Prevention, Diagnosis, and Management of Radiation-Associated Cardiac Disease

Dose constraints in breast cancer radiotherapy. A critical review

Radiotherapy plays an essential role in the treatment of breast cancer (BC). Recent advances in treatment technology and radiobiological knowledge have a major impact in BC patients with locoregional disease as the majority are now long-term survivors. Over the last three decades, intensity-modulated radiotherapy (IMRT), volumetric-modulated arc therapy (VMAT) and deep inspiration breath-hold (DIBH) techniques, together with the increasing adoption of moderately hypofractionated and ultra-hypofractionated treatment schedules as well as the possibility to offer partial breast radiotherapy to a well-defined patient subset have significantly changed radiotherapy for BC patients. As dose-volume constraints (DVCs) have to be adapted to these new treatment paradigms we have reviewed available evidence-based data concerning dose-constraints for the main organs at risk (OARs) that apply to the treatment of whole breast/chest wall radiotherapy, whole breast/chest wall radiotherapy including regional nodal irradiation (RNI) and partial breast irradiation (PBI), for the most relevant fractionation schedules that have been introduced recently. This narrative review provides a comprehensive summary that may help to harmonize treatment planning strategies.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Radiation-associated cardiovascular disease in patients with cancer: current insights from a cardio-oncologist

Radiation-associated cardiovascular disease (RACD), a complex disease characterized with pericarditis, myocardial damage, valvular heart diseases, heart failure, vasculopathy and ischemic heart disease, has a generally poor prognosis. While RACD may be acute, it often manifests in the late years or even decades following radiation exposure to the chest. With an increasing number of cancer survivors, RACD is likely to become an important issue in cardio-oncology. This review discusses pre-radiation therapy (RT) preparation, peri-RT patient management and long follow-up planning post-RT from a cardiology perspective. Additionally, a novel technique of stereotactic radiotherapy, which has been applied for the treatment of intractable cardiac arrhythmias, is presented. Appropriate patient examination and management during and after RT are essential to support patients undergoing cancer treatment to improve long life expectancy. A multidisciplinary team is needed to determine how to manage patients who receive RT to reduce RACD, to detect early phases of RACD and to provide the best treatment for RACD. Recent studies increasingly report advances in diagnosis using new equipment that has the potential to detect early phases of RACD, along with growing evidence for the optimal treatment for RACD. This review provides an overview of recent studies and guidelines to report on the latest findings, and to identify unresolved issues surrounding RACD that require validation in future studies.

How We Monitor Cardiac Health in Breast Cancer Survivors

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Cardio-oncology and radiation oncology: How collaboration between cardiologists and oncologists can be realised in radiation oncology

Increased survivorship, improvements in cancer treatments, and the potential for cardiac side effects from cancer treatments have resulted in increased collaboration between oncologists and cardiologists and the development of cardio-oncology clinics. This collaboration is important given its role in ensuring greater patient satisfaction, aiding teams of clinicians in making complex treatment decision, and ensuring cardiac complications are diagnosed at an early stage. The particularities of implementing this collaboration in the field of radiation oncology and how this setting is different from other areas of cardio-oncology have not been well detailed in the literature. This paper will discuss what is currently understood about the need for and role of cardio-oncology and what a cardio-oncology services involves, with a particular emphasis on patient and clinician needs in the field of radiation oncology. The literature and recent guidelines do advocate for a detailed baseline assessment of cancer patients undergoing radiotherapy, especially patients with treatment or patient risk factors that increase their risk of cancer-therapy related cardiotoxicity. Advancements in cardiac imaging techniques will be discussed as these may help to diagnose cardiac side effects of certain cancer treatments, including radiotherapy, at an early stage. A multi-disciplinary and collaborative approach is well received by patients and such an approach, guided by the aim of maintaining a patient's cancer treatment wherever possible, should be the cornerstone of cardio-oncology clinics regardless of the patient's treatment regime.

Cardiac Disease in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review

PURPOSE

Radiation therapy (RT) is an essential component in the treatment of many pediatric malignancies. Thoracic RT may expose the heart to radiation dose and thereby increase the risk of late cardiac disease. This comprehensive review from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative focused on late cardiac disease in survivors of childhood cancer treated with RT.

METHODS AND MATERIALS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We identified 1496 articles; 4 were included for dose-response modeling between mean cardiac radiation dose and risk of late coronary artery disease, heart failure (HF), valvular disease, and any cardiac disease.

RESULTS

For each 10-Gy increase in corrected mean cardiac radiation dose in 1.8- to 2.0-Gy fractions, we estimated a hazard ratio of 2.01 (95% confidence interval [CI], 1.79-2.25) for coronary artery disease, of 1.87 (95% CI, 1.70-2.06) for HF, of 1.87 (95% CI, 1.78-1.96) for valvular disease, and of 1.88 (95% CI, 1.75-2.03) for any cardiac disease. From the same model, for each 100-mg/m2 increase in cumulative anthracycline dose, the hazard ratio for the development of HF was 1.93 (95% CI, 1.58-2.36), equivalent to an increase in mean heart dose of approximately 10.5 Gy. Other nontreatment factors were inconsistently reported in the analyzed articles.

CONCLUSIONS

Radiation dose to the heart increases the risk of late cardiac disease, but survivors of childhood cancer who receive a mean dose <10 Gy at standard fractionation are at low absolute risk (<∼2% approximately 30 years after exposure) of late cardiac disease in the absence of anthracycline exposure. Minimizing cardiac radiation dose is especially relevant in children receiving anthracyclines. When cardiac sparing is not possible, we recommend prioritizing target coverage. It is likely that individual cardiac substructure doses will be a better predictor of specific cardiac diseases than mean dose, and we urge the pediatric oncology community to further study these relationships.

