Interventional Cardio-Oncology: Adding a New Dimension to the Cardio-Oncology Field

Outcomes of patients with active cancer after transcatheter aortic valve replacement: an updated meta-analysis

BACKGROUND

Patients with active cancer and aortic stenosis may be under-referred for valve interventions due to concerns over a prohibitive risk. However, whether active cancer impacts outcomes after transcatheter aortic valve replacement (TAVR) remains unknown.

METHODS

We searched PubMed, Embase, and Cochrane Library in December 2023 for studies comparing the post-TAVR outcomes of patients with versus without active cancer. We pooled odds ratios (OR) and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) applying a random-effects model. Statistical analyses were performed in R version 4.3.2.

RESULTS

We included nine observational studies analyzing 133,906 patients, of whom 9,792 (7.3%) had active cancer. Compared with patients without cancer, patients with active cancer had higher short- (OR 1.33; 95% CI 1.15-1.55; p < 0.001) and long-term mortality (OR 2.29; 95% CI 1.80-2.91; p < 0.001) rates, not driven by cardiovascular mortality (OR 1.30; 95% CI 0.70-2.40; p = 0.40), and higher major bleeding rates (OR 1.66; 95% CI 1.15-2.42; p = 0.008). The higher mortality rate was sustained in an adjusted analysis (aHR 1.77; 95% CI 1.34-2.35; p < 0.001). There was no significant difference in cardiac, renal, and cerebral complications at a follow-up ranging from 180 days to 10 years.

CONCLUSION

Patients with active cancer undergoing TAVR had higher non-cardiovascular mortality and bleeding rates, with comparable incidences of other complications. This highlights the need for a shared decision and appropriate patient selection considering cancer type, staging, bleeding risk, and optimal timing for intervention.

Mechanisms of Myocardial Ischemia in Cancer Patients: A State-of-the-Art Review of Obstructive Versus Non-Obstructive Causes

In patients with cancer, myocardial infarction (MI) has distinct features and mechanisms compared to the non-oncology population. Triggers of myocardial ischemia specific to the oncology population have been increasingly identified. Coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary oxygen supply-demand mismatch are all causes of MI that have been shown to have specific triggers related to either the treatments or complications of cancer. MI can occur in the presence or absence of atherosclerotic coronary artery disease (CAD). MI with nonobstructive CAD (MINOCA) is a heterogeneous syndrome that has distinct pathophysiology and different epidemiology from MI with significant CAD (MI-CAD). Recognition and differentiation of MI-CAD and MINOCA is essential in the oncology population, due to unique etiology and impact on diagnosis, management, and overall outcomes. There are currently no reports in the literature concerning MINOCA as a unified syndrome in oncology patients. The purpose of this review is to analyze the literature for studies related to known triggers of myocardial ischemia in cancer patients, with a focus on MINOCA. We propose that certain cancer treatments can induce MINOCA-like states, and further research is warranted to investigate mechanisms that may be unique to certain cancer states and types of treatment.

Study on the Correlation Factors of Tumour Prognosis after Intravascular Interventional Therapy

Noninvasive or minimally invasive interventional surgery was selected, and the complications were less and had no significant impact on the quality of life of patients. Tumour patients are often accompanied by cerebrovascular diseases, metabolic diseases, and other basic diseases, which more or less adversely affect the surgical efficacy of tumour. In this paper, endovascular remobilization was used to treat tumour; the basic condition of patients before operation and the interventional operation plan were introduced. Through the analysis of clinical data and prognosis evaluation results of tumour patients receiving intravascular interventional therapy, the patients were divided into good prognosis group and poor prognosis group according to the modified Rankin scale score at discharge. The relationship between gender, age, history of hypertension, tumour width, tumour size, preoperative Hunt-Hess grade, interventional surgery method, and prognosis related to intravascular interventional therapy was explored. The results showed that intravascular interventional therapy for tumour patients can obtain a good prognosis, which provides a reference for the future preoperative assessment of treatment risk and possible prognosis and provides a theoretical basis for the formulation of treatment plan to improve prognosis.

Interventional Strategies in Cancer-induced Cardiovascular Disease

PURPOSE OF REVIEW

To highlight the range of illnesses and procedures that the interventional onco-cardiologists face in their daily practice, along with the recent additions to anti-cancer therapies and their related cardiotoxicity.

RECENT FINDINGS

Immune checkpoint inhibitors (ICI) are not devoid of cardiotoxicity as thought earlier and lead to an increased incidence of myocarditis. Transcatheter valve replacement has been shown to be a safer alternative to surgical replacement in cancer patients. Interventional onco-cardiology is a novel field that addresses cardiovascular diseases in the setting of cancer. Traditionally excluding cancer patients from clinical trials has led to a dearth of information needed to tackle cardiac conditions like Takotsubo cardiomyopathy, malignant pericardial effusions, and radiation-induced vascular diseases encountered either exclusively or predominantly in this high-risk population. This review discusses the various treatment options available in the interventional armamentarium with a particular focus on ICI-myocarditis and transcatheter aortic valve replacement in cancer patients.

