States
| | - Eric H. Yang
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Eric H. Yang,
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13
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DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Shen X, Hernandez AF, Fonarow GC. The Association of Improvement in Left Ventricular Ejection Fraction with Outcomes in Patients with Heart Failure with Reduced Ejection Fraction: Data from CHAMP-HF. Eur J Heart Fail 2022; 24:762-770. [PMID: 35293088 DOI: 10.1002/ejhf.2486] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS We assessed for an association between improvements in left ventricular ejection fraction (LVEF) and future outcomes, including health status, in routine clinical practice. METHODS AND RESULTS CHAMP-HF was a registry of outpatients with heart failure (HF) and LVEF <40%. Enrolled participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at regular intervals and were followed as part of routine care. We assessed for associations between improvements in LVEF (>10%) over time and concurrent changes in KCCQ-12, as well as the subsequent risk of poor outcomes. We included 2092 participants in the study. They had the following characteristics: median age 67 years (25th , 75th percentile 58, 75), 29% female, median duration of HF 2.7 years (0.6, 6.8), and median baseline LVEF 30% (23, 35). Of the study participants, 689 (34%) had a >10% absolute improvement in LVEF. Participants with an LVEF improvement also had an improvement in KCCQ-12 overall summary score compared with participants without an LVEF improvement (+7.6 vs +3.5, adjusted effect estimate +4.1 [95% CI 2.3 to 5.7]). Similarly, subsequent all-cause death or HF hospitalization occurred in 12% in the LVEF improvement group vs 25% in the group without an LVEF improvement (adjusted HR 0.50, 95% CI 0.41 to 0.61). CONCLUSION In a large cohort of outpatients with chronic HF, improvements in LVEF were associated with improved health status and a reduced risk for future clinical events. These data underscore the importance of improvement in LVEF as a treatment target for medical interventions for patients with chronic HF.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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14
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Herrmann J, McCullough KB, Habermann TM. How I treat cardiovascular complications in patients with lymphoid malignancies. Blood 2022; 139:1501-1516. [PMID: 34752600 PMCID: PMC8914183 DOI: 10.1182/blood.2019003893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
The prognosis of several lymphoid malignancies has improved through development of novel therapies, combination with traditional chemotherapies, and delineation of appropriate therapeutic sequencing. Toxicities that are arising because of prolonged or multiple sequential therapeutic interventions are becoming increasingly impactful. Among the broad spectrum of complications that patients with lymphoid malignancies may experience, cardiovascular toxicities are significant in terms of morbidity and mortality. The entire cardiovascular system can be affected, but cardiomyopathy, heart failure, and arrhythmias remain of greatest concerns with the use of anthracyclines, hematopoietic stem cell transplantation, and radiation therapy in patients with lymphoid malignancies. These aspects will be covered in this article within the framework of case-based discussions. Key to the management of cardiovascular complications in patients with lymphoid malignancies is awareness and preparedness across the cancer continuum. Baseline risk stratification helps to direct surveillance and early intervention efforts before, during, and after cancer therapy, which are paramount for the best possible outcomes. Along these lines, the overall goal is to enable the best possible therapies for lymphoid malignancies without the complications of clinically significant cardiovascular events.
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Affiliation(s)
| | | | - Thomas M Habermann
- 3Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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15
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Nijst P, Tang WHW. Managing Cancer Patients and Survivors With Advanced Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00953-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Tunuguntla HP, Puri K, Denfield SW. Management of Advanced Heart Failure in Children with Cancer Therapy-Related Cardiac Dysfunction. CHILDREN (BASEL, SWITZERLAND) 2021; 8:872. [PMID: 34682138 PMCID: PMC8534565 DOI: 10.3390/children8100872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022]
Abstract
The evolution of cancer therapies has led to marked improvement in survival of those affected by childhood malignancies, while also increasing the recognition of early and late toxicities associated with cancer therapies. Cardiotoxicity can include cardiomyopathy/heart failure, coronary artery disease, stroke, pericardial disease, arrhythmias, and valvular and vascular dysfunction as a result of exposure to chemotherapy and/or radiation. Anthracyclines remain the most common cause of chemotherapy-induced cardiomyopathy (CCM) with varying clinical presentations including: acute, early onset, and late-onset. Many individuals develop cardiac dysfunction over the long-term, ranging from subclinical cardiac dysfunction to end-stage symptomatic heart failure. The focus of this review is on characterization of symptomatic heart failure in children with cancer therapy-related cardiac dysfunction (CTRCD) primarily due to CCM and utilization of advanced heart failure therapies, including ventricular assist device (VAD) support and heart transplantation, with consideration of unique patient-related factors.