Atherosclerosis and the Bidirectional Relationship between Cancer and Cardiovascular Disease: From Bench to Bedside-Part 1

Atherosclerosis, a complex metabolic-immune disease characterized by chronic inflammation driven by the buildup of lipid-rich plaques within arterial walls, has emerged as a pivotal factor in the intricate interplay between cancer and cardiovascular disease. This bidirectional relationship, marked by shared risk factors and pathophysiological mechanisms, underscores the need for a comprehensive understanding of how these two formidable health challenges intersect and influence each other. Cancer and its treatments can contribute to the progression of atherosclerosis, while atherosclerosis, with its inflammatory microenvironment, can exert profound effects on cancer development and outcomes. Both cancer and cardiovascular disease involve intricate interactions between general and personal exposomes. In this review, we aim to summarize the state of the art of translational data and try to show how oncologic studies on cardiotoxicity can broaden our knowledge of crucial pathways in cardiovascular biology and exert a positive impact on precision cardiology and cardio-oncology.

Early and Accurate Detection of Radiation-induced Heart Damage by Cardiodynamicsgram

Cardiodynamicsgram (CDG) has emerged recently as a noninvasive spatiotemporal electrocardiographic method for subtle cardiac dynamics information analysis within electrocardiogram (ECG). This study explored the feasibility of CDG for detecting radiation-induced heart damage (RIHD) in a rat model. A single radiation dose of 40 Gy was delivered to the cardiac apex of female Wistar rats. First, CDG was generated through dynamic modeling of ECG signals using the deterministic learning algorithm. Furthermore, CDG indexes were calculated using the wavelet transform and entropy. In this model, CDG entropy indexes decreased significantly after radiotherapy. The shape of CDG changed significantly after radiotherapy (irregular shape) compared with controls (regular shape). Macrophage and fibrosis in myocardium of rats increased significantly after radiotherapy. CDG changes after radiotherapy were significantly correlated with histopathological changes and occurred significantly earlier than histopathological changes. This study provides an experimental basis for the clinical application of CDG for the early detection of RIHD.

Contemporary experience with the Commando procedure for anterior mitral anular calcification

Objective

Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements.

Methods

From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs).

Results

Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47).

Conclusions

The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

NDP52 SUMOylation contributes to low-dose X-rays-induced cardiac hypertrophy through PINK1/Parkin-mediated mitophagy via MUL1/SUMO2 signalling

Radiation-induced heart damage caused by low-dose X-rays has a significant impact on tumour patients' prognosis, with cardiac hypertrophy being the most severe noncarcinogenic adverse effect. Our previous study demonstrated that mitophagy activation promoted cardiac hypertrophy, but the underlying mechanisms remained unclear. In the present study, PARL-IN-1 enhanced excessive hypertrophy of cardiomyocytes and exacerbated mitochondrial damage. Isobaric tags for relative and absolute quantification-based quantitative proteomics identified NDP52 as a crucial target mediating cardiac hypertrophy induced by low-dose X-rays. SUMOylation proteomics revealed that the SUMO E3 ligase MUL1 facilitated NDP52 SUMOylation through SUMO2. Co-IP coupled with LC-MS/MS identified a critical lysine residue at position 262 of NDP52 as the key site for SUMO2-mediated SUMOylation of NDP52. The point mutation plasmid NDP52K262R inhibited mitophagy under MUL1 overexpression, as evidenced by inhibition of LC3 interaction with NDP52, PINK1 and LAMP2A. A mitochondrial dissociation study revealed that NDP52K262R inhibited PINK1 targeting to endosomes early endosomal marker (EEA1), late/lysosome endosomal marker (LAMP2A) and recycling endosomal marker (RAB11), and laser confocal microscopy confirmed that NDP52K262R impaired the recruitment of mitochondria to the autophagic pathway through EEA1/RAB11 and ATG3, ATG5, ATG16L1 and STX17, but did not affect mitochondrial delivery to lysosomes via LAMP2A for degradation. In conclusion, our findings suggest that MUL1-mediated SUMOylation of NDP52 plays a crucial role in regulating mitophagy in the context of low-dose X-ray-induced cardiac hypertrophy. Two hundred sixty-second lysine of NDP52 is identified as a key SUMOylation site for low-dose X-ray promoting mitophagy activation and cardiac hypertrophy. Collectively, this study provides novel implications for the development of therapeutic strategies aimed at preventing the progression of cardiac hypertrophy induced by low-dose X-rays.

A new perspective in the prevention and treatment of antitumor therapy-related cardiotoxicity: Intestinal microecology

The continuous development of antitumor therapy has significantly reduced the mortality of patients with malignancies. However, the antitumor-related cardiotoxicity has become the leading cause of long-term mortality in patients with malignancies. Besides, the pathogenesis of antitumor-related cardiotoxicity is still unclear, and practical means of prevention and treatment are lacking in clinical practice. Therefore, the major challenge is how to combat the cardiotoxicity of antitumor therapy effectively. More and more studies have shown that antitumor therapy kills tumor cells while causing damage to sensitive tissues such as the intestinal mucosa, leading to the increased permeability of the intestine and the dysbiosis of intestinal microecology. In addition, the dysbiosis of intestinal microecology contributes to the development and progression of cardiovascular diseases through multiple pathways. Thus, the dysbiosis of intestinal microecology may be a potential mechanism and target for antitumor-related cardiotoxicity. We summarized the characteristics of intestinal microecology disorders induced by antitumor therapy and the association between intestinal microecological dysbiosis and CVD. And on this basis, we hypothesized the potential mechanisms of intestinal microecology mediating the occurrence of antitumor-related cardiotoxicity. Then we reviewed the previous studies targeting intestinal microecology against antitumor-associated cardiotoxicity, aiming to provide a reference for future studies on the occurrence and prevention of antitumor-related cardiotoxicity by intestinal microecology.

