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Open full size image KEY POINTS Exercise therapy is a pleiotropic intervention with the potential to prevent/reverse therapy-related cardiotoxicity across the cancer continuum Patients at high cardiovascular risk according to American Society of Clinical Oncology (ASCO) guidelines may need clearance from a cardiologist prior to initiating an exercise program Preexercise screening should include assessment of current physical activity levels and/or cardiopulmonary exercise test for exercise safety…
Open full size image KEY POINTS Current and former heavy smokers and patients with respiratory symptoms should be screened for the presence of pulmonary disease at the time of cancer diagnosis Smoking cessation improves treatment outcomes in patients with cancer All patients with cancer should receive inactivated influenza vaccination (yearly) and either have documentation of or receive appropriate pneumococcal vaccination Physiologic evaluation (pulmonary function test [PFT],…
Open full size image KEY POINTS Hypertension and renal disease, which are common in patients with cancer, can have a significant impact on outcomes, including induction and aggravation of cardiotoxicity Baseline risk factors for hypertension and renal disease/toxicity should be recognized and addressed as much as possible before starting anticancer therapy Vascular endothelial growth factor (VEGF) inhibitors, in particular, are associated with both hypertension and the…
Open full size image KEY POINTS All patients with cancer should be evaluated for the presence and risk of developing arrhythmias because these can significantly complicate treatments and outcomes The intake should include preexisting atrial fibrillation, QTc prolongation, and cardiac device status In patients with cancer who have atrial fibrillation, rhythm control strategies to maintain sinus rhythm can be challenging and drug-drug interactions must be anticipated…
Open full size image KEY POINTS Patients with cancer account for more than 20% of all newly diagnosed cases of venous thromboembolic events (VTEs); they are six times more likely to develop VTEs Risk factors for VTE in patients with cancer are patient-, cancer-, and treatment-related As one single risk factor does not reliably predict risk, risk assessment models have been developed, such as the Khorana…
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Open full size image KEY POINTS All patients should undergo screening for preexisting/concomitant cardiovascular (CV) risk factors, cancer-specific risks for cardiomyopathy, and previous cancer therapy-related risk factors for cardiomyopathy before initiation of cancer treatment. Cardiomyopathy or heart failure (CM/HF) can emerge early during cancer therapy, shortly after completion, or many years later. The goal of the pretherapy assessment is to identify the presence or risks of…
Open full size image KEY POINTS Cardiovascular risks depend on traditional risk factors, cancer type, and type of surgical procedures. Assessment of left ventricular (LV) function should be performed preoperatively in patients who have received potentially cardiotoxic chemotherapies, including but not limited to anthracyclines and her-2 receptor antagonists. Preoperative coronary ischemia assessment should be reserved for symptomatic patients or patients with coronary artery disease (CAD) risk…
Open full size image KEY POINTS Hematopoietic stem cell transplantation (HSCT) involves the infusion of multipotent hematopoietic stem cells, usually derived from the bone marrow, peripheral blood, or umbilical cord, and using cells from either the patient him-/herself (autologous), a donor (allogeneic), or an identical twin (syngeneic). A preparative or conditioning regimen is a critical element in HSCT for two reasons: to eradicate the underlying disease…
Open full size image KEY POINTS Radiation therapy can lead to various forms of cardiovascular disease, including cardiomyopathy, heart failure, coronary artery disease, valvular heart disease, pericardial disease, and autonomic dysfunction. Dose sparing is the single most important preventive strategy, accomplished by shifting from a large field (e.g., mantle radiation) to an involved field, from photons to protons, and from none to standard use of ancillary…
Open full size image KEY POINTS Cancer therapies can be associated with a broad range of cardiovascular toxicities The three most important cardiovascular toxicities in terms of reported incidence and severity are 1) cardiomyopathy and heart failure, 2) vascular toxicities and hypertension, and 3) QTC prolongation and arrhythmias The absolute and relative risks of cardiovascular toxicities are drug class specific and will be presented as such…
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Open full size image KEY POINTS The cardio-oncology clinic covers all cardiovascular aspects of patients with cancer, including tumors that involve the heart and vasculature, cancer therapies that affect the heart and vasculature, and cardiovascular diseases in patients with cancer. The key goal of the clinic is to enable patients with cancer to receive the best possible cancer therapy at the lowest possible cardiovascular risk (to…
1 What is the most common cause of cardiac injury? Motor vehicle accidents are the most common cause of cardiac injury. 2 List the physical mechanisms of injury in cardiac trauma. Physical mechanisms of injury include