European Society of Cardiology quality indicators for the prevention and management of cancer therapy-related cardiovascular toxicity in cancer treatment

AIMS

To develop quality indicators (QIs) for the evaluation of the prevention and management of cancer therapy-related cardiovascular toxicity.

METHODS AND RESULTS

We followed the European Society of Cardiology (ESC) methodology for QI development which comprises (i) identifying the key domains of care for the prevention and management of cancer therapy-related cardiovascular toxicity in patients on cancer treatment, (ii) performing a systematic review of the literature to develop candidate QIs, and (iii) selecting of the final set of QIs using a modified Delphi process. Work was undertaken in parallel with the writing of the 2022 ESC Guidelines on Cardio-Oncology and in collaboration with the European Haematology Association, the European Society for Therapeutic Radiology and Oncology and the International Cardio-Oncology Society. In total, 5 main and 9 secondary QIs were selected across five domains of care: (i) Structural framework, (ii) Baseline cardiovascular risk assessment, (iii) Cancer therapy related cardiovascular toxicity, (iv) Predictors of outcomes, and (v) Monitoring of cardiovascular complications during cancer therapy.

CONCLUSION

We present the ESC Cardio-Oncology QIs with their development process and provide an overview of the scientific rationale for their selection. These indicators are aimed at quantifying and improving the adherence to guideline-recommended clinical practice and improving patient outcomes.

Baseline characteristics of patients with atrial fibrillation and cancer enrolled in the BLITZ-AF Cancer registry

Background

Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy.

Methods

BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing.

Results

From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled.

The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases.

AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF.

Baseline characteristics are presented in Table 1. Males were more than women and almost half of the subjects was >75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3.

As shown in Figure 1, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined.

Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22–2.05), age (OR 2.00, 95% CI 1.39–2.88 and OR 2.63, 95% CI 1.84–3.76, respectively, for 65–74 years and ≥75 years vs <65 years), hypertension (OR 1.43, 95% CI 1.10–1.87), long-standing persistent or permanent AF (OR 1.36, 95% CI 1.05–1.78). Haemoglobin <12 g/dL (OR 0.57, 95% CI 0.45–0.73), and planned cancer treatment (OR 0.72, 95% CI 0.57–0.92) were independently associated with a lower prescription of DOACs.

Conclusions

BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo.

C48 PROGNOSTIC IMPACT OF ECHOCARDIOGRAPHIC RESTRICTIVE FILLING PATTERN IN PATIENTS AFFECTED BY HYPERTROPHIC CARDIOMYOPATHY AND PRESERVED SYSTOLIC EJECTION FRACTION

Background

“Restrictive phenotype” is an uncommon presentation of Hypertrophic Cardiomyopathy (HCM), associated with severe functional limitation and poor prognosis. For this reason, current therapeutic aims are prevention of complications through periodic follow–ups and diagnostic investigations, up to the ICD placement.

Objectives

The primary aim of this study was to evaluate the impact of the restrictive filling pattern in HCM on the incidence of complex composite outcome included arrhythmic events, events related to heart failure and general events, correlating it to clinical and imaging data.

Methods

This study is an experimental, multicentric, retrospective and non–randomized analysis, including all patients over the age of 18 suffering from classical HCM, excluding phenocopies and systolic dysfunction. Patients were followed up and selected by specialized Centers of Trieste and Turin and divided by degree of diastolic dysfunction, particularly on the basis of the presence or absence of the restrictive filling pattern.

Results

A total of 367 patients with HCM were included. Restrictive filling pattern was present in 23 patients (6.3%). This subgroup of patients was younger than all other patients (P < 0.001); percentage of ICD patients suffering from severe diastolic dysfunction at follow–up is significantly higher than patients without restrictive filling pattern (39.1% vs 4.1%, P < 0.001). On average, left atrial volume has larger sizes in restrictive filling pattern (109.7ml, SD 43.06 vs 82.8ml, SD 35.81, P = 0.003). Patients with restrictive filling pattern, compared to other patients, are more subjected to heart transplantation (8.7% vs 0.3%, P = 0.009) and hospitalized for heart failure (21.7% vs 7.8%, P = 0.028). Restrictive pattern was not an independent predictor of adverse events at the multivariable analysis. In our cohort, the independent predictors were found to be the left atrium diameter and the presence of LGE on CMR.

Conclusions

In patients with HCM and preserved EF, the evidence of a restrictive diastolic pattern identifies a poor prognosis subgroup. Severe diastolic alteration was not associated with a significant independent role either for events related to heart failure, or for arrhythmic events during a median follow up of 7 years. However, the high rate of ICD implantation in patients with severe diastolic dysfunction suggests a high clinical perception of adverse events in this subgroup.