Cardiac Post-Chest Radiotherapy Complications in a 50-Year-Old Patient with Hodgkin Lymphoma

Lymphomas are a group of malignant tumors that originate in the lymphatic system. It is the most common type of blood cancer. It affects the lymph nodes, spleen, bone marrow, blood, and other organs. They can be aggressive or chronic. Hodgkin lymphoma survival rate is 2 in 100,000 people. Young adults aged 20-30 and people over 50 are most often affected. The prognosis of Hodgkin's lymphoma is good, with a survival rate of up to 80 percent. Nevertheless, in 20-30 percent of patients who initially respond to treatment, the disease has a tendency to progress. The positive effect of radiotherapy (RT) on patients' survival rates has been proven in many randomized clinical trials. Although the dose of chest RT has significantly reduced over the years, we still struggle with the long-term complications of post-RT repercussions, mainly because there is no established safe dose of RT affecting the heart. Other complications include earlier onset of coronary artery disease, early and late onset of pericarditis, valve degeneration (predominantly of the left heart), calcification of the aorta and its branches, heart failure, and arrhythmias. One patient can manifest each of the abovementioned complications, as in the present case. That is why choosing the right treatment strategy is crucial.

Sex-Based Differences in Clinical Outcomes of Acute Coronary Syndrome Among Patients With Mediastinal Radiation Exposure: Insights From The National Inpatient Sample (2009-2020)

There is a paucity of data about the sex differences in acute coronary syndrome (ACS) outcomes in patients with prior mediastinal radiation. The National Inpatient Sample database from years 2009 to 2020 were queried for ACS hospitalizations of patients with prior mediastinal radiation. The primary outcome was MACCE (major cardiovascular events), and secondary outcomes included other clinical outcomes. A total of 23,385 hospitalizations for ACS with prior mediastinal radiation exposure ([15,904 (68.01%) females, and 7481 (31.99%) males]) were included in analysis. Males were slightly younger than females (median, age (70 [62-78] vs 72 [64-80]). Female patients with ACS had a higher burden of hypertension (80.82% vs 73.55%), diabetes mellitus (33% vs 28.35%), hyperlipidemia (66.09% vs 62.2%), obesity (17.02% vs 8.6%) however, males had a higher burden of peripheral vascular disease (18.29% vs 12.51%), congestive heart failure (41.8% vs 39.35%) and smoking (70.33% vs 46.92%). After propensity matching, primary outcome MACCE was higher in males (20.85% vs 13.29%, aOR: 1.80 95% CI (1.65-1.96), P < 0.0001) along with cardiogenic shock (8.74% vs 2.42%, aOR: 1.77 95% CI (1.55-2.02), P < 0.0001) and mechanical circulatory support use (aOR: 1.48 95% CI [1.29 -1.71], P < 0.0001). We observed no differences in the length of hospital stay, however total hospitalization cost was higher in males. This nationwide analysis showed significant disparities in outcomes among male and female ACS patients with prior mediastinal radiation history, with increasing trend in hospitalization for ACS among males and females but decreasing mortality among females.

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

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

Radiation-associated Arrhythmias: Putative Pathophysiological Mechanisms, Prevalence, Screening and Management Strategies

Radiation-associated cardiovascular disease, an increasingly recognised disease process, is a significant adverse effect of radiation therapy for common malignancies that involve the chest, and include lymphomas, lung, mediastinal and breast cancers. Two factors contribute to the increasing incidence of radiation-associated cardiovascular disease: advances in malignancy detection and the improved survival of cancer patients, by which many symptoms of radiation-associated cardiovascular disease, specifically radiation-associated arrhythmias, present years and/or decades following initial radiotherapy. We present a focused overview of the currently understood pathophysiology, prevalence and management strategies of radiation-associated arrhythmias, which include bradyarrhythmias, tachyarrhythmias and autonomic dysfunction.

Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring

Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.

Cardiovascular disease treatment using traditional Chinese medicine：Mitochondria as the Achilles' heel

Cardiovascular disease (CVD), involving the pathological alteration of the heart or blood vessels, is one of the main causes of disability and death worldwide, with an estimated 18.6 million deaths per year. CVDs are caused by a variety of risk factors, including inflammation, hyperglycemia, hyperlipidemia, and increased oxidative stress. Mitochondria, the hub of ATP production and the main generator of reactive oxygen species (ROS), are linked to multiple cellular signaling pathways that regulate the progression of CVD and therefore are recognized as an essential target for CVD management. Initial treatment of CVD generally focuses on diet and lifestyle interventions; proper drugs or surgery can prolong or save the patient's life. Traditional Chinese medicine (TCM), a holistic medical care system with an over 2500-year history, has been proven to be efficient in curing CVD and other illnesses, with a strengthening effect on the body. However, the mechanisms underlying TCM alleviation of CVD remain elusive. Recent studies have recognized that TCM can alleviate cardiovascular disease by manipulating the quality and function of mitochondria. This review systematically summarizes the association of mitochondria with cardiovascular risk factors, and the relationships between mitochondrial dysfunction and CVD progression. We will investigate the research progress of managing cardiovascular disease by TCM and cover widely used TCMs that target mitochondria for the treatment of cardiovascular disease.

Cancer and Postradiotherapy Cardiotoxicity: How to Face Damage in Women’s Hearts?