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Affiliation(s)
- Hari P. Tunuguntla
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA; (H.P.T.); (K.P.)
| | - Kriti Puri
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA; (H.P.T.); (K.P.)
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Susan W. Denfield
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA; (H.P.T.); (K.P.)
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17
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Patel D, Kumar A, Moennich LA, Trulock K, Nemer DM, Donnellan E, Il'Giovine ZJ, Martyn T, Callahan TD, Hussein AA, Tarakji KG, Kanj M, Cantillon DJ, Baranowski B, Starling RC, Tang WHW, Wazni OM, Varma N, Wilkoff BL, Rickard J. Cardiac resynchronisation therapy in anthracycline-induced cardiomyopathy. Heart 2021; 108:274-278. [PMID: 34489312 DOI: 10.1136/heartjnl-2020-318333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Chemotherapy-induced cardiomyopathy has been increasingly recognised as patients are living longer with more effective treatments for their malignancies. Anthracyclines are known to cause left ventricular (LV) dysfunction. While heart failure medications are frequently used, some patients may need consideration for device-based therapies such as cardiac resynchronisation therapy (CRT). However, the role of CRT in anthracycline-induced cardiomyopathy (AIC) is not well understood. METHODS We performed a retrospective review of all patients undergoing CRT implantation at our centre from 2003 to 2019 with a diagnosis of AIC. The LV remodelling and survival outcomes of this population were obtained and then compared with consecutive patients with other aetiologies of non-ischaemic cardiomyopathy (NICM). RESULTS A total of 34 patients underwent CRT implantation with a diagnosis of AIC with a mean age of 60.5±12.7 years, left ventricular ejection fraction (LVEF) of 21.7%±7.4%, and 11.3±7.5 years and 10.2±7.4 years from cancer diagnosis and last anthracycline exposure, respectively. At 9.6±8.1 months after CRT implantation, there was an increase of LVEF from 21.8%±7.6% to 30.4%±13.0% (p<0.001). Patients whose LVEF increased by at least 10% post-CRT implant (42.5% of cohort) survived significantly longer than patients who failed to improve their LVEF by that amount (p=0.01). A propensity matched analysis between patients with AIC and 369 consecutive patients with other aetiologies of NICM who underwent CRT implantation during the same period revealed no significant differences in improvement in LVEF or long-term survival. CONCLUSIONS Patients with AIC undergo LV remodelling with CRT at rates similar to other aetiologies of NICM. Furthermore, AIC post-CRT responders have a favourable long-term mortality compared with non-responders.
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Affiliation(s)
- Divyang Patel
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Anirudh Kumar
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Kevin Trulock
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David M Nemer
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Eoin Donnellan
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Trejeeve Martyn
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas D Callahan
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ayman A Hussein
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Khaldoun G Tarakji
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Daniel J Cantillon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bryan Baranowski
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Randall C Starling
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - W H Wilson Tang
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Oussama M Wazni
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Niraj Varma
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bruce L Wilkoff
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - John Rickard
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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18
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Statin Use Can Attenuate the Decline in Left Ventricular Ejection Fraction and the Incidence of Cardiomyopathy in Cardiotoxic Chemotherapy Recipients: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10163731. [PMID: 34442027 PMCID: PMC8397057 DOI: 10.3390/jcm10163731] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 11/20/2022] Open
Abstract
There is insufficient evidence about the cardioprotective effects of statins against chemotherapy-induced cardiomyopathy. The MEDLINE and EMBASE databases were searched from inception to March 2021 for studies that reported the mean left ventricular ejection fraction (LVEF) before and after chemotherapy and the incidence of chemotherapy-induced cardiotoxicity in patients who received concurrent statin therapy and those who received chemotherapy alone. A random effects meta-analysis was performed to obtain the pooled weighted mean difference (WMD) and the 95% confidence interval (CI) for the mean final LVEF and the mean LVEF change, and the pooled odds ratio (OR) and the 95% CI of the incidence of chemotherapy-induced cardiomyopathy. Seven studies with 3042 patients were included in this meta-analysis (statin group: 1382 patients received concurrent statin with chemotherapy; control group: 1660 patients received chemotherapy alone). Patients in the control group had a more significant decline in LVEF (WMD = −6.08%, 95% CI: −8.55 to −3.61, p < 0.001) compared to those in the statin group. Additionally, the statin group had a significantly lower incidence of chemotherapy-induced cardiomyopathy compared to the control group (OR = 0.41, 95% CI = 0.28–0.60, p < 0.001). Consequently, our study showed a significant reduction in the incidence of chemotherapy-induced cardiomyopathy and the degree of LVEF decline in patients in the statin group compared to those in the control group.
