Diet quality and cardiovascular disease risk among breast cancer survivors in the Pathways Study

BACKGROUND

Women with breast cancer are at higher risk of cardiovascular disease (CVD) compared with women without breast cancer. Whether higher diet quality at breast cancer diagnosis lowers this risk remains unknown. We set out to determine if higher diet quality at breast cancer diagnosis was related to lower risk of CVD and CVD-related death.

METHODS

This analysis included 3415 participants from the Pathway Study, a prospective cohort of women diagnosed with invasive breast cancer at Kaiser Permanente Northern California between 2005 and 2013 and followed through December 31, 2021. Scores from 5 diet quality indices consistent with healthy eating were obtained at the time of breast cancer diagnosis. Scores were categorized into ascending quartiles of concordance for each diet quality index, and multivariable adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated. P values were 2-sided.

RESULTS

The Dietary Approaches to Stop Hypertension diet quality index was associated with lower risk of heart failure (HR = 0.53, 95% CI = 0.33 to 0.87; Ptrend = .03), arrhythmia (HR = 0.77, 95% CI = 0.62 to 0.94; Ptrend = .008), cardiac arrest (HR = 0.77, 95% CI = 0.61 to 0.96; Ptrend = .02), valvular heart disease (HR = 0.79, 95% CI = 0.64 to 0.98; Ptrend = .046), venous thromboembolic disease (HR = 0.75, 95% CI = 0.60 to 0.93; Ptrend = .01), and CVD-related death (HR = 0.70, 95% CI = 0.50 to 0.99; Ptrend = .04), when comparing the highest with lowest quartiles. Inverse associations were also found between the healthy plant-based dietary index and heart failure (HR = 0.60, 95% CI = 0.39 to 0.94; Ptrend = .02), as well as the alternate Mediterranean dietary index and arrhythmia (HR = 0.74, 95% CI = 0.60 to 0.93; Ptrend = .02).

CONCLUSION

Among newly diagnosed breast cancer patients, higher diet quality at diagnosis was associated with lower risk of CVD events and death.

Development of cardiometabolic risk factors following endocrine therapy in women with breast cancer

PURPOSE

Studies comparing the effect of aromatase inhibitor (AI) and tamoxifen use on cardiovascular disease (CVD) risk factors in hormone receptor-positive breast cancer (BC) survivors report conflicting results. We examined associations of endocrine therapy use with incident diabetes, dyslipidemia, and hypertension.

METHODS

The Pathways Heart Study examines cancer treatment exposures with CVD-related outcomes in Kaiser Permanente Northern California members with BC. Electronic health records provided sociodemographic and health characteristics, BC treatment, and CVD risk factor data. Hazard ratios (HR) and 95% confidence intervals (CI) of incident diabetes, dyslipidemia, and hypertension in hormone receptor-positive BC survivors using AIs or tamoxifen compared with survivors not using endocrine therapy were estimated using Cox proportional hazards regression models adjusted for known confounders.

RESULTS

In 8985 BC survivors, mean baseline age and follow-up time was 63.3 and 7.8 years, respectively; 83.6% were postmenopausal. By treatment, 77.0% used AIs, 19.6% used tamoxifen, and 16.0% used neither. Postmenopausal women who used tamoxifen had an increased rate (HR 1.43, 95% CI 1.06-1.92) of developing hypertension relative to those who did not use endocrine therapy. Tamoxifen use was not associated with incident diabetes, dyslipidemia, or hypertension in premenopausal BC survivors. Postmenopausal AI users had higher hazard rates of developing diabetes (HR 1.37, 95% CI 1.05-1.80), dyslipidemia (HR 1.58, 95% CI 1.29-1.92), and hypertension (HR 1.50, 95% CI 1.24-1.82) compared with non-endocrine therapy users.

CONCLUSION

Hormone receptor-positive BC survivors treated with AIs may have higher rates of developing diabetes, dyslipidemia, and hypertension over an average 7.8 years post-diagnosis.

Development of cardiometabolic risk factors following endocrine therapy in women with breast cancer

PURPOSE

Studies comparing the effect of aromatase inhibitor (AI) and tamoxifen use on cardiovascular disease (CVD) risk factors in hormone-receptor positive breast cancer (BC) survivors report conflicting results. We examined associations of endocrine therapy use with incident diabetes, dyslipidemia, and hypertension.