Cancer and cardiovascular disease are the two main causes of death worldwide in both men and women. In the past decades, survival rate in cancer patients has substantially improved due to new treatments and developments in radiation therapy (RT). In women, breast cancer (BC) is the leading cause of cancer death and thoracic RT is a main component of the treatment in many cases. Nevertheless, despite new techniques that limit the area receiving RT, cardiac damage is still an important concern in BC patients. In this review, the following aspects will be addressed: pathophysiology of postradiotherapy heart damage in women with BC; mechanisms, diagnosis and prevention/management of heart damage; and future areas of potential research for radiotherapy injury in women.

The Evaluation and Management of Visceral Complications in Radiation Fibrosis Syndrome Part 1

Abstract

External beam ionizing radiation is a fundamental component of cancer treatment and is incorporated into approximately 50% of cancer treatments. Radiation therapy causes cell death directly by apoptosis and indirectly by disruption of mitosis.

Purpose of Review

This study aims to inform rehabilitation clinicians of the visceral toxicities of radiation fibrosis syndrome and how to detect and diagnose these complications.

Recent Findings

Latest research indicates that radiation toxicity is primarily related to radiation dose, patient co-morbidity, and concomitant use of chemotherapies and immunotherapies for the treatment of cancer. While cancer cells are the primary target, surrounding normal cells and tissues are also affected. Radiation toxicity is dose dependent, and tissue injury develops from inflammation that may progress to fibrosis. Thus, radiation dosing in cancer therapy is often limited by tissue toxicity. Although newer radiotherapeutic modalities aim to limit delivery of radiation to non-cancerous tissues, many patients continue to experience toxicity.

Summary

To ensure early recognition of radiation toxicity and fibrosis, it is imperative that all clinicians are aware of the predictors, signs, and symptoms of radiation fibrosis syndrome. Here, we present part 1 of the visceral complications of radiation fibrosis syndrome, addressing radiation-related toxicity in the heart, lungs, and thyroid gland.

Graphical abstract

Screening for Coronary Artery Disease in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review

Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. This review identifies features that could help guide decisions about the benefit of screening to assess the risk or presence of subclinical CAD. Screening may be appropriate in selected survivors based on risk factors and inflammatory burden. In cancer survivors who have undergone genetic testing, polygenic risk scores and clonal hematopoiesis markers may become useful CAD risk prediction tools in the future. The type of cancer (especially breast, hematological, gastrointestinal, and genitourinary) and the nature of treatment (radiotherapy, platinum agents, fluorouracil, hormonal therapy, tyrosine kinase inhibitors, endothelial growth factor inhibitors, and immune checkpoint inhibitors) are also important in determining risk. Therapeutic implications of positive screening include lifestyle and atherosclerosis interventions, and in specific instances, revascularization may be indicated.

Radiation-Induced Aortic Stenosis: An Update on Treatment Modalities

The adverse effects of radiation therapy for cancer are well described and can include a wide array of cardiac complications. Radiation-induced aortic stenosis (AS) is an increasingly recognized entity that poses particular therapeutic challenges. Several retrospective studies comparing the outcomes after transcatheter aortic valve replacement (TAVR) vs those after surgical aortic valve replacement patients with radiation-induced AS have found a trend toward decreased mortality and fewer major complications with TAVR. Surgical aortic valve replacement is associated with increased mortality in patients with radiation-induced AS compared with patients without a history of prior radiation. TAVR has been shown to be a safe and effective alternative in patients with radiation-induced AS, with safety similar to that for patients who have not received prior radiation. However, rare and unexpected complications may occur after TAVR from the deleterious effects of radiation on mediastinal structures. More studies are needed to identify the optimal way of managing patients with radiation-induced AS, and algorithms are needed for planning these complex interventions.

Outcomes of Coronary Artery Bypass Grafting in Patients With Previous Mediastinal Radiation

Studies have shown that patients with radiation therapy-associated coronary artery disease tend to have worse outcomes with percutaneous revascularization. Previous irradiation has been linked with future internal mammary artery graft disease. Studies investigating the outcomes of coronary artery bypass surgery (CABG) among patients with previous radiation are limited. The Nationwide Readmission Database for the years 2016 to 2019 was queried for hospitalizations with CABG and history of mediastinal radiation. Complex samples multivariable logistic and linear regression models were used to determine the association between the history of mediastinal radiation and in-hospital mortality, 90 days all-cause unplanned readmission rates, and acute coronary syndrome readmission rates. A total of 533,702 hospitalizations (2,070 in the irradiation history group and 531,632 in the control group) were included in this analysis. Patients with radiation therapy history were less likely to have traditional coronary artery disease risk factors and more likely to have associated valvular disease. Patients with a history of irradiation had similar in-hospital mortality and 90-day readmission risk at the expense of higher hospitalizations costs (β coefficient: $2,764; p = 0.005). They had a higher likelihood of readmission with acute coronary syndrome within 90 days (adjusted odds ratio 1.67, p = 0.02). In a conclusion, a history of mediastinal irradiation is not associated with increased rates of short-term mortality or increased all-cause readmission risk after CABG. However, it may be associated with increased acute coronary syndrome readmission rates.

Application of Amiodarone and Cedilan in the Treatment of Patients with Arrhythmia after Esophageal and Lung Cancer

Objective

To explore the effect of amiodarone and cedilan in the treatment of patients with arrhythmia after esophageal and lung cancer.

Methods

The data of 60 patients with postoperative complications of arrhythmias after esophageal and lung cancer from January 2018 to July 2021 were retrospectively analyzed and divided into an observation group (n = 30) and control group (n = 30) according to the random number grouping principle. The former group was treated with amiodarone, and the latter group received cedilan.

Results

The effective rate of treatment was significantly higher in the observation group than the control group (P < 0.05). The observation group had the drug onset time obviously shorter than the control group (P < 0.001). The average ventricular rate after treatment in the observation group was remarkably lower than the control group (P < 0.001). The observation group exhibited obviously better cardiac function after treatment as compared to the control group (P < 0.05). The incidence of adverse reactions in the observation group was notably lower than the control group (P < 0.05). Moreover, the observation group had less stress after treatment than the control group (P < 0.001). The blood pressure level of the observation group after treatment was significantly better than the control group (P < 0.05).