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19
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Fradley MG, Beckie TM, Brown SA, Cheng RK, Dent SF, Nohria A, Patton KK, Singh JP, Olshansky B. Recognition, Prevention, and Management of Arrhythmias and Autonomic Disorders in Cardio-Oncology: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e41-e55. [PMID: 34134525 DOI: 10.1161/cir.0000000000000986] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
With the advent of novel cancer therapeutics and improved screening, more patients are surviving a cancer diagnosis or living longer with advanced disease. Many of these treatments have associated cardiovascular toxicities that can manifest in both an acute and a delayed fashion. Arrhythmias are an increasingly identified complication with unique management challenges in the cancer population. The purpose of this scientific statement is to summarize the current state of knowledge regarding arrhythmia identification and treatment in patients with cancer. Atrial tachyarrhythmias, particularly atrial fibrillation, are most common, but ventricular arrhythmias, including those related to treatment-induced QT prolongation, and bradyarrhythmias can also occur. Despite increased recognition, dedicated prospective studies evaluating true incidence are lacking. Moreover, few studies have addressed appropriate prevention and treatment strategies. As such, this scientific statement serves to mobilize the cardio-oncology, electrophysiology, and oncology communities to develop clinical and scientific collaborations that will improve the care of patients with cancer who have arrhythmias.
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20
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Nejadeh M, Bayat P, Kheirkhah J, Moladoust H. Predicting the response to cardiac resynchronization therapy (CRT) using the deep learning approach. Biocybern Biomed Eng 2021. [DOI: 10.1016/j.bbe.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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21
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Lee C, Maan A, Singh JP, Fradley MG. Arrhythmias and device therapies in patients with cancer therapy-induced cardiomyopathy. Heart Rhythm 2021; 18:1223-1229. [PMID: 33640446 DOI: 10.1016/j.hrthm.2021.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022]
Abstract
Our knowledge of associated cardiotoxicities from novel therapeutics in oncology continues to expand. These include arrhythmias from cancer-therapy induced cardiomyopathy resulting from both direct and indirect effects on cardiomyocytes and other mechanisms that can adversely impact cardiovascular outcomes and overall mortality. In this review, we focus on both the arrhythmias of various classes of oncologic agents as well as the use of cardiac implantable electronic devices (cardioverter-defibrillators, permanent pacemakers, and cardiac resynchronization therapy) in cardio-oncology patients.
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Affiliation(s)
- Charlotte Lee
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Abhishek Maan
- Department of Cardiac Electrophysiology, The Mount Sinai Hospital, New York, New York
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael G Fradley
- Cardio-Oncology Center of Excellence, Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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22
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Ezzeddine FM, Saliba AN, Jain V, Villarraga HR, Herrmann J, Asirvatham SJ, Cha YM. Outcomes of cardiac resynchronization therapy in patients with chemotherapy-induced cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:625-632. [PMID: 33592678 DOI: 10.1111/pace.14196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/25/2021] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several chemotherapy agents are associated with the development of non-ischemic cardiomyopathy (NIC). When chemotherapy-induced cardiomyopathy (CHIC) is associated with left bundle branch block (LBBB) and a left ventricular ejection fraction (LVEF) 35% or lower, cardiac resynchronization therapy (CRT) is often utilized to improve cardiac function and relieve symptoms. OBJECTIVE To determine the echocardiographic and clinical outcomes of CRT in patients with CHIC. METHODS The study included 29 patients with CHIC (CHIC group) and 58 patients with other types of NIC (control group) who underwent CRT implantation between 2004 and 2017. The primary endpoints were changes in LVEF, left ventricular end-systolic diameter (LVESD), and left ventricular end-diastolic diameter (LVEDD) at 6-18 months after CRT. The secondary outcomes included changes in left ventricular global longitudinal strain (GLS), systolic strain rate (SRS), early diastolic strain rate (SRE), and overall survival. RESULTS Out of 29 patients with CHIC, 62.1% received chemotherapy for lymphoma, 13.7% for breast cancer, and 24.1% for sarcoma. The agent implicated in 93.1% of the patients was an anthracycline. Half of the patients had LBBB. The mean baseline LVEF was 28% ± 8%. The mean baseline QRS duration was 146 ± 26 ms. Twenty-eight patients had post-CRT follow-up data. CRT was associated with improvement in echocardiographic outcomes in the CHIC group and the control group. There was no difference in overall survival between the two groups (log-rank p = .148). CONCLUSION CRT improves left ventricular function and reverses remodeling in patients with CHIC.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vaibhav Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector R Villarraga
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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23
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Cuomo A, Pirozzi F, Attanasio U, Franco R, Elia F, De Rosa E, Russo M, Ghigo A, Ameri P, Tocchetti CG, Mercurio V. Cancer Risk in the Heart Failure Population: Epidemiology, Mechanisms, and Clinical Implications. Curr Oncol Rep 2020; 23:7. [PMID: 33263821 PMCID: PMC7716920 DOI: 10.1007/s11912-020-00990-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Along with population aging, the incidence of both heart failure (HF) and cancer is increasing. However, little is known about new-onset cancer in HF patients. This review aims at showing recent discoveries concerning this subset of patients. RECENT FINDINGS Not only cancer and HF share similar risk factors but also HF itself can stimulate cancer development. Some cytokines produced by the failing heart induce mild inflammation promoting carcinogenesis, as it has been recently suggested by an experimental model of HF in mice. The incidence of new-onset cancer is higher in HF patients compared to the general population, and it significantly worsens their prognosis. Moreover, the management of HF patients developing new-onset cancer is challenging, especially due to the limited therapeutic options for patients affected by both cancer and HF and the higher risk of cardiotoxicity from anticancer drugs.