METHODS

The Pathways Heart Study examines cancer treatment exposures with CVD-related outcomes in Kaiser Permanente Northern California members with BC. Electronic health records provided sociodemographic and health characteristics, BC treatment, and CVD risk factor data. Hazard ratios (HR) and 95% confidence intervals (CI) of incident diabetes, dyslipidemia, and hypertension in hormone-receptor positive BC survivors using AIs or tamoxifen compared with survivors not using endocrine therapy were estimated using Cox proportional hazards regression models adjusted for known confounders.

RESULTS

In 8,985 BC survivors, mean baseline age and follow-up time was 63.3 and 7.8 years, respectively; 83.6% were postmenopausal. By treatment, 77.0% used AIs, 19.6% used tamoxifen, and 16.0% used neither. Postmenopausal women who used tamoxifen had an increased rate (HR: 1.43, 95% CI: 1.06-1.92) of developing hypertension relative to those who did not use endocrine therapy. Tamoxifen use was not associated with incident diabetes, dyslipidemia, or hypertension in premenopausal BC survivors. Postmenopausal AI users had higher hazard rates of developing diabetes (HR: 1.37, 95% CI: 1.05-1.80), dyslipidemia (HR: 1.58, 95% CI: 1.29-1.92) and hypertension (HR: 1.50, 95% CI: 1.24-1.82) compared with non-endocrine therapy users.

CONCLUSION

Hormone-receptor positive BC survivors treated with AIs may have higher rates of developing diabetes, dyslipidemia, and hypertension over an average 7.8 years post-diagnosis.

Abstract 5303: Cardiovascular disease risk associated with breast cancer chemotherapy drugs: The Pathways Heart Study

Purpose: Chemotherapy drugs to treat breast cancer (BC) are cardiotoxic, but few studies have examined the effects of specific chemotherapy combinations on cardiovascular disease (CVD). We examined the additive effects of combinations of BC chemotherapy drugs associated with incident CVD events among women with a history of BC compared to those without.

Methods: The Pathways Heart Study is a cohort study within Kaiser Permanente Northern California (KPNC) examining incident CVD events and risk factors in women with BC. Eligibility criteria included invasive BC diagnosis from 11/2005 to 3/2013, age≥21 years, and KPNC membership≥12 months at BC diagnosis. Controls without BC were matched 5:1 on birth year and race/ethnicity. KPNC electronic health records were used to collect demographic, clinical, and treatment characteristics. Chemotherapy drugs identified from clinical data included anthracyclines, cyclophosphamides, taxanes, and trastuzumab. Mutually exclusive groups were created according to the types of chemotherapy drugs received. Outcomes identified from ICD9/10 diagnosis codes included incident ischemic heart disease, heart failure (HF)/cardiomyopathy and stroke. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) of the CVD outcome by chemotherapy drug combinations received relative to matched controls.

Results: A total of 6,761 women with BC who received chemotherapy were identified and were matched to 33,801 controls. On average, women were 55.2 years old (standard deviation (SD)=10.9) and were followed for 7.1 years (SD=3.6). Four groups of women with distinct chemotherapy combinations were identified: anthracyclines + cyclophosphamide (AC, 10.5%), AC + taxanes (39.0%), AC + taxanes + trastuzumab (8.8%), and cyclophosphamide + taxanes (20.7%). Women who received AC had a 2.00 (95% CI: 1.27-3.14) increased risk of incident HF/cardiomyopathy relative to matched controls without BC. When taxanes were added to this combination, risk was similar (HR=1.88; 95% CI: 1.44-2.47). However, when trastuzumab was further added, risk of HF/cardiomyopathy increased more than 1.5-fold (HR=3.18; 95% CI: 1.91-5.30). The combined receipt of cyclophosphamide and taxanes was associated with a 1.42 (95% CI: 1.05-1.92) increased risk of developing stroke, but including anthracyclines with this combination inversed the association for stroke (HR: 0.73, 95% CI: 0.54- 0.99). No combinations examined were associated with incidence of ischemic heart disease.

Conclusion: Findings suggest specific chemotherapy drug combinations may differentially affect the risk of incident HF/cardiomyopathy and stroke in BC survivors. Future work will examine dosage and duration of chemotherapy exposure, comparisons of the groups’ characteristics to account for possible confounding by indication, and competing risk analysis.

Citation Format: Hanjie Shen, Eileen Rillamas-Sun, Carlos Iribarren, Richard Cheng, Jamal S. Rana, Mai Nguyen-Huynh, Cecile A. Laurent, Valerie S. Lee, Janise M. Roh, Dawn L. Hershman, Lawrence H. Kushi, Marilyn L. Kwan, Heather Greenlee. Cardiovascular disease risk associated with breast cancer chemotherapy drugs: The Pathways Heart Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5303.

