Coronary Artery Bypass Grafting in Cancer Patients: Prevalence and Outcomes in the United States

Patients with metastatic cancer have worse short-term coronary artery bypass grafting outcomes: A population-based study of National Inpatient Sample from 2015 to 2020

BACKGROUND

Metastasis is a hallmark for cancer progression. While patients with metastatic cancer (MC) have higher risk profiles, outcomes of coronary artery bypass grafting (CABG) in these patients have not been established, likely due to their smaller representation in the CABG patient population. This study aimed to examine the short-term outcomes of patients with MC who underwent CABG.

METHODS

Patients who underwent CABG were identified in National Inpatient Sample from Q4 2015-2020. Exclusion criteria included age <18 years, concomitant procedures, and non-metastatic malignancies. A 1:3 propensity-score matching was used to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status between MC and non-MCC patients. In-hospital post-CABG outcomes were evaluated.

RESULTS

There were 379 (0.23 %) patients with MC who underwent CABG. All MC patients were matched to 1161 out of 164,351 non-MC patients who underwent CABG during the same period. Patients with MC had higher risks of mortality (4.76 % vs 2.58 %, p = 0.04), pacemaker implantation (2.91 % vs 1.12 %, p = 0.03), venous thromboembolism (1.85 % vs 0.43 %, p = 0.01), and hemorrhage/hematoma (61.11 % vs 55.04 %, p = 0.04). In addition, MC patients had a longer time from admission to operation (3.35 ± 4.19 vs 2.82 ± 3.54 days, p = 0.03) and longer hospital length of stay (11.86 ± 8.17 vs 10.65 ± 8.08 days, p = 0.01).

CONCLUSION

Patients with MC had higher short-term mortality and morbidities after CABG. These findings can help provide insights for clinicians in the management of patients with concurrent coronary artery disease and MC, particularly in terms of preoperative risk stratification and therapeutic decision-making.

Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

Transcatheter Aortic Valve Replacement in Patients With or Without Active Cancer

Background Data on clinical outcomes after transcatheter aortic valve replacement (TAVR) in specific cancer types or the presence of metastatic disease remain sparse. This study aimed to investigate the impact of active cancer on short-term mortality, complications, and readmission rates after TAVR across different cancer types. Methods and Results The authors assessed the Nationwide Readmissions Database for TAVR cases from 2012 to 2019. Patients were stratified by specific cancer types. Primary outcome was in-hospital mortality. Secondary outcomes included bleeding requiring blood transfusion and readmissions at 30, 90, and 180 days after TAVR. Overall, 122 573 patients undergoing TAVR were included in the analysis, of whom 8013 (6.5%) had active cancer. After adjusting for potential confounders, the presence of active cancer was not associated with increased in-hospital mortality (adjusted odds ratio [aOR], 1.06 [95% CI, 0.89-1.27]; P=0.523). However, active cancer was associated with an increased risk of readmission at 30, 90, and 180 days after TAVR and increased risk of bleeding requiring transfusion at 30 days. Active colon and any type of metastatic cancer were individually associated with readmissions at 30, 90, and 180 days after TAVR. At 30 days after TAVR, colon (aOR, 2.51 [95% CI, 1.68-3.76]; P<0.001), prostate (aOR, 1.40 [95% CI, 1.05-1.86]; P=0.021), and any type of metastatic cancer (aOR, 1.65 [95% CI, 1.23-2.22]; P=0.001) were individually associated with an increased risk of bleeding requiring transfusion. Conclusions Patients with active cancer had similar in-hospital mortality after TAVR but higher risk of readmission and bleeding requiring transfusion, the latter depending on certain types of cancer.