Conclusion

Amiodarone can relieve stress in patients with arrhythmia following esophageal and lung cancer surgery, stabilize blood pressure, and mitigate arrhythmia symptoms. Our findings are worthy of promotion and application in clinic.

Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS)

Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.

MG149 Inhibits MOF-Mediated p53 Acetylation to Attenuate X-Ray Radiation-Induced Apoptosis in H9c2 Cells

Cardiomyocyte apoptosis is involved in the pathogenesis of radiation-induced heart disease, but the underlying epigenetic mechanism remains elusive. We evaluated the potential mediating role of males absent on the first (MOF) in the association between epigenetic activation of p53 lysine 120 (p53K120) and X-ray radiation-induced apoptosis in H9c2 cells. H9c2 cells were pretreated for 24 h with the MOF inhibitor MG149 after 4 Gy irradiation, followed by assessment of cell proliferation, injury, and apoptosis. MOF expression was upregulated by X-ray radiation. MG149 suppressed the proliferation inhibition, reduction of mitochondrial membrane potential, ROS production, and cell apoptosis. MG149 may promote the survival of H9c2 cells via inhibition of MOF-mediated p53K120 acetylation in response to X-ray radiation-induced apoptosis. Our data indicates a MOF-associated epigenetic mechanism in H9c2 cells that promotes attenuation of X-ray radiation-induced injury.

Mediastinal irradiation and valvular heart disease

Anticancer therapy has the potential to cause unwanted cardiovascular side effects. Utilization of radiation therapy to treat tumors near the heart can result in radiation-induced valvular heart disease among other cardiovascular pathologies. The aim of this review is to describe the epidemiology, pathophysiology, risk prediction, non-invasive imaging modalities and management of radiation-induced valvular heart disease with a focus on pre-operative risk assessment and contemporary treatment options.

A Rare Case of Radiation-Associated Aortic and Mitral Valve Stenosis Treated With Transcatheter Valve Replacements

Radiation therapy is the standard of care for achieving cure for many thoracic malignancies, but it can result in long-term cardiovascular sequelae such as valve disease. We describe a rare case of severe aortic and mitral stenosis due to prior radiation therapy for giant cell tumor treated successfully with percutaneous aortic and off-label mitral valve replacements. (Level of Difficulty: Intermediate.).

Overdrive pacing in the acute management of osimertinib-induced ventricular arrhythmias: A case report and literature review

QT interval prolongation and ventricular arrhythmias (VAs) induced by osimertinib, a third-generation epidermal growth factor receptor tyrosine kinase inhibitor, are life-threatening complications. However, no consensus has been achieved regarding their management. Overdrive pacing has been shown to be effective in shortening the QT interval and terminating torsade de pointes (TdP). Here, we report a case of osimertinib-induced QT prolongation accompanied by frequent VAs and TdP. Osimertinib was immediately discontinued after it was identified as the etiology for QT prolongation and VAs. A temporary pacemaker and overdrive pacing were used after other anti-arrhythmia treatments had failed and successfully shortened the QTc interval and terminated VAs. Repeated Holter monitoring at 1 week showed no remaining VAs or TdP, and the pacemaker was removed. Routine electrocardiography (ECG) surveillance was conducted afterward, and three- and 6-month follow-ups showed good recovery and normal ECG results. Vigilance is required for rare vital arrhythmias in patients taking osimertinib, and ECG surveillance should be conducted.

Pharmaceutical Prevention and Management of Cardiotoxicity in Hematological Malignancies

Modern treatment modalities in hematology have improved clinical outcomes of patients with hematological malignancies. Nevertheless, many new or conventional anticancer drugs affect the cardiovascular system, resulting in various cardiac disorders, including left ventricular dysfunction, heart failure, arterial hypertension, myocardial ischemia, cardiac rhythm disturbances, and QTc prolongation on electrocardiograms. As these complications may jeopardize the significantly improved outcome of modern anticancer therapies, it is crucial to become familiar with all aspects of cardiotoxicity and provide appropriate care promptly to these patients. In addition, established and new drugs contribute to primary and secondary cardiovascular diseases prevention. This review focuses on the clinical manifestations, preventive strategies, and pharmaceutical management of cardiotoxicity in patients with hematologic malignancies undergoing anticancer drug therapy or hematopoietic stem cell transplantation.

Primary site as a novel prognostic factor for cardiovascular mortality post-radiotherapy in limited-stage small cell lung cancer: A large population-based study

Background

The effect of primary site on cardiovascular mortality (CVM) post-radiotherapy (RT) in patients with limited-stage small cell lung cancer (LS-SCLC) remains unclear.

Methods

We screened the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2013. We used cumulative incidence function (CIF) curves to compare CVM incidences, and performed Cox proportional hazards and Fine-Gray competing risk analyses to identify independent risk factors of CVM. Propensity score matching (PSM) analysis was conducted.

Results

Among enrolled 4,824 patients (median age 57 years old, 49.2% were male), CVM accounts for 10.0% of all deaths after 5 years since cancer diagnosis. Hazard ratios (HRs) for CVM were 1.97 (95% CI: 1.23–3.16, P = 0.005) for main bronchus (MB) patients, 1.65 (95% CI: 1.04–2.63, P = 0.034) for lower lobe (LL) patients and 1.01 (95% CI: 0.40–2.59, P = 0.977) for middle lobe (ML) patients compared to upper lobe (UL) patients. CIF curves showed that the cumulative CVM incidence was greater in the re-categorized MB/LL group compared to UL/ML group both before PSM (P = 0.005) and after PSM (P = 0.012). Multivariate regression models indicated that MB/LL was independently associated with an increased CVM risk, before PSM (HR_Cox: 1.79, 95% CI: 1.23–2.61, P = 0.002; HR_Fine−Gray: 1.71, 95% CI: 1.18–2.48, P = 0.005) and after PSM (HR_Cox: 1.88, 95% CI: 1.20–2.95, P = 0.006; HR_Fine−Gray: 1.79, 95% CI: 1.15–2.79, P = 0.010).