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Affiliation(s)
- Alessandra Cuomo
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Flora Pirozzi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Umberto Attanasio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Riccardo Franco
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Francesco Elia
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Eliana De Rosa
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Michele Russo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Italian Cardiovascular Network, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
- Interdepartmental Center of Clinical and Translational Research, Federico II University, Naples, Italy.
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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24
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DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, Hernandez AF, Fonarow GC. Improvement in Left Ventricular Ejection Fraction in Outpatients With Heart Failure With Reduced Ejection Fraction: Data From CHAMP-HF. Circ Heart Fail 2020; 13:e006833. [PMID: 32580657 DOI: 10.1161/circheartfailure.119.006833] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among patients with heart failure (HF) with reduced ejection fraction (EF), improvements in left ventricular EF (LVEF) are associated with better outcomes and remain an important treatment goal. Patient factors associated with LVEF improvement in routine clinical practice have not been clearly defined. METHODS CHAMP-HF (Change the Management of Patients with Heart Failure) is a prospective registry of outpatients with HF with reduced EF. Assessments of LVEF are recorded when performed for routine care. We analyzed patients with both baseline and ≥1 follow-up LVEF assessments to describe factors associated with LVEF improvement. RESULTS In CHAMP-HF, 2623 patients had a baseline and follow-up LVEF assessment. The median age was 67 (interquartile range, 58-75) years, 40% had an ischemic cardiomyopathy, and median HF duration was 2.8 years (0.7-6.8). Median LVEF was 30% (23-35), and median change on follow-up was 4% (-2 to -13); 19% of patients had a decrease in LVEF, 31% had no change, 49% had a ≥5% increase, and 34% had a ≥10% increase. In a multivariable model, the following factors were associated with ≥5% LVEF increase: shorter HF duration (odds ratio [OR], 1.21 [95% CI, 1.17-1.25]), no implantable cardioverter defibrillator (OR, 1.46 [95% CI, 1.34-1.55]), lower LVEF (OR, 1.15 [95% CI, 1.10-1.19]), nonischemic cardiomyopathy (OR, 1.24 [95% CI, 1.09-1.36]), and no coronary disease (OR, 1.20 [95% CI, 1.03-1.35]). CONCLUSIONS In a large cohort of outpatients with chronic HF with reduced EF, improvements in LVEF were common. Common baseline cardiac characteristics identified a population that was more likely to respond over time. These data may inform clinical decision making and should be the basis for future research on myocardial recovery.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.)
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.)
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO (J.A.S.)
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (C.I.D.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.)
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25
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Affiliation(s)
- Arielle M Schwartz
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Stacy Westerman
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Anant Mandawat
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
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26
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Singh JP, Fradley MG, Kutyifa V. Cardiac Resynchronization Therapy for Chemotherapy-Induced Cardiomyopathy-Reply. JAMA 2020; 323:1317. [PMID: 32259225 DOI: 10.1001/jama.2020.1397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Valentina Kutyifa
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, New York
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27
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Meijers WC, Moslehi JJ. Need for Multidisciplinary Research and Data-Driven Guidelines for the Cardiovascular Care of Patients With Cancer. JAMA 2019; 322:1775-1776. [PMID: 31714975 PMCID: PMC7228138 DOI: 10.1001/jama.2019.17415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Wouter C Meijers
- Cardio-oncology Program, Divisions of Cardiovascular Medicine and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Javid J Moslehi
- Cardio-oncology Program, Divisions of Cardiovascular Medicine and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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