Dual Antiplatelet Therapy and Cancer; Balancing between Ischemic and Bleeding Risk: A Narrative Review

Cardiovascular (CV) events in patients with cancer can be caused by concomitant CV risk factors, cancer itself, and anticancer therapy. Since malignancy can dysregulate the hemostatic system, predisposing cancer patients to both thrombosis and hemorrhage, the administration of dual antiplatelet therapy (DAPT) to patients with cancer who suffer from acute coronary syndrome (ACS) or undergo percutaneous coronary intervention (PCI) is a clinical challenge to cardiologists. Apart from PCI and ACS, other structural interventions, such as TAVR, PFO-ASD closure, and LAA occlusion, and non-cardiac diseases, such as PAD and CVAs, may require DAPT. The aim of the present review is to review the current literature on the optimal antiplatelet therapy and duration of DAPT for oncologic patients, in order to reduce both the ischemic and bleeding risk in this high-risk population.

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.

Coronary artery disease, left ventricular function and cardiac biomarkers determine all-cause mortality in cancer patients-a large monocenter cohort study

Cancer patients are at risk of suffering from cardiovascular diseases (CVD). Nevertheless, the impact of cardiovascular comorbidity on all-cause mortality (ACM) in large clinical cohorts is not well investigated. In this retrospective cohort study, we collected data from 40,329 patients who were subjected to cardiac catherization from 01/2006 to 12/2017 at University Hospital Heidelberg. The study population included 3666 patients with a diagnosis of cancer prior to catherization and 3666 propensity-score matched non-cancer patients according to age, gender, diabetes and hypertension. 5-year ACM in cancer patients was higher with a reduced left ventricular function (LVEF < 50%; 68.0% vs 50.9%) or cardiac biomarker elevation (high-sensitivity cardiac troponin T (hs-cTnT; 64.6% vs 44.6%) and N-terminal brain natriuretic peptide (NT-proBNP; 62.9% vs 41.4%) compared to cancer patients without cardiac risk. Compared to non-cancer patients, NT-proBNP was found to be significantly higher (median NT-proBNP cancer: 881 ng/L, IQR [254; 3983 ng/L] vs non-cancer: 668 ng/L, IQR [179; 2704 ng/L]; p < 0.001, Wilcoxon-rank sum test) and turned out to predict ACM more accurately than hs-cTnT (NT-proBNP: AUC: 0.74; hs-cTnT: AUC: 0.63; p < 0.001, DeLong's test) in cancer patients. Risk factors for atherosclerosis, such as diabetes and age (> 65 years) were significant predictors for increased ACM in cancer patients in a multivariate analysis (OR diabetes: 1.96 (1.39-2.75); p < 0.001; OR age > 65 years: 2.95 (1.68-5.4); p < 0.001, logistic regression). Our data support the notion, that overall outcome in cancer patients who underwent cardiac catherization depends on cardiovascular comorbidities. Therefore, particularly cancer patients may benefit from standardized cardiac care.

Overview of Cardiothoracic Surgeon Compensation: Practice Setting, Productivity, and Payment Structures

The Centers for Medicare and Medicaid Services recently proposed a substantial cut to reimbursement for surgical services, punctuating a steady decline in reimbursement for clinical services provided by cardiothoracic surgeons during the last several decades. Meanwhile, the costs of practicing cardiothoracic surgery continue to increase. In an effort to defect against diminishing control over patient care and further negative changes affecting reimbursement, cardiothoracic surgeons must be able to convincingly demonstrate their value to patients and the health care system. However, the overall contribution of a cardiothoracic surgeon can be difficult to measure objectively and varies widely according to a host of factors, including practice setting, experience, subspecialization, and the local market. To address these challenges, The Society of Thoracic Surgeons Workforce on Practice Management has commissioned a Writing Task Force to raise awareness, to concentrate knowledge, and to organize information related to compensation as a comprehensive resource for cardiothoracic surgeons. The purpose of this initial report is to provide an overview of the major factors having an impact on compensation for cardiothoracic surgeons.

Impact of cancer diagnosis on causes and outcomes of 5.9 million US patients with cardiovascular admissions

INTRODUCTION

There are limited data on causes of cardiovascular (CV) admissions and associated outcomes among patients with different cancers.

METHODS

All CV admissions from the US National Inpatient Sample between October 2015 to December 2017 were stratified by cancer type as well as metastatic status. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital mortality in different groups.

