Risk and Management of Patients with Cancer and Heart Disease

Cancer and cardiovascular disease are two of the leading causes of global mortality and morbidity. Medical research has generated powerful lifesaving treatments for patients with cancer; however, such treatments may sometimes be at the expense of the patient's myocardium, leading to heart failure. Anti-cancer drugs, including anthracyclines, can result in deleterious cardiac effects, significantly impacting patients' functional capacity, mental well-being, and quality of life. Recognizing this, recent international guidelines and expert papers published recommendations on risk stratification and care delivery, including that of cardio-oncology services. This review will summarize key evidence with a focus on anthracycline therapy, providing clinical guidance for the non-oncology professional caring for a patient with cancer and heart failure.

Circulating biomarkers for management of cancer therapeutics related cardiac dysfunction

Cancer therapeutics related cardiac dysfunction (CTRCD) has emerged as a major cause of morbidity and mortality in cancer survivors. Effective clinical management of CTRCD is impeded by a lack of sensitive diagnostic and prognostic strategies. Circulating molecular markers could potentially address this need as they are often indicative of cardiac stress before cardiac damage can be detected clinically. A growing understanding of the underlying physiological mechanisms for CTRCD has inspired research efforts to identify novel pathophysiologically-relevant biomarkers that may also guide development of cardio-protective therapeutic approaches. The purpose of this review is to evaluate current circulating biomarkers of cardiac stress and their potential role in diagnosis and management of CTRCD. We also discuss some emerging avenues for CTRCD-focused biomarker investigations.

Clinical Outcomes of Deferred Revascularisation Using Fractional Flow Reserve in Diabetic Patients

BACKGROUND

Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery lesions. Diabetic patients are associated with high burden of atherosclerosis and microvascular dysfunction. We studied the clinical outcomes of diabetic patients who underwent FFR-guided deferred revascularisation.

METHODS

Consecutive patients from a single large volume centre who underwent FFR assessment were included. Clinical endpoints were prospectively collected using the national electronic care records system. The primary endpoint was defined as the four-year risk of the vessel-oriented composite outcome of cardiac death, vessel-related myocardial infarction (VMI), and vessel-related urgent revascularisation (VUR). Absolute FFR values groups (0.81 to 0.85; 0.86 to 0.90; and >0.90) were used to further stratify patient outcomes.

RESULTS

FFR-guided deferred revascularisation occurred in 860 patients (63%), of whom 159 were diabetic. The primary endpoint was significantly higher in the diabetic compared to the non-diabetic group [HR 1.76 (95%CI 1.08 to 2.88), P = 0.024]. The difference was driven from cardiac death (6.3% vs. 3.0%, P = 0.044) and VMI (5.0% vs. 1.7%, P = 0.012) but not VUR (8.8% vs. 5.1%, P = 0.07). There was a significant decrease in the incidence of the primary endpoint in the diabetic group according to FFR groups (23.6%, 12.3%, 2.4%, P = 0.001) with comparable clinical outcomes in the non-diabetic group (11.8%, 6.4%, 7.4%, P = 0.085).

CONCLUSIONS

Our study demonstrated an increased risk of death and target vessel MI in diabetic patients undergoing FFR-guided deferred revascularisation compared to non-diabetic group. Nonetheless, FFR remained a useful tool to identify those at future risk, mainly in diabetic patients.

A Review of the Key Clinical Trials of 2015: Results and Implications

Introduction

Multiple significant, potentially practice changing clinical trials in cardiology have been conducted and subsequently presented throughout the past year.

Methods

In this paper, the authors have reviewed and contextualized significant cardiovascular clinical trials presented at major international conferences of 2015 including American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, American Diabetes Association, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics, Heart Rhythm Congress, and the American Heart Association Scientific Sessions.

Results

The authors describe new trial data for heart failure (including eplerenone, finerenone, patiromer, sacubitril/valsartan, the beta 3 agonist mirabegron, sitagliptin, empagliflozin, alginate-hydrogel LV epicardial implant), anticoagulation (idarucizumab and andexanet alfa reversal agents, adherence programmes, practice in ablation), transcatheter aortic valve replacement (long-term data, valve-in-valve use, the TriGuard embolic deflecting device), patent foramen ovale closure, cardiovascular prevention (PCSK9 inhibitors, hypertension treatment) and antiplatelets strategies (extended duration therapy with clopidogrel or ticagrelor). Trial data are also described for contemporary technologies including the Biofreedom polymer-free drug coated stent, bioabsorbable stents, PCI strategies, left main treatment, atrial fibrillation ablation techniques, leadless pacemakers and the role of coronary computed tomographic angiography.

Conclusions

This paper summarizes and contextualizes multiple pertinent 2015 clinical trials and will be of interest to both clinicians and cardiology researchers.

The Essentials of Cardiac Computerized Tomography

Cardiac computerized tomography (CT) has evolved from a research tool to an important diagnostic investigation in cardiology, and is now recommended in European, US, and UK guidelines. This review is designed to give the reader an overview of the current state of cardiac CT. The role of cardiac CT is multifaceted, and includes risk stratification, disease detection, coronary plaque quantification, defining congenital heart disease, planning for structural intervention, and, more recently, assessment of ischemia. This paper addresses basic principles as well as newer evidence.