Conclusions

MB/LL as the primary site is independently associated with an increased CVM risk post-RT in patients with LS-SCLC.

Comparison of Breast Cancer Radiotherapy Techniques Regarding Secondary Cancer Risk and Normal Tissue Complication Probability - Modelling and Measurements Using a 3D-Printed Phantom

Background

Radiotherapy after breast-conserving therapy is a standard postoperative treatment of breast cancer, which can be carried out with a variety of irradiation techniques. The treatment planning must take into consideration detrimental effects on the neighbouring organs at risk-the lung, the heart, and the contralateral breast, which can include both short- and long-term effects represented by the normal tissue complication probability and secondary cancer risk.

Patients and Methods

In this planning study, we investigate intensity-modulated (IMRT) and three-dimensional conformal (3D-CRT) radiotherapy techniques including sequential or simultaneously integrated boosts as well as interstitial multicatheter brachytherapy boost techniques of 38 patients with breast-conserving surgery retrospectively. We furthermore develop a 3D-printed breast phantom add-on to allow for catheter placement and to measure the out-of-field dose using thermoluminescent dosimeters placed inside an anthropomorphic phantom. Finally, we estimate normal tissue complication probabilities using the Lyman-Kutcher-Burman model and secondary cancer risks using the linear non-threshold model (out-of-field) and the model by Schneider et al. (in-field).

Results

The results depend on the combination of primary whole-breast irradiation and boost technique. The normal tissue complication probabilities for various endpoints are of the following order: 1%-2% (symptomatic pneumonitis, ipsilateral lung), 2%-3% (symptomatic pneumonitis, whole lung), and 1%-2% (radiation pneumonitis grade ≥ 2, whole lung). The additional relative risk of ischemic heart disease ranges from +25% to +35%. In-field secondary cancer risk of the ipsilateral lung in left-sided treatment is around 50 per 10,000 person-years for 20 years after exposure at age 55. Out-of-field estimation of secondary cancer risk results in approximately 5 per 10,000 person-years each for the contralateral lung and breast.

Conclusions

In general, 3D-CRT shows the best risk reduction in contrast to IMRT. Regarding the boost concepts, brachytherapy is the most effective method in order to minimise normal tissue complication probability and secondary cancer risk compared to teletherapy boost concepts. Hence, the 3D-CRT technique in combination with an interstitial multicatheter brachytherapy boost is most suitable in terms of risk avoidance for treating breast cancer with techniques including boost concepts.

Exercise echocardiography for a differential diagnosis in a patient with radiation-induced heart disease: A case report

Advances in radiation therapy (RT) have dramatically improved the survival rates of patients with cancer, but radiation-induced heart disease (RIHD) has become an emerging problem, which is complex and multifaceted.

A 65-year-old man with a medical history of chemoradiotherapy for esophageal cancer, who had multiple admissions for acute heart failure (AHF), was readmitted to our hospital. Transthoracic echocardiography at rest revealed left ventricular diastolic dysfunction, moderate aortic stenosis with mild aortic regurgitation, and mild mitral regurgitation (MR). A diagnosis of RIHD was obtained, however, the main cause of the AHF was not clearly understood. Exercise echocardiography (ExE) revealed an exacerbation of the MR and exercise-induced pulmonary hypertension (EIPH), and the severe dynamic MR was considered to be the main cause of the AHF. A transcatheter edge-to-edge repair (TEER) with a MitraClip (Abbott Vascular, Menlo Park, CA, USA) was performed, and the post-procedural ExE showed the mitigation of the dynamic MR and EIPH. He had no further heart failure admissions for more than one year.

Our case showed that ExE may be useful in the management of patients with RIHD, and a TEER with a MitraClip may be an effective treatment for RT-related dynamic MR.

Learning objective

Radiation therapy (RT) has improved the survival rates of patients with cancer, but which involves radiation-induced heart disease (RIHD). RIHD is complex and multifaceted, and RT-related valvular disease may be underestimated with transthoracic echocardiography at rest alone. Then exercise echocardiography may be useful in the management. It is important to perform an individualized approach including medical therapy, surgery, and percutaneous intervention by a heart team.

Radiation-Induced Cardiac Dysfunction: Optimizing Radiation Delivery and Postradiation Care

Radiation therapy (RT) is part of standard-of-care treatment of many thoracic cancers. More than 60% of patients receiving thoracic RT may eventually develop radiation-induced cardiac dysfunction (RICD) secondary to collateral heart dose. This article reviews factors contributing to a thoracic cancer patient's risk for RICD, including RT dose to the heart and/or cardiac substructures, other anticancer treatments, and a patient's cardiometabolic health. It is also discussed how automated tracking of these factors within electronic medical record environments may aid radiation oncologists and other treating physicians in their ability to prevent, detect, and/or treat RICD in this expanding patient population.

Next Generation Risk Markers in Preventive Cardio-oncology

PURPOSE OF REVIEW

Cardiovascular disease (CVD) and cancer are the first and second most common causes of death within the USA. It is well established that a diagnosis of cancer increases risk and predisposes the patient to CVD, and vice versa. Despite these associations, cancer is not yet incorporated into current CVD risk calculators, necessitating additional CV risk markers for improved stratification in this at-risk population. In this review, we consider the utility of breast arterial calcification (BAC), coronary artery calcification (CAC), clonal hematopoiesis of indeterminate potential (CHIP), and cancer and cancer treatment in CVD risk assessment.