RESULTS

From 5,936,014 eligible CV admissions, cancer was present in 265,221 (4.5%) hospitalizations. There was significant variation in the admission diagnoses among the different cancers, with hematological malignancies being principally associated with heart failure (HF), lung cancer with atrial fibrillation (AF), and colorectal and prostate cancer with acute myocardial infarction (AMI). Admission with haemorrhagic stroke has the highest associated mortality across cancers (20.0-38.4%). In-hospital mortality was higher in cancer than non-cancer patients across most CV admissions (P < 0.001) with AF having the worst prognosis. Compared to group without any cancer, the greatest aOR of mortality was associated with lung cancer in AMI (aOR 2.32, 95% CI 2.18-2.47), ischemic stroke (aOR 2.21, 95%CI 2.08-2.34), AF (aOR 4.69, 95%CI 4.32-5.10) and HF (aOR 2.07, 95%CI 1.89-2.27).

CONCLUSIONS

The most common causes of CV admission to hospital vary in patients with different types of cancer, with AMI being most common in patients with colon cancer, HF in patients with hematological malignancies and AF in patients with lung cancer. Patients with cancer, particularly lung cancer, have greater mortality than non-cancer patients after admissions with a CV cause.

Coronary revascularisation outcomes in patients with cancer

Cancer and coronary artery disease (CAD) overlap in traditional risk factors as well as molecular mechanisms underpinning the development of these two disease states. Patients with cancer are at increased risk of developing CAD, representing a high-risk population that are increasingly undergoing coronary revascularisation. Over 1 in 10 patients with CAD that require revascularisation with either percutaneous coronary intervention or coronary artery bypass grafting have either a history of cancer or active cancer. These patients are typically older, have more comorbidities and have more extensive CAD compared with patients without cancer. Haematological abnormalities with competing risks of thrombosis and bleeding pose further unique challenges during and after revascularisation. Management of patients with concurrent cancer and CAD requiring revascularisation is challenging as these patients carry a higher risk of morbidity and mortality compared with those without cancer, often driven by the underlying cancer and associated comorbidities. However, due to variability by different types and stages of cancer, revascularisation outcomes are specific to cancer characteristics such as the timing of onset, cancer subtype and site, stage, presence of metastases, and cancer-related therapies received. Recent studies have provided insights into defining revascularisation outcomes, procedural considerations and best practices in managing patients with cancer. Nevertheless, many gaps remain that require further studies to inform clinical best practices in this population.

Challenges and Management of Acute Coronary Syndrome in Cancer Patients

Cancer and cardiovascular disease are the leading causes of mortality in the world. The prevalence of cardiovascular risk factors and coronary artery disease in cancer patients is elevated, and it is associated with high mortality. Several mechanisms, such as the proinflammatory and procoagulant states present in cancer patients, may contribute to these scenarios. Oncological therapy can predispose patients to acute thrombosis, accelerated atherosclerosis and coronary spasm. Treatment decisions must be individualized and based on the cancer history and balancing bleeding and thrombosis risks.

Coronary artery disease in patients with cancer: challenges and opportunities for improvement

PURPOSE OF REVIEW

Coronary artery disease (CAD) is a common comorbidity in patients with cancer. We review shared risk factors between the two diseases and cancer treatments that increase the risk of CAD. We also discuss outcomes and management considerations of patients with cancer who develop CAD.

RECENT FINDINGS

Several traditional and novel risk factors promote the development of both CAD and cancer. Several cancer treatments further increase the risk of CAD. The presence of cancer is associated with a higher burden of comorbidities and thrombocytopenia, which predisposes patients to higher bleeding risks. Patients with cancer who develop acute coronary syndromes are less likely to receive timely revascularization or appropriate medical therapy, despite evidence showing that receipt of these interventions is associated with substantial benefit. Accordingly, a cancer diagnosis is associated with worse outcomes in patients with CAD. The risk-benefit balance of revascularization is becoming more favorable due to the improving prognosis of many cancers and safer revascularization strategies, including shorter requirements for dual antiplatelet therapy after revascularization.

SUMMARY

Several factors increase the complexity of managing CAD in patients with cancer. A multidisciplinary approach is recommended to guide treatment decisions in this high-risk and growing patient group.