Risk of Cardiovascular Disease in Women With and Without Breast Cancer: The Pathways Heart Study

PURPOSE

To examine cardiovascular disease (CVD) and mortality risk in women with breast cancer (BC) by cancer therapy received relative to women without BC.

METHODS

The study population comprised Kaiser Permanente Northern California members. Cases with invasive BC diagnosed from 2005 to 2013 were matched 1:5 to controls without BC on birth year and race/ethnicity. Cancer treatment, CVD outcomes, and covariate data were from electronic health records. Multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% CIs of CVD incidence and mortality by receipt of chemotherapy treatment combinations, radiation therapy, and endocrine therapy.

RESULTS

A total of 13,642 women with BC were matched to 68,202 controls without BC. Over a 7-year average follow-up (range < 1-14 years), women who received anthracyclines and/or trastuzumab had high risk of heart failure/cardiomyopathy relative to controls, with the highest risk seen in women who received both anthracyclines and trastuzumab (HR, 3.68; 95% CI, 1.79 to 7.59). High risk of heart failure and/or cardiomyopathy was also observed in women with BC with a history of radiation therapy (HR, 1.38; 95% CI, 1.13 to 1.69) and aromatase inhibitor use (HR, 1.31; 95% CI, 1.07 to 1.60), relative to their controls. Elevated risks for stroke, arrhythmia, cardiac arrest, venous thromboembolic disease, CVD-related death, and death from any cause were also observed in women with BC on the basis of cancer treatment received.

CONCLUSION

Women with BC had increased incidence of CVD events, CVD-related mortality, and all-cause mortality compared with women without BC, and risks varied according to the history of cancer treatment received. Studies are needed to determine how women who received BC treatment should be cared for to improve cardiovascular outcomes.

Abstract PD5-03: Development of cardiometabolic risk factors following endocrine therapy: The pathways heart study

Purpose: Endocrine therapy is associated with cardiovascular disease among breast cancer (BC) survivors, with observed opposing effects between aromatase inhibitors (AIs) and tamoxifen. AIs deplete endogenous estrogen levels, while tamoxifen has mixed estrogenic and antiestrogenic activity. Yet, observational studies comparing AI vs. tamoxifen use may be confounded by indication and few have tested their associations with cardiometabolic risk factors. Therefore, we examined the association of AI or tamoxifen use on the incidence of newly diagnosed hypertension, diabetes, and dyslipidemia in a cohort of BC survivors within Kaiser Permanente Northern California (KPNC). Methods: The Pathways Heart Study is an ongoing cohort study within KPNC examining incident CVD outcomes and risk factors in 14,942 women with history of BC. Eligibility was: 1) stage I-IV invasive BC diagnosis between Nov 2005 and Mar 2013; 2) &ge;21 years; and 3) active KPNC membership &ge;12 months at diagnosis. KPNC records were used to collect demographic, socioeconomic, and health characteristics. Endocrine therapy was collected from outpatient pharmacy data. Incident hypertension, diabetes, and dyslipidemia were identified from ICD-9/10 codes, laboratory results, and/or medication use. Hazard ratios (HR) and 95% confidence intervals (CI) from Cox proportional models were used to determine whether AI and tamoxifen use were associated with incident hypertension, diabetes, and dyslipidemia compared to BC survivors not receiving either of these therapies. For each cardiometabolic risk factor, models adjusted for demographic, socioeconomic, and health characteristics and excluded women with the cardiometabolic risk factor at baseline. Results: Among 14,942 women with a history of BC, mean age at baseline was 61.2±12.8 years and mean follow-up time was 7.0±3.5 years (range 1-13.4). The frequency of use was: AI, n=6,070 (40.6%); tamoxifen, n=1,755 (11.8%); and neither, n=7,117 (47.6%). Regression models showed AI use was associated with increased risk of incident hypertension (HR: 1.1, 95% CI: 1.00-1.21) and increased risk of incident dyslipidemia (HR: 1.18, 95% CI: 1.07-1.3) relative to BC survivors who did not use endocrine therapy. (Table). In contrast, tamoxifen use was associated with decreased risk of dyslipidemia (HR: 0.8, 95% CI: 0.68-0.94) relative to BC survivors who did not use endocrine therapy. Neither AI nor tamoxifen use was associated with risk of incident diabetes. Conclusion: Compared to BC survivors who did not use endocrine therapy, women treated with AIs had a higher risk of incident hypertension and dyslipidemia, while women treated with tamoxifen had a lower risk of dyslipidemia. AIs reduce endogenous estrogen levels, which can alter lipid profiles, although prior studies have been inconsistent, possibly due to differences in steroidal and non-steroidal AIs. More work is needed to understand the implications of these associations on long-term cardiovascular health and how to best manage cardiometabolic risk factors in BC survivors with a history of endocrine therapy use.