Machine Learning-Augmented Propensity Score Analysis of Percutaneous Coronary Intervention in Over 30 Million Cancer and Non-cancer Patients

Background: It is unknown to what extent the clinical benefits of PCI outweigh the risks and costs in patients with vs. without cancer and within each cancer type. We performed the first known nationally representative propensity score analysis of PCI mortality and cost among all eligible adult inpatients by cancer and its types.

Methods: This multicenter case-control study used machine learning–augmented propensity score–adjusted multivariable regression to assess the above outcomes and disparities using the 2016 nationally representative National Inpatient Sample.

Results: Of the 30,195,722 hospitalized patients, 15.43% had a malignancy, 3.84% underwent an inpatient PCI (of whom 11.07% had cancer and 0.07% had metastases), and 2.19% died inpatient. In fully adjusted analyses, PCI vs. medical management significantly reduced mortality for patients overall (among all adult inpatients regardless of cancer status) and specifically for cancer patients (OR 0.82, 95% CI 0.75–0.89; p < 0.001), mainly driven by active vs. prior malignancy, head and neck and hematological malignancies. PCI also significantly reduced cancer patients' total hospitalization costs (beta USD$ −8,668.94, 95% CI −9,553.59 to −7,784.28; p < 0.001) independent of length of stay. There were no significant income or disparities among PCI subjects.

Conclusions: Our study suggests among all eligible adult inpatients, PCI does not increase mortality or cost for cancer patients, while there may be particular benefit by cancer type. The presence or history of cancer should not preclude these patients from indicated cardiovascular care.

Cardiac Interventional Procedures in Cardio-Oncology Patients

Comorbidities specific to the cardio-oncology population contribute to the challenges in the interventional management of patients with cancer and cardiovascular disease (CVD). Patients with cancer have generally been excluded from cardiovascular randomized clinical trials. Endovascular procedures may represent a valid option in patients with cancer with a range of CVDs because of their minimally invasive nature. Patients with cancer are less likely to be treated according to societal guidelines because of perceived high risk. This article presents the specific challenges that interventional cardiologists face when caring for patients with cancer and the modern tools to optimize care.

Differential predictive factors for cardiovascular events in patients with or without cancer history

Although attention has been paid to the relationship between malignant diseases and cardiovascular diseases, few data have been reported. Moreover, there have also been few reports in which the preventive factors were examined in patients with or without malignant disease histories requiring percutaneous coronary intervention (PCI).This was a retrospective, single-center, observational study. A total of 1003 post-PCI patients were divided into a malignant group, with current or past malignant disease, and a nonmalignant group. The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, revascularization, and admission due to heart failure within 5 years of PCI. Kaplan-Meier analysis showed a significantly higher probability of the primary endpoint in the malignant group (P = .002). Multivariable Cox hazard analyses showed that in patients without a history of malignant, body mass index (BMI) and the presence of dyslipidemia were independent and significant negative predictors of the primary endpoint (BMI: hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.53-0.99, P = .041; prevalence of dyslipidemia: HR 0.72, 95% CI 0.52-0.99, P = .048), and the presence of multi-vessel disease (MVD) and the prevalence of peripheral artery disease (PAD) were independent and significant positive predictors of the primary endpoint (prevalence of MVD: HR 1.68, 95% CI 1.18-2.40, P = .004; prevalence of PAD: HR 1.51, 95% CI 1.03-2.21, P = .034). In patients with histories of malignancy, no significant independent predictive factors were identified.Patients undergoing PCI with malignancy had significantly higher rates of adverse cardiovascular events but might not have the conventional prognostic factors.

The Impending Epidemic of Cardiovascular Diseases in Patients With Cancer in Japan

Onco-cardiology, a new academic field, aims to improve the quality of life and prognosis of cancer patients and survivors with cardiovascular diseases (CVD). With the aging of the population, an epidemic of cancer with CVD is emerging in developed countries. Cancer and CVD share risk factors, pathophysiology, treatments, and preventive and rehabilitative measures. A multidisciplinary team-based approach is needed to support cancer treatment to maximize its effectiveness and minimize its cardiotoxic potential. Basic and clinical onco-cardiology are already being practiced harmoniously. However, systematization in academia and clinical practice and accumulation of evidence have just started. In this review, we present the epidemiology, common risk factors between cancer and CVD, future epidemic of CVD in patients with cancer, and the necessity for an onco-cardiological approach to managing the burden of CVD in cancer patients and survivors.

