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Cardio-oncology rehabilitation for patients with cancer and survivors

(From Gilchrist SC, Barac A, Ades PA et al. Cardio-oncology rehabilitation to manage cardiovascular outcomes in patients with cancer and survivors: a scientific statement from the American Heart Association. Circulation . 2019;139(21):139 e997–e1012.) Open full size image KEY POINTS Patients with cancer experience an increased risk of developing cardiovascular diseases owing, in part, to the direct effects of cancer treatments (cardiotoxicity), a high prevalence of standard…

Monitoring for and management of delayed complications after cancer therapy

Open full size image KEY POINTS Several different delayed pulmonary complications can occur after chemotherapy, radiation therapy, and stem cell transplantation. Pulmonary fibrosis is the most common delayed parenchymal process and needs to be distinguished from organizing pneumonia, which may develop months after therapy and, unlike fibrosis, is usually reversible with steroids. Obliterative bronchiolitis is a rare but serious complication that develops several months to years…

Hypertension and renal failure prevention and management after cancer therapy

Open full size image KEY POINTS Hypertension is an important cardiovascular risk factor in cancer survivors and it potentiates the risk of heart failure in patients previously exposed to cardiotoxic chemotherapy or mediastinal radiation Regular routine blood pressure surveillance is an important measure in cancer survivorship with blood pressure goals that match the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines (<130/80 mm Hg) First-line…

Arrhythmia prevention and management in cancer survivors

Open full size image KEY POINTS Cancer survivors are at risk of developing arrhythmias, often not diagnosed until clinically evident, and at times with life-threatening consequences. The long-term risk of recurrent arrhythmias once in remission and after cessation of cancer therapies is unknown. Arrhythmias occur with similar frequency in patients with chemotherapy-induced cardiomyopathy and other forms of left ventricular dysfunction. Cardiac resynchronization demonstrates benefit in patients…

Prevention of VTE after initial presentation and cancer treatment

Open full size image KEY POINTS In patients with cancer with venous thromboembolism (VTE), the risk of VTE recurrence is increased six-fold with an annual rate as high as 30% in the absence of anticoagulation and as high as 20% even within the initial 6 months on anticoagulation therapy. The majority of VTEs occur within the first months of cancer diagnosis. Several additional risk score tools…

Vascular disease prevention and management after cancer therapy

Open full size image KEY POINTS Vascular disease after completion of cancer therapy can be due to (1) the continuum of preexisting vascular disease and/or (2) as a new development owing to cancer therapy exposure. The first category requires optimal, guideline-directed therapies in the overall context of the patient’s care, conditions, and goals. The second category needs definition of the contributing role of the cancer therapy,…

Long-term consequences of radiation therapy

CAD, Coronary artery disease; CCTA, coronary computed tomography; CMR, cardiac magnetic resonance imaging; CV, cardiovascular; EKG, electrocardiogram; Gy, gray; HPI, history of present illness; RIHD, radiation-induced heart disease; RT, radiation therapy; TTE, transthoracic echocardiography. Open full size image KEY POINTS Patients with cancer who are exposed to radiation therapy are at increased risk for numerous cardiac complications, including cardiomyopathy, valve disease, pericardial disease, arrhythmias, conduction abnormalities,…

Long-term complications of chemotherapy

Open full size image KEY POINTS Despite improvement in cancer survival, many cancer survivors have shortened life spans owing to the late effects of cardiovascular disease (CVD) from their cancer and its treatment Cancer therapeutics can lead to a wide spectrum of acute and long-term cardiovascular complications owing to on-target and off-target effects Anthracyclines are the best studied anticancer therapy associated with cardiotoxicity with established risk…

Cancer survivorship and comorbidity disease risk after cancer treatment

Open full size image KEY POINTS Cancer survivors are a growing population Age at time of cancer treatment, health behaviors, comorbid conditions, genetics, and cancer treatment all weigh into the cardiovascular risk assessment of cancer survivors Anthracycline chemotherapy, mediastinal radiation, cranial radiation, Bcr-Abl tyrosine kinase inhibitor therapy, testicular cancer treatment, androgen deprivation therapy for prostate cancer, and pregnancy are among the areas of heightened cardiovascular concern…

Cardiovascular testing in patient with cancer

Open full size image KEY POINTS New imaging modalities play a central role in identifying cardiovascular complications. Cardiotoxicity can manifest in a number of ways, depending on the agent, and can include disease states such as heart failure and cardiomyopathy, coronary artery disease, coronary vasospasm, myocarditis, pericardial constriction, and pulmonary hypertension. In light of the many potential cardiovascular diseases (CVD), a broad range of cardiovascular imaging…

Pulmonary disease during cancer therapy

Open full size image KEY POINTS Pulmonary complications in patients with cancer may involve any intrathoracic structures Differential diagnosis of parenchymal infiltrates in patients with cancer includes infection, inflammation, neoplastic involvement, and other miscellaneous diagnoses (e.g., pulmonary edema). Clinical presentation of drug-induced pneumonitis ranges from asymptomatic infiltrates to hypoxemic respiratory failure Drug-induced pneumonitis is a diagnosis of exclusion; its work-up includes laboratory and imaging studies with…

Hypertension and renal disease during anti-cancer therapies

Open full size image KEY POINTS Blood pressure measurement is part of the routine assessment during clinic or hospital-delivered cancer care, but should also be measured at home where possible, especially in patients receiving oral cancer therapy, such as vascular endothelial growth factor inhibitors (VEGFIs; weekly during the first cycle, then every 2 to 3 weeks). The treatment goal during VEGFI therapy should be less than…

Arrhythmia and device assessment during cancer treatments

Open full size image KEY POINTS Atrial fibrillation and other atrial arrhythmias are common complications of many different cancer therapeutics. The CHA 2 DS 2 -VASc and the HAS-BLED scores may not be appropriate to determine thromboembolic and bleeding risk in patients with cancer receiving active therapy. Ventricular arrhythmias are an infrequent, but potentially life-threatening, complication of various cancer therapeutics, most often related to QT prolongation…

Thromboembolic disease treatment during cancer therapy

Open full size image KEY POINTS Active cancer increases the risk of venous thromboembolism (VTE) by four-fold without chemotherapy and seven-fold with chemotherapy The likelihood of developing VTE is highest during the first 3 months after the cancer diagnosis and the majority of thrombotic events occur within the first year Management of cancer-associated VTE is challenging because these patients are at risk of both thrombotic and…

Vascular disease during cancer therapy

Open full size image KEY POINTS Patients who have cancer are at risk of developing vascular complications during cancer therapy owing to preexisting cardiovascular disease and/or risk factors and the toxicity potential of cancer therapeutics Three principal presentations of arterial vascular complications/toxicity can be distinguished: acute vasospasm, acute thrombosis, and accelerated atherosclerosis The diagnostic evaluation needs to keep both a broad differential and to define the…

Structural heart disease management during cancer treatment

Open full size image KEY POINTS Baseline transthoracic echocardiogram is important for the assessment of heart structure and function, and the determination of the presence or absence of pericardial or valvular heart disease prior to initiation of cancer treatment. On autopsy, pericardial involvement is noted in 1% to 20% of patients with cancer, most commonly lung cancer, but also breast and esophageal cancer, melanoma, lymphoma, and…