Table. Adjusted1 hazard ratios (95% confidence intervals) of incident cardiometabolic risk factors among women with a history of breast cancer, by endocrine therapy useNo Endocrine Therapy(n=7,117)Endocrine TherapyAromatase inhibitor(n=6,070)Tamoxifen(n=1,755)Incident HypertensionRef1.10 (1.00, 1.21)0.98 (0.85, 1.14)Incident DiabetesRef0.99 (0.87, 1.13)0.98 (0.80, 1.20)Incident DyslipidemiaRef1.18 (1.07, 1.30)0.80 (0.68, 0.94)1Adjusted for age, race/ethnicity, baseline body mass index, AJCC stage, menopausal status, smoking status, education level, income, chemotherapy, radiation therapy, and prevalent cardiovascular disease.

Citation Format: Heather Greenlee, Eileen Rillamas-Sun, Carlos Iribarren, Richard Cheng, Romain Neugebauer, Jamal S. Rana, Mai Nguyen-Huynh, Zaixing Shi, Cecile A. Laurent, Valerie S. Lee, Janise M. Roh, Hanjie Shen, Dawn L. Hershman, Lawrence H. Kushi, Marilyn L. Kwan. Development of cardiometabolic risk factors following endocrine therapy: The pathways heart study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD5-03.

Abstract PD5-01: Cardiovascular disease risk of breast cancer therapies: The pathways heart study

Purpose: Studies on long-term cardiovascular disease (CVD) risk in breast cancer (BC) survivors are limited. We examined CVD risk associated with exposure to specific BC therapies and explored whether body mass index (BMI) or prevalent CVD risk factors at BC diagnosis modified these associations. Methods: The Pathways Heart Study is a prospective cohort study examining incident CVD outcomes and risk factors in women with BC at Kaiser Permanente Northern California (KPNC). Eligible women were diagnosed with stage I-IV invasive BC from 2005-2013, &ge;21 years old, and KPNC members &ge;12 months at diagnosis. KPNC records provided demographic and BC therapy characteristics. Incident CVD outcomes [ischemic heart disease, heart failure/cardiomyopathy (HF/CM), stroke] were assessed from ICD9/10 codes. Multivariable Cox models estimated hazard ratios (HR) and 95% confidence intervals (CI) of each CVD outcome by cancer therapy received compared to not receiving that therapy, excluding those with prevalent CVD. Separate regression models included interaction terms for cancer therapy by overweight, obesity, diabetes, dyslipidemia, and hypertension to test whether the CVD outcome risk varied by presence of these factors at diagnosis. Results: Among 4,181 BC survivors with mean age of 59.6±12.0 years and mean follow-up of 7.9±3.5 years (range: 0.04-13.3), cancer therapies were not associated with incident CVD. However, CVD risks varied by BMI and prevalence of CVD risk factors at BC diagnosis. Normal weight (NW) women who received anthracyclines had higher risk of ischemic heart disease and HF/CM relative to NW women not receiving these therapies; interaction terms indicated HF/CM risk was statistically different than risks for obese women (Table). NW women who received cyclophosphamide or left-sided radiation had higher risk of HF/CM and stroke relative to NW women not receiving these therapies; these risks were statistically different from obese (for cyclophosphamide) or overweight (for radiation) women. Relative to women not receiving these therapies, higher HRs for HF/CM were observed among non-diabetic women who received cyclophosphamide (2.03, CI: 1.22-3.37), non-dyslipidemic women who received anthracyclines (3.65, CI: 1.69-7.87), and non-hypertensive women who received either anthracyclines (4.04, CI: 1.81-9.03) or cyclophosphamide (2.66, CI: 1.23-5.74) (P for interaction range: 0.04 to 0.06). Conclusion: Certain chemotherapy drugs may increase the risk of CVD in NW BC survivors; overweight and obese BC survivors may experience less risk than NW women. While chemotherapy also appears to increase HF/CM risk for women without diabetes, dyslipidemia, and hypertension, these conditions are more prevalent among overweight/obese women. Analysis within these subgroups is needed and forthcoming.