Diagnostic value of echocardiography in infective endocarditis: a probabilistic approach

The high sensitivity and specificity of echocardiography in the diagnosis of infective endocarditis have been well established for a number of years. However, little is known yet about the incremental value of this technique over the clinical and serological findings already available in subsets of patients presenting different initial probabilities in infective endocarditis. In this report, sensitivity and specificity of echocardiography were calculated in 173 consecutive patients with suspected infective endocarditis who underwent echocardiography within 5 days following admission. The echocardiogram was considered positive when Duke major criteria were fulfilled. Infective endocarditis was diagnosed in 88 patients, while other illnesses in the remaining 85. The diagnoses were confirmed retrospectively with a follow-up done after at least 3 months, at surgery or during autopsy. Sensitivity and specificity of the echocardiography in this population were 85 and 97% respectively. The initial probabilities of infective endocarditis in patients with different clinical presentations were taken from a thorough review of the literature available in English and from personal research. The positive predictive value of echocardiography is already high or very high even at low or very low levels of initial probability, and this has a strong impact on clinical decisions. In these situations and with intermediate probabilities, a negative echocardiogram would theoretically rule out the disease. However, this result, if considered alone, calls for a careful reassessment of the entire clinical context. As with any other test, when the initial probabilities of infective endocarditis are highest, the incremental value of echocardiography is poor.

[Cardiac complications in HIV infections]

Cardiological involvement in HIV infection is relatively rare but it presents important clinical aspects that are still open questions. We report our experience with HIV patients who underwent cardiological evaluation, Doppler echocardiography and follow-up.

MATERIAL AND METHOD

We selected 127 patients (9%) on the basis of clinical suspicion of heart disease, taking them from the 1398 admitted for HIV infection between 1992 and 1995. Ninety-six patients had AIDS (group A) and 31 were in pre-AIDS phase (group B). The age was 21-52 years: 83 were males, 44 were females and 91% of the patients had been drug addicts. Echocardiography was executed with Hp Sonos 1000 and Sonos 2500 devices. Follow-up was 6-36 months.

RESULTS

Ninety-two patients (6.5% on total admitted patients) had heart disease. Thirty-five patients were normal on echocardiography. Other diseases were: pericardial effusion in 38 cases (30%), with CD4+ number significantly lower (p < 0.005); dilated cardiomyopathy in 20 patients (16%), with a low CD4+ number (p < 0.005); reversible segmental or diffuse hypokinesia compatible with clinical myocarditis was seen in 11 patients (9%), especially in group A (p < 0.005); infective endocarditis in 17 patients (13%), especially group B (p < 0.005); right ventricular dilatation in 7; discrete right ventricular mass in 3 patients. Sixty-five patients (51%) died during follow-up (group A only). There were 19 cardiac deaths (15%), which represents 1.3% of the total number of patients. Nine of these (47%) were in patients with cardiomyopathy. Total mortality was 85% in patients with dilated cardiomyopathy, 73% in myocarditis cases, 71% in pericarditis cases (especially extracardiac), 66% in right ventricular dilatation cases, 18% in endocarditis cases, 34% in normal cases.

CONCLUSIONS

Cardiac complications assume clinical importance, especially in the AIDS phase of HIV infection, but early diagnosis in the pre-AIDS phase is important for treatment. Clinical evaluation and echocardiography are corner-stones of the diagnosis. Prognosis depends especially on the clinical stage of HIV infection and myocardial involvement.

New diagnostic criteria for infective endocarditis. A study of sensitivity and specificity

OBJECTIVE

The purpose of this study was to determine the sensitivity and specificity of new criteria proposed by Duke University for case definition of infective endocarditis as compared to the previously accepted Von Reyn criteria.

PATIENTS

A total of 143 consecutive suspected cases of infective endocarditis in 137 febrile patients were included. Of these, 69 had infective endocarditis, pathologically proven in 28, but with only a clinical diagnosis in 41. In the remaining 74 cases, the diagnosis of infective endocarditis was rejected after a follow-up of at least 3 months.

RESULTS

The sensitivity of Duke's criteria was significantly higher, both when patients with possible infective endocarditis were considered as true-positive (definition 1; 100% vs 69%, P < 0.001) and when possible cases were considered as rejected (definition 2; 76% vs 51%, P < 0.01). Specificity was very high with both criteria: 92% Von Reyn vs 88% Duke (ns) with definition 1 and 99% Von Reyn vs 97% Duke (ns) with definition 2. The overall accuracy of the Duke criteria in the entire population was significantly higher with both definitions (0.94 vs 0.81 definition 1, P < 0.001; 0.87 vs 0.75, P = 0.015 definition 2).

CONCLUSION

Duke's criteria for defining infective endocarditis has been shown to be more sensitive than previously adopted criteria, while maintaining a high degree of specificity. Therefore, they must be accepted as a substitute for previous criteria.