Conjugated Linoleic Acid Isomers Affect Profile of Lipid Compounds and Intensity of Their Oxidation in Heart of Rats with Chemically-Induced Mammary Tumors-Preliminary Study

Breast cancer and cardiovascular diseases (CVD) have shared risk factors and mechanisms of pathogenicity, as proven by increased cardiac risk in breast cancer patients receiving anticancerogenic therapies and in cancer survivors. A growing mammary tumor may cause heart injury in cancer patients who have not yet been treated. This study aimed to evaluate the effect of conjugated linoleic acid (CLA) supplementation of female rats with 7,12-dimethylbenz(a)anthracene (DMBA)-induced cancerogenesis on fatty acids (FAs), conjugated FAs (CFAs), malondialdehyde (MDA), cholesterol and oxysterols content in cardiac tissue. FAs, cholesterol and oxysterols contents were determined by gas chromatography coupled with mass spectrometry, while the contents of CFAs and MDA were determined by high performance liquid chromatography with photodiode detection. Our results indicate that both CLA supplementation and the presence of tumors influence the lipid biomarkers of CVD. A significant interaction of both experimental factors was observed in the content of polyunsaturated FAs (PUFAs), n-6 PUFAs and CFAs. CLA supplementation significantly inhibited PUFA oxidation, as evidenced by the lower content of MDA in rats' hearts, while the cancerous process intensified the oxidation of cholesterol, as confirmed by the elevated levels of 7-ketocholesterol in DMBA-treated rats. These results may significantly expand knowledge about CLA properties in terms of the prevention of co-existing non-communicable diseases.

Percutaneous coronary intervention and in-hospital outcomes in patients with leukemia: a nationwide analysis

OBJECTIVES

To examine the association between current leukemia diagnosis and in-hospital clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) in the United States.

BACKGROUND

Leukemia is the most common hematological malignancy and is associated with an increased risk of thrombotic and bleeding complications in patients undergoing PCI. There are limited data around clinical outcomes of leukemia patients undergoing PCI.

METHODS

We used the National Inpatient Sample to investigate the outcomes of leukemia patients undergoing PCI between 2004 and 2014. Patients were then subdivided into diagnoses of acute myeloid leukemia (AML) or chronic myeloid leukemia and acute lymphoid leukemia or chronic lymphoid leukemia (CLL). Multiple logistic regressions were used to study the association of a leukemia diagnosis with in-hospital outcomes: mortality, bleeding, vascular and cardiac complications, and stroke.

RESULTS

There were 6,561,445 records of patients who underwent PCI during the study time, of which 15,789 patients had a diagnosis of leukemia. The most common leukemia subtype was CLL accounting for 75% of the cohort (n = 10,800). After multivariable adjustment, a leukemia diagnosis was associated with significantly increased odds of in-hospital mortality (odds ratio [OR]: 1.41; 95% confidence interval [CI]: [1.11-1.79]) and bleeding (OR: 1.87; 95% CI: [1.56-2.09]), whereas patients with AML had a fivefold increase of in-hospital mortality (OR: 5.38; 95% CI: [2.94-9.76]).

CONCLUSIONS

Patients with current diagnosis of leukemia are at increased risk of procedure-related complications following PCI. A multidisciplinary approach is needed among interventional cardiologists, oncologists, and hematologists to minimize procedural complications and improve outcomes in this high-risk cohort.

Cardiovascular safety of oncologic agents: a double-edged sword even in the era of targeted therapies - Part 2

INTRODUCTION

Patients with cancer are subject to the cardiotoxic effects of cancer therapy. Improved cancer treatments lead to more cancer-survivors, who though are exposed to various forms of cardiovascular (CV) disease (CVD) as they age. Aging patients are at increased risk of developing both malignancy and CVD or they may have survived some form of CVD as a result of effective CV treatments. Furthermore, patients with CVD may develop cancer and require treatment (and vice versa), all contributing to increased morbidity and mortality. The prevalence of both malignancy and CVD will increase due to the trend toward a longer lifespan.

AREAS COVERED

In part 2 of this review, the discussion of the CV effects of specific oncology drugs is completed with inclusion of additional immunological agents, current hormonal and other agents. Early detection and monitoring of cardiotoxicity, use of biomarkers and other imaging and diagnostic methods and prevention and treatment options are also discussed.

EXPERT OPINION

As outlined in part 1 of this review, oncologists need to be aware of the CV adverse-effects of their treatments and make careful and expectant clinical decisions, especially in patients with preexisting CVD or CV risk factors. Similarly, cardiologists should consider a detailed previous history of treatment for malignant disease, including prior chemotherapy exposure, dose(s) received, and/or combined modality therapy with chest radiotherapy. Both specialists should collaborate in order to minimize the impact of these two ubiquitous diseases (cancer and CVD) and mitigate the adverse effects of treatment modalities.