Table. Adjusted HRs (95% CI) of CVD outcomes among breast cancer survivors receiving select cancer therapies* stratified by BMI status at diagnosisBMI Ischemic heart diseaseHeart failure/CardiomyopathyStrokeAnthracycline, n=1283Normal4.22 (1.59, 11.2)5.27 (2.54, 10.9)1.89 (0.79, 4.53)Overweight1.66 (0.73, 3.77)2.17 (1.15, 4.11)0.40 (0.16, 0.99)Obese1.26 (0.56, 2.85)1.1 (0.54, 2.27)a0.33 (0.13, 0.83)aCyclophosphamide, n=1705Normal1.63 (0.61, 4.31)3.28 (1.59, 6.75)2.21 (1.01, 4.84)Overweight1.59 (0.75, 3.39)1.63 (0.9, 2.97)0.73 (0.34, 1.58)Obese0.85 (0.39, 1.86)0.75 (0.38, 1.47)a0.31 (0.13, 0.71)aLeft-Side Radiation, n=1331Normal1.44 (0.56, 3.69)2.04 (1.0, 4.18)2.38 (1.28, 4.42)Overweight1.47 (0.68, 3.16)0.68 (0.34, 1.34)b0.72 (0.37, 1.4)bObese1.32 (0.73, 2.38)1.30 (0.79, 2.16)1.05 (0.61, 1.82)*Cancer therapies with non-significant findings (i.e., Trastuzumab, taxanes, aromatase inhibitors, Tamoxifen, and any-side radiation) are not shown.ap≤0.05 normal weight v. obese; bp≤0.05 normal weight v. overweight

Citation Format: Heather Greenlee, Eileen Rillamas-Sun, Carlos Iribarren, Richard Cheng, Romain Neugebauer, Jamal S. Rana, Mai Nguyen-Huynh, Zaixing Shi, Cecile A. Laurent, Valerie S. Lee, Janise M. Roh, Hanjie Shen, Dawn L. Hershman, Lawrence H. Kushi, Marilyn L. Kwan. Cardiovascular disease risk of breast cancer therapies: The pathways heart study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD5-01.

Risk of Cardiometabolic Risk Factors in Women With and Without a History of Breast Cancer: The Pathways Heart Study

PURPOSE

The incidence of cardiometabolic risk factors in breast cancer (BC) survivors has not been well described. Thus, we compared risk of hypertension, diabetes, and dyslipidemia in women with and without BC.

METHODS

Women with invasive BC diagnosed from 2005 to 2013 at Kaiser Permanente Northern California (KPNC) were identified and matched 1:5 to noncancer controls on birth year, race, and ethnicity. Cumulative incidence rates of hypertension, diabetes, and dyslipidemia were estimated with competing risk of overall death. Subdistribution hazard ratios (sHRs) were estimated by Fine and Gray regression, adjusted for cardiovascular disease-related risk factors, and stratified by treatment and body mass index (BMI).

RESULTS

A total of 14,942 BC cases and 74,702 matched controls were identified with mean age 61.2 years and 65% non-Hispanic White. Compared with controls, BC cases had higher cumulative incidence rates of hypertension (10.9% v 8.9%) and diabetes (2.1% v 1.7%) after 2 years, with higher diabetes incidence persisting after 10 years (9.3% v 8.8%). In multivariable models, cases had higher risk of diabetes (sHR, 1.16; 95% CI, 1.07 to 1.26) versus controls. Cases treated with chemotherapy (sHR, 1.23; 95% CI, 1.11 to 1.38), left-sided radiation (sHR, 1.29; 95% CI, 1.13 to 1.48), or endocrine therapy (sHR, 1.23; 95% CI, 1.12 to 1.34) continued to have higher diabetes risk. Hypertension risk was higher for cases receiving left-sided radiation (sHR, 1.11; 95% CI, 1.02 to 1.21) or endocrine therapy (sHR, 1.10; 95% CI, 1.03 to 1.16). Normal-weight (BMI < 24.9 kg/m²) cases had higher risks overall and within treatment subgroups versus controls.

CONCLUSION

BC survivors at KPNC experienced elevated risks of diabetes and hypertension compared with women without BC depending on treatments received and BMI. Future studies should examine strategies for cardiometabolic risk factor prevention in BC survivors.