RECENT FINDINGS

There is evidence supporting the use of BAC, CAC, CHIP, and cancer and cancer treatment for improved CV risk stratification in patients with cancer and those who are being screened for cancer. BAC has been shown to predict CAC, coronary atherosclerotic plaque on coronary CTA, coronary artery stenosis on coronary angiography, and CVD events and accordingly enhances CVD risk stratification beyond the atherosclerotic CVD (ASCVD) risk pooled cohort equation. Additionally, CAC visualized on CT utilized for lung cancer screening, radiation planning, and cancer staging is predictive of coronary artery disease (CAD). Furthermore, CHIP can also be utilized in risk stratification, as the presence of CHIP carries a 40% increase in CV risk independent of traditional CV risk factors. Finally, cancer and many oncologic therapies confer a lifelong increased risk of CVD. We propose an emerging set of tools to be incorporated into the routine continuum of CVD risk assessment in individuals who have been treated for cancer or who are being screened for cancer development. In this review, we discuss BAC, CAC, CHIP, and cancer and cancer treatment as emerging risk markers in cardiovascular health assessment. Their effectiveness in predicting and influencing the burden of CVD will be discussed, along with suggestions on their incorporation into preventive cardio-oncology practice. Future research will focus on short- and long-term CVD outcomes in these populations.

Ultra-Hypofractionated vs. Moderate Fractionated Whole Breast Three Dimensional Conformal Radiotherapy during the COVID-19 Pandemic

Background and Objectives: Reducing time of treatment during COVID-19 outbreaks has been recommended by the leading Radiation Oncology societies. Still minimizing radiation induced tissue toxicity is one of the most important issues in breast cancer patients. The study aimed to investigate compliance, clinical and dosimetry normal tissue toxicity, and cosmetic results between moderated and ultra-fractionated regimes for breast cancer patients during COVID-19 pandemic. Materials and Methods: This pilot prospective randomized study included 60 patients with early breast cancer after preserving surgery, 27 patients advocated to ultra-hypofractionated whole-breast three dimensional (3D) conformal radiotherapy of 26 Gy in 5 fractions over 1 week and 33 patients with moderate fractionated breast 3D conformal radiotherapy patients between March 2020 and July 2020, during the COVID pandemic outbreak. The compliance to treatment, dosimetric parameters, acute and late skin toxicity, subcutaneous tissue toxicity, cosmetic results and clinical follow up for 18 months for the two regimes were analyzed and compared. Results: When two regimes were compared 5 fraction group had significantly lower prevalence of newly infected cases of SARS-CoV-2 and thus delayed/interrupted treatment (p = 0.05), comparable grade 1 CTCAE v5, acute skin toxicity (p = 0.18), Grade 1 Radiation Morbidity Scoring Scheme (RESS) subcutaneous tissue toxicity (p = 0.18), Grade 1 RESS late skin toxicity (p = 0.88) and cosmetic results (p = 0.46). Dosimetric results reveled that patients in 5 fraction group received significantly lower median ipsilateral lung doses (p < 0.01) in addition to left breast cancer patients that received significantly lower median heart dose (p < 0.01) and median left anterior descending artery (LAD) dose (p < 0.01). Conclusion: Ultra-hypofractionated radiotherapy for breast cancer is comparable to moderate hypofractionation regimen regarding grade 1 acute skin toxicity, grade 1 subcutaneous tissue toxicity, late skin toxicity and cosmetic results. Application of ultra-hypofractionated radiotherapy with significantly lower radiation doses for lung and heart could be crucial in reducing the risk of acute/late pulmonary and heart radiation-induced toxicity.

Potential Role of Neutrophil Extracellular Traps in Cardio-Oncology

Cardiovascular toxicity has emerged as the leading cause of death in patients undergoing cancer treatment. Thus, cardio-oncology (CO) care must also focus on the prevention and management of related cardiovascular (CV) complications caused by cancer therapy. Neutrophil extracellular traps (NETs)—entities with released DNA, proteases, proinflammatory and prooxidative substances from blasted neutrophils—play an important role in cancer proliferation, propagation metastasis, and incident CV events (acute coronary syndrome, thromboembolic events, and heart failure). Although NETs have been shown to be involved in cancer progression and incident CV events, little is known about their relationship with cardio-oncology, especially on cancer treatment-related cardiovascular toxicity (CTRCT). This review aims to explore the evidence of the impact of NETs on cancer, CV events, and CTRCT, and the possible solutions based on the mechanism of NETs activation and NETs released toxic substances.

New Onset Coronary Obstruction in Established Nonischemic Heart Failure: A Late Consequence of Radiation

The column in this issue is provided by Salil Kumar, MD, and Joe Aoun, MD, chief cardiology fellows in the Houston Methodist Cardiology Department, and Arvind Bhimaraj, MD, associate professor of Clinical Cardiology at the Houston Methodist Academic Institute. Dr. Bhimaraj specializes in cardiovascular disease and advanced heart failure and transplantation.

Non-invasive Stereotactic Body Radiation Therapy for Refractory Ventricular Arrhythmias: Venturing into the Unknown

Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.

Differential Biological Effects of Dietary Lipids and Irradiation on the Aorta, Aortic Valve, and the Mitral Valve

Aims

Dietary cholesterol and palmitic acid are risk factors for cardiovascular diseases (CVDs) affecting the arteries and the heart valves. The ionizing radiation that is frequently used as an anticancer treatment promotes CVD. The specific pathophysiology of these distinct disease manifestations is poorly understood. We, therefore, studied the biological effects of these dietary lipids and their cardiac irradiation on the arteries and the heart valves in the rabbit models of CVD.

