Identifying the High-Risk Population
Cancer and cardiovascular disease: The multiple hit hypothesis
|RR (95% CI)||10.4 (4.1-25.9)||15.1 (4.8-47.9)||1.9 (1.6-2.2)||1.7 (1.2-2.3)||1.6 (1.3-2.0)|
Patient- and treatment-related risk factors for cardiotoxicity from cancer therapy
Myocardial ischemia/arterial thrombosis
- 1.We recommend evaluation of traditional cardiovascular risk factors and optimal treatment of cardiovascular disease, as per current CCS guidelines, be part of routine care for all patients before, during, and after receiving cancer therapy (Strong Recommendation, Moderate-Quality Evidence).
- 2.We recommend that patients who receive potentially cardiotoxic cancer therapy undergo evaluation of LV ejection fraction (LVEF) before initiation of cancer treatments known to cause impairment in LV function (Weak Recommendation, Moderate-Quality Evidence).
Detection and Prevention of Cardiotoxicity
Complementary imaging modalities for LVEF assessment
Subclinical LV dysfunction evaluation using novel echocardiographic techniques
- Fallah-Rad N.
- Walker J.R.
- Wassef A.
- et al.
Utility of cardiac biomarkers for the early detection of chemotherapy-mediated cardiotoxicity
- 3.We recommend the same imaging modality and method be used to determine LVEF before, during, and after completion of cancer therapy (Suggestion, Low-Quality Evidence).
- 4.We suggest that myocardial strain imaging be considered a method for early detection of subclinical LV dysfunction in patients treated with potentially cardiotoxic cancer therapy (Suggestion, Low-Quality Evidence).
- 5.We suggest that serial use of cardiac biomarkers (eg, BNP, troponin) be considered for early detection of cardiotoxicity in cancer patients who receive cardiotoxic therapies implicated in the development of LV dysfunction (Weak Recommendation, Moderate-Quality Evidence).
Drug therapy in primary prevention
- Bosch X.
- Rovira M.
- Sitges M.
- et al.
- Pituskin E.
- Haykowsky M.
- Mackey J.R.
- et al.
- 6.We suggest that in patients deemed to be at high risk for cancer treatment-related LV dysfunction, an ACE inhibitor or angiotensin receptor blocker, and/or β-blocker, and/or statin be considered to reduce the risk of cardiotoxicity (Weak Recommendation, Moderate-Quality Evidence).
Prevention related to RIHD
- Lancellotti P.
- Nkomo V.T.
- Badano L.P.
- et al.
- 7.We suggest that modern radiotherapy techniques (eg, 3-D conformal radiotherapy, intensity-modulated radiotherapy) be used during planning mediastinal and chest radiation to reduce the risk of short- and long-term cardiotoxicity (Weak Recommendation, Moderate-Quality Evidence).
Treatment of Cardiotoxicity
- Amsterdam E.A.
- Wenger N.K.
- Brindis R.G.
- et al.
- Amsterdam E.A.
- Wenger N.K.
- Brindis R.G.
- et al.
- Welsh R.C.
- Travers A.
- Huynh T.
- Cantor W.J.
- Lancellotti P.
- Nkomo V.T.
- Badano L.P.
- et al.
HF and LV dysfunction
- 8.We recommend that for patients with preexisting hypertension or for those who experience hypertension related to their cancer therapy, it is important to start, maintain, or augment antihypertensive therapy as per the Canadian Hypertension Education Program guidelines. A target BP of < 140/90 mm Hg should be established for all patients except those with diabetes in whom the goal should be adjusted to < 130/80 mm Hg (Strong Recommendation, High-Quality Evidence).
- 9.We suggest in patients who receive QTc-prolonging agents, a baseline electrocardiogram examination before cancer treatment and periodic monitoring of the QTc during treatment. If the QTc interval exceeds 500 ms during treatment, metabolic and electrolyte disturbances should be identified and corrected, and the use of concomitant QT-prolonging drugs be minimized where possible (Weak Recommendation, Moderate-Quality Evidence).
- 10.We recommend that in cancer patients who develop clinical HF or an asymptomatic decline in LVEF (eg, > 10% decrease in LVEF from baseline or LVEF < 53%) during or after treatment, investigations, and management follow current CCS guidelines. Other causes of LV dysfunction should be excluded (Strong Recommendation, High-Quality Evidence).
- 11.We suggest that alternate antineoplastic treatments be considered if patients experience myocardial ischemia due to their cancer therapy (Suggestion, Low-Quality Evidence).
- i.Treatment targets (eg, hypertension) should be tailored on the basis of goals of care (eg, curative vs palliative) and by assessing the overall risks and benefits of cancer therapies within this context.
- ii.We suggest cautious use of drugs metabolized by the cytochrome P450 system (eg, diltiazem or verapamil) for hypertension management in patients who receive tyrosine kinase inhibitors because of potential drug-drug interactions.
- iii.Although the CCS guidelines recommend institution of ACE inhibitors/angiotensin receptor blockers, and β-blockers in patients with an LVEF < 40%, in clinical practice, the combination of LV enhancement therapy might be considered in patients with an asymptomatic decline in LVEF (eg, > 10% decrease in LVEF from baseline or LVEF < 53%) during cancer therapy.
- iv.In the setting of trastuzumab-related LV dysfunction, we recommend following the algorithm proposed by Jones et al.,30recognizing there might be clinical scenarios in which continuing trastuzumab alongside initiation of evidence-based HF therapies might be considered.
Recommendations for a Multidisciplinary Approach to Cardio-oncology
A Call to Action
- 12.We suggest that patients at high risk of cancer therapy-related cardiovascular disease or patients who develop cardiovascular complications during cancer therapy (eg, > 10% decrease in LVEF from baseline or LVEF < 53%) be referred to a cardio-oncology clinic or practitioner skilled in the management of this patient population, for optimization of cardiac function and consideration of primary or secondary prevention strategies (Suggestion, Low-Quality Evidence).
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The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.