Changes in Patterns of Hospital Visits for Acute Myocardial Infarction or Ischemic Stroke During COVID-19 Surges

This study evaluates changes in rates of patients hospitalized for acute myocardial infarction (AMI) or suspected stroke during COVID-19 surges in the US as a measure of willingness to seek care during the pandemic.

Validation Study of Kaiser Permanente Bedside Dysphagia Screening Tool in Acute Stroke Patients

INTRODUCTION

Dysphagia occurs in up to 50% of patients with acute stroke symptoms, resulting in increased aspiration pneumonia rates and mortality. The purpose of this study was to validate a health system's dysphagia (swallow) screening tool used since 2007 on all patients with suspected stroke symptoms. Annual rates of aspiration pneumonia for ischemic stroke patients have ranged from 2% to 3% since 2007.

METHODS

From August 17, 2015 through September 30, 2015, a bedside dysphagia screening was prospectively performed by 2 nurses who were blinded to all patients age 18 years or older admitted through the emergency department with suspected stroke symptoms at 21 Joint Commission accredited primary stroke centers in an integrated health system. The tool consists of 3 parts: pertinent history, focused physical examination, and progressive testing from ice chips to 90 mL of water. A speech language pathologist blinded to the nurse's screening results performed a formal swallow evaluation on the same patient.

RESULTS

The end study population was 379 patients. Interrater reliability between 2 nurses of the dysphagia screening was excellent at 93.7% agreement (Ƙ = 0.83). When the dysphagia screenings were compared with the gold standard speech language pathologist professional swallow evaluation, the tool demonstrated both high sensitivity (86.4%; 95% confidence interval = 73.3-93.6) and high negative predictive value (93.8%; 95% confidence interval = 87.2-97.1).

CONCLUSION

This tool is highly reliable and valid. The dysphagia screening tool requires minimal training and is easily administered in a timely manner.

Onset of cardiovascular disease risk factors in women with and without a history of breast cancer: The Pathways Heart Study

12017

Background: Women with a history of breast cancer (BC) are at increased long-term risk of dying from cardiovascular disease (CVD). However, the onset of CVD risk factors in women with BC has not been well-described. We compared risk of incident CVD risk factors in women with and without BC enrolled in the Kaiser Permanente Northern California (KPNC) integrated health system. Methods: Data were extracted from KPNC electronic health records. All invasive BC cases diagnosed between 2005-2013 were identified and matched 1:5 with controls on birth year, race/ethnicity and KPNC membership at the date of BC diagnosis. Cox regression models assessed the hazard of incident hypertension (based on diagnosis codes and filled prescriptions), dyslipidemia (based on diagnosis codes, filled prescriptions, and lab values), and diabetes (KPNC Diabetes Registry). Models were adjusted for baseline BMI, menopausal status, smoking status, neighborhood median household income, education, prevalent CVD conditions, and other baseline CVD risk factors. Subgroups of women who received chemotherapy, radiation therapy, and endocrine therapy were compared with controls. Results: A total of 14,942 women with a new diagnosis of invasive BC were identified and matched to 74,702 controls. On average, women were 62.0 years, 28.3 kg/m2BMI, 64.9% non-Hispanic white. Overall, cases were more likely to develop hypertension (HR: 1.18, 95% CI: 1.13, 1.24) and diabetes (HR: 1.23, 95% CI: 1.16, 1.31). Across the board, receipt of any of the three therapies (chemotherapy, radiation therapy and endocrine therapy) was associated with increased risk of hypertension and diabetes, compared to controls. Risk-factor specific hazard ratios for receipt of chemotherapy were (HR 1.18, 95% CI: 1.10, 1.27) and (HR 1.38, 95% CI: 1.26, 1.51), for hypertension and diabetes, respectively. For receipt of radiation therapy, risk-factor specific hazard ratios were (HR: 1.17, 95% CI: 1.09, 1.26) and (HR: 1.15, 95% CI: 1.04, 1.27), for hypertension and diabetes, respectively. Risk-factor specific hazard ratios for receipt of endocrine therapy were (HR: 1.22, 95% CI: 1.14, 1.30) and (HR: 1.16, 95% CI: 1.06, 1.27), for hypertension and diabetes, respectively. Conclusions: The risk of developing hypertension and diabetes is increased in women with BC who received chemotherapy, radiation therapy, and/or endocrine therapy. Future studies should examine the roles of CVD risk factor diagnosis and management on cardiometabolic risk in women with a BC history.