Methods and Results

Cholesterol-enriched diet led to the thickening of the aortic wall and the aortic valve leaflets, immune cell infiltration in the aorta, mitral and aortic valves, as well as aortic valve calcification. Numerous cells expressing α-smooth muscle actin were detected in both the mitral and aortic valves. Lard-enriched diet induced massive aorta and aortic valve calcification, with no detectable immune cell infiltration. The addition of cardiac irradiation to the cholesterol diet yielded more calcification and more immune cell infiltrates in the atheroma and the aortic valve than cholesterol alone. RNA sequencing (RNAseq) analyses of aorta and heart valves revealed that a cholesterol-enriched diet mainly triggered inflammation-related biological processes in the aorta, aortic and mitral valves, which was further enhanced by cardiac irradiation. Lard-enriched diet rather affected calcification- and muscle-related processes in the aorta and aortic valve, respectively. Neutrophil count and systemic levels of platelet factor 4 and ent-8-iso-15(S)-PGF2α were identified as early biomarkers of cholesterol-induced tissue alterations, while cardiac irradiation resulted in elevated levels of circulating nucleosomes.

Conclusion

Dietary cholesterol, palmitic acid, and cardiac irradiation combined with a cholesterol-rich diet led to the development of distinct vascular and valvular lesions and changes in the circulating biomarkers. Hence, our study highlights unprecedented specificities related to common risk factors that underlie CVD.

Bradyarrhythmias in Cardio-Oncology

The relationship between bradyarrhythmias and cancer therapies has not been well described but is increasingly recognized. There have been extensive advances in oncological pharmacotherapy, with several new classes of drugs available including targeted agents, immune checkpoint inhibitors and CAR T cell therapy. This increasing repertoire of available drugs has revolutionized overall prognosis and survival of cancer patients but the true extent of their cardiovascular toxicity is only beginning to be understood. Previous studies and published reviews have traditionally focused on conventional chemotherapies and in arrhythmias in general, particularly tachyarrhythmias. The number of patients with both cancer and cardiovascular problems is increasing globally and oncologists and cardiologists need to be adept at managing arrythmia based scenarios. Greater collaboration between the two specialties including studies with prospective data collection in Cardio-Oncology are much needed to fill in knowledge gaps in this arena. This case-based review summarizes current available evidence of cancer treatment-related bradyarrhythmia incidence (including its different subtypes), possible mechanisms and outcomes. Furthermore, we propose a stepwise surveillance and management protocol for patients with suspected bradyarrhythmia related to cancer treatment.

Cardiologic Long-Term Follow-Up of Patients Treated With Chest Radiotherapy: When and How?

Introduction: Radiotherapy may cause valvular (VHD), pericardial, coronary artery disease (CAD), left ventricular dysfunction (LVD), arrhythmias. The risk of radiation induced heart disease (RIHD) increases over time. The current guidelines suggest a screening for RIHD every 5 years in the long-term survivors who had been treated by chest RT.

Methods: We reviewed the clinical and instrumental data of 106 patients diagnosed with RIHD. In one group (Group A: 69 patients) RIHD was diagnosed in an asymptomatic phase through a screening with ECG, echocardiogram and stress test. A second group (37 patients) was seen when RIHD was symptomatic. We compared the characteristics of the two groups at the time of RT, of RIHD detection and at last follow-up.

Results: Overall, 64 patients (60%) had CAD (associated to other RIHD in 18); 39 (36.7%) had LVD (isolated in 20); 24 (22.6%) had VHD (isolated in 10 cases). The interval between the last negative test and the diagnosis of moderate or severe RIHD was <5 years in 26 patients, and <4 years in 18. In group A, 63% of the patients with CAD had silent ischemia. The two groups did not differ with regard to type of tumor, cardiovascular risk factors, use of anthracycline-based chemotherapy, age at RT treatment, radiation dose and interval between RT and toxicity detection. The mean time from RT and RIHD was 16 years in group A and 15 in group B. Interventional therapy at RIHD diagnosis was more frequent in group B (54 vs. 30%, p < 0.05). At last follow-up, 27 patients had died (12 of cancer, 9 of cardiac causes, 6 of other causes); mean ejection fraction was 60% in group A and 50% in group B (p < 0.01). Patients with ejection fraction ≤ 50% were 14.5% in group A and 40% in group B (p < 0.01).

Conclusions: Clinically relevant RIHD become evident at a mean interval of 16 years after RT. The most frequent clinical manifestations are CAD and LVD. RIHD diagnosis in asymptomatic patients may preserve their cardiac function with timely interventions. We suggest -after 10 years from radiotherapy- a screening every 2–3 years.

The Importance of Primary Care in Cardio-Oncology

OPINION STATEMENT

There is significant interplay between cancer and cardiovascular disease involving shared risk factors, cross disease communication where cardiovascular events can influence cancer recurrence, and mortality rates and cardiotoxicity from cancer treatments with resultant increased cardiovascular mortality and morbidity in cancer patients. This is a major cause of death in many long-term cancer survivors. As a result, cardio-oncology, which involves the prevention, early detection, and optimal treatment of cardiovascular disease in patients treated for cancer, is expanding globally. However, there is still limited awareness of its importance and limited application of the lessons already learnt. Primary care physicians, and their clinical teams, especially nursing colleagues, have a foundation role in the management of all patients, and this paper outlines areas where they can lead in the cardio-oncology management of cancer patients. Although there is currently a lack of an adequate clinical framework or shared care plan, primary care physicians have a role to play in the various phases of cancer treatment: pre-therapy, during therapy, and survivorship.