HbA1c for Diabetes Screening in Acute Coronary Syndrome: time for a reappraisal of the guidelines?

OBJECTIVE

Diabetes is highly prevalent in individuals with acute coronary syndrome (ACS). Current NICE guidelines recommend diabetes screening of hyperglycaemic patients using a fasting plasma glucose after 4 days from admission. In 2012 the World Health Organisation (WHO) approved the use of HbA1c in the diagnosis and targeted screening for type 2 diabetes. We introduced a service improvement project using HbA1c for diabetes screening in patients with no previous diagnosis of diabetes admitted with ACS regardless of glycaemic state.

METHOD

An initial retrospective audit utilised 21 months of data from the MINAP database to identify patients meeting current NICE criteria for diabetes screening. A prospective service improvement project was undertaken over a 4 month period using HbA1c as a universal screening test to categorise ACS patients based on WHO criteria.

RESULTS

The retrospective audit identified 93 of 420 (22%) patients with pre-existing diabetes and 8 of the remaining 327 (2.4%) were hyperglycaemic, thus meeting NICE criteria for diabetes screening. In the service improvement project 2/49 patients (4%) met NICE criteria for diabetes screening. Twenty six of these 49 patients had a HbA1c test on admission and 17/26 (65.4%) were classified as probable diabetes or high risk.

CONCLUSION

A significant proportion of ACS patients have diabetes, which may be undetected by current NICE criteria. Universal HbA1c testing offers utility as a simple and effective screening test for diabetes in the ACS population.

A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients

The elderly constitute a sizeable proportion of the acute coronary syndrome (ACS) population, and this population is continually increasing in number. Guideline-directed therapy is frequently underutilized in the elderly due to concerns about patient safety. However, studies suggest that this subgroup could benefit from many of the conventional and newer therapies available. This paper reviews current literature in the context of contemporary American and European guidance.

Multiple fractionated stereotactic radiotherapy of residual pituitary macroadenomas: initial experience

OBJECTIVE

We describe our initial experience with fractionated stereotactic radiotherapy (SRT) for the treatment of 19 patients with secretory and nonsecretory pituitary macroadenomas. The primary endpoints of local control and the documentation of any MRI T2-weighted changes in contiguous brain tissues are discussed.

METHODS

Between 1/95 and 1/97, 19 patients were planned with the X-Knife 3-D planning system (Radionics, Burlington, Mass., USA) and received a median dose of 46 Gy in daily 2.0-Gy fractions. Treatments were delivered stereotactically with a dedicated 600SR linear accelerator (Varian Corporation, Palo Alto, Calif., USA). Immobilization was achieved with the Gill-Thomas-Cosman relocatable frame. The mean tumor size was 2.24 cm. The mean prescription isodose was 87%. The mean age was 53 years (10 male, 9 female). The mean follow-up time was 10 months (range 1-24 months). The mean optic chiasm and brain stem doses were calculated at 38 and 13 Gy, respectively. All patients were evaluated with pre- and postgadolinum-enhanced MRI scans and Humphrey visual field tests.

RESULTS

In the posttreatment period, local control (absence of tumor progression) has been achieved in all of the patients. The treatment was well tolerated in all patients. No acute complications, no visual changes and no T2-weighted MRI or proton density changes were documented in any of the 19 patients.

CONCLUSION

These preliminary results suggest that SRT compares favorably with conventional radiotherapy in achieving local control. The doses to the brainstem and the temporal lobes are significantly decreased and at early follow-up no white matter changes are seen on MRI after SRT. The true frequency of grade 1-4 changes are likely underestimated as similar changes often occur in association with tumor edema or after surgery. Given the uncertain neurocognitive significance of the white matter changes associated with treating these benign tumors by conventional radiotherapy, we are currently treating all pituitary adenomas with fractionated SRT to reduce the potential sequelae.

Use of the lipid emulsion system and Salmonella typhimurium mitogen adjuvant to stimulate IgG production in chickens

Chickens were immunized with the lipid emulsion system and Salmonella typhimurium mitogen adjuvant for fowl plus synthetic peptides corresponding to the divergent amino acid sequences at the carboxyl terminus of each of two different alpha-tubulin isoforms from Arabidopsis thaliana. Antibodies were extracted from egg yolks and used in immunoblot assays to determine the time course of antibody production in two chickens. Specific immunoglobulin production increased 10-14 days after the primary injection in both chickens and reached peak levels shortly thereafter. Booster injections helped maintain IgG production, which eventually dropped off after the final injection.

A study of aminoglutethemide and hydrocortisone in patients with advanced and refractory prostate carcinoma

We have studied aminoglutethemide (AG) combined with hydrocortisone in 28 patients with advanced and refractory prostate carcinoma. All the patients had failed at least one endocrine therapy. Six patients received only one prior hormonal treatment. Five patients were off study within 3 weeks due to early death and toxicity, 14 had progressive disease, and 9 had stable disease. No objective partial remission was observed, but the nine stable patients had therapeutic benefit, with improvement in bone pain and performance status for a median duration of 153 days. Three patients withdrew because of postural hypotension, dizziness, weakness, and lethargy. The median survival of the entire group was 186 days (range 41-606 days). Our results suggest that aminoglutethemide and hydrocortisone can be an alternative treatment for patients with advanced and refractory prostate carcinoma.