Risk of cardiovascular disease in women with and without a history of breast cancer: The Pathways Heart Study

12016

Background: Breast cancer (BC) survivors are at increased risk of cardiovascular disease (CVD) following diagnosis, as compared to women without BC. To provide a population-based estimate of CVD risk in BC survivors, we compared risk of CVD events in women with and without BC history enrolled in the Kaiser Permanente Northern California (KPNC) integrated health system. Methods: Data were extracted from KPNC electronic health records. All invasive BC cases diagnosed between 2005-2013 were identified and matched 1:5 with non-BC controls on birth year, race/ethnicity and KPNC membership at date of BC diagnosis. Cox regression models were used to assess differences in the hazard of four major CVD events (ischemic heart disease (IHD), heart failure (HF), cardiomyopathy, and stroke). Models were adjusted for factors known to influence risk of breast cancer or CVD.Other CVD events included arrhythmia, cardiac arrest, carotid disease, myocarditis/pericarditis, transient ischemic attack, valvular disease, and venous thromboembolism (VTE). We additionally examined subgroups of cases who received chemotherapy, radiation, and endocrine therapy, and their controls. Results: A total of 14,942 women with a new diagnosis of invasive BC were identified and matched to 74,702 women without BC history. On average, women were 62.0 years, 28.3 kg/m2BMI, 64.9% non-Hispanic white. Among all cases and controls, there were no significant differences in hazard of developing IHD, cardiomyopathy, and stroke; there was a borderline difference in HF (HR: 1.08, 95% CI: 0.99, 1.19). Cases were more likely to have a cardiac arrest (HR: 1.39, 95% CI: 1.09, 1.78) and develop VTE (HR: 1.97, 95% CI: 1.74, 2.23). Women treated with chemotherapy were more likely than controls to develop HF (HR: 1.44, 95% CI: 1.21, 1.72), cardiomyopathy (HR: 2.01, 95% CI: 1.02, 3.98), and VTE (HR: 3.15, 95% CI: 2.62, 3.79). Women who received radiation therapy were more likely to develop carotid disease (HR: 5.49, 95% CI: 1.22, 24.66) and VTE (HR: 1.65, 95% CI: 1.35, 2.03) than controls. Women who received endocrine therapy were more likely to experience a cardiac arrest (HR: 1.49, 95% CI: 1.07, 2.09) and develop VTE (HR: 1.70, 95% CI: 1.42, 2.03) than controls. Conclusions: Women with BC were at increased risk of heart failure, cardiomyopathy, cardiac arrest, VTE and carotid disease. These risks varied by cancer treatment, with higher risk in those who received chemotherapy. Future studies should explore the effects of chemotherapy class and radiation dose exposure on diverse CVD endpoints in BC survivors.

Abstract TP185: Framingham Score Predicts Short-Term Risk of Major Clinical Events after a Recent Stroke

Background: Identifying patients with a recent stroke at high risk for future major vascular events may provide opportunities to improve clinical outcomes. Although Framingham Coronary Risk Score (FCRS) predicts major coronary events over 10 years in the general population free of symptomatic vascular disease, few studies have examined its role as a prognosticator after stroke. We assessed the link between the baseline FCRS and major clinical events among patients with a recent stroke.

Methods: We analyzed data on ischemic stroke patients enrolled in a randomized quality improvement trial of secondary stroke prevention, conducted in 14 Kaiser Permanente hospitals in Northern California between January 2004 and September 2006. Electronic records from the index hospitalization and for 6 months following hospitalization were reviewed. Framingham Risk Scores (FRS) were calculated for each patient but all patients >74 years of age (the upper age limit included in the FRS) were excluded from the analysis. FRS scores were dichotomized into high (≥20%) and low (<20%) risk according to gender guidelines. The primary outcome was recurrent stroke, myocardial infarction and all-cause mortality after hospital discharge; and secondary outcomes were any stroke and any MI. Analyses were adjusted for age, gender, race, BMI, serum lipid levels, and discharge prescription of antithrombotics and statins.

Results: Among 1667 patients discharged alive, mean age was 62.9 (8.6), 46% were male, 58% white, 32% had high FCRS. In adjusted analyses, high FCRS scores were associated with Black race (vs. White), higher BMI, and elevated serum triglycerides. Compared to those with low FCRS, high FCRS was associated with higher odds of the composite primary outcome 1.50 (1.16-1.93, p=0.002) and any recurrent stroke 1.53 (95% CI 1.18-1.98, p=0.001), but not any MI 1.14(95% CI 0.42-3.14, p=0.79). Additionally adjusting for age slightly attenuated these results, but did not change the significance level. A low incidence of MI (12 cases) resulted in a lack of power for this outcome.

Conclusions: A baseline FRCS>20% predicts higher short-term risk of major clinical events in recent ischemic stroke patients.

Abstract TMP93: Level of Renal Function and Short-term Risk of Recurrent Stroke

Introduction: Renal insufficiency is an established risk factor for first-time vascular events including stroke. There is a paucity of data on the relation of renal function to recurrent stroke risk, especially in a population-based setting. We evaluated the associations of different levels of renal function with short-term recurrent stroke risk.

Methods: Our cohort included patients admitted to 12 hospitals in a Northern California healthcare network with acute ischemic stroke between 2004 and 2007. Records from the index hospitalization and for 6 month follow ups were reviewed. Estimated Glomerular Filtration Rate (eGFR) in mL/min/1.73 m 2 , calculated using the MDRD equation, was categorized by modified National Kidney Foundation stage: 1 (≥90), 2(60-90), 3(30-60), 4 (<30). Multivariate analyses, using generalized estimating equations to adjust for within and between hospital variances, were adjusted for age, race, sex, hypertension, diabetes, and hyperlipidemia.

Results: Of 2,882 patients with eGFR, mean age was 73±13 ; 66% were Caucasian, 14% African-American, 11% Asian and 52% were female. On admission, renal function was stage 1 in 693 (24%), 2 in 1341 (47%), 3 in 706 (25%), and 4 in 142 (5%). An inverse relationship between age and eGFR was observed (p<0.001). African Americans were most likely to have stage 1 and stage 4 renal function (p<0.001) and Caucasians were more likely to have stage 2 and 3 renal function (p<0.001). Hypertension was most common among those with stage 3 renal function (p<0.001), and diabetes and hyperlipidemia were most common among those with stage 4 renal function (p<0.001 for both). In multivariate analysis, blood pressure control at 6 month follow up was less likely with stage 4 renal function compared with lower stages (OR 0.47, p<0.001), but there was no difference between stages 1, 2 and 3. There was a direct relationship between stage of renal function and risk of recurrent stroke (stage 1 REF, stage 2 OR 1.6, stage 3 OR 1.7, stage 4 OR 1.8, p<0.01 for all).

Conclusions: Decreased renal function is an independent predictor of short-term recurrent stroke in a graded dose-dependent manner. Even among those with “normal” renal function (eGFR 60-90), recurrent stroke risk was 60% greater than in those with higher eGFR.

A cost-utility analysis of mechanical thrombectomy as an adjunct to intravenous tissue-type plasminogen activator for acute large-vessel ischemic stroke

BACKGROUND AND PURPOSE

Mechanical thrombectomy has the potential to improve recanalization rates and outcomes for patients with ischemic stroke, but potential gains could be offset by procedural complications and costs. We evaluated the cost and utility of combined intravenous (IV) tissue-type plasminogen activator (tPA) and mechanical thrombectomy compared to IV tPA alone for acute large-vessel ischemic stroke.

METHODS

We constructed a decision tree for a hypothetical 68-year-old with a large-vessel ischemic stroke who is eligible for IV tPA. The interventional strategy was IV tPA, a cerebral angiogram, and mechanical thrombectomy and thrombolysis if indicated. Recanalization, hemorrhage complications, and outcomes for the interventional strategy were from the Multi-MERCI study. The medical strategy was IV tPA using inputs from a comprehensive systematic review. Costs were estimated from Medicare reimbursements. We modeled lifetime costs and utilities for disability using a Markov model and Monte-Carlo multivariable sensitivity analysis.

RESULTS

For the baseline scenario, the recanalization rate was 72.9% for the interventional strategy and 46.2% for the medical strategy. For the interventional strategy, the symptomatic hemorrhage rate was 8.6% with recanalization and 15.4% without. For the medical strategy, the corresponding rates were 3.6% and 13.3%, respectively. The interventional strategy was cost-effective in 97.6% of simulations (incremental cost-effectiveness ratio $16 001/quality-adjusted life year; 95% CI, $2736-$39,232).

CONCLUSIONS

Based on observational data, the combination of IV tPA and mechanical thrombectomy for large-vessel ischemic stroke appears to be cost-effective compared to IV tPA alone. These findings require additional validation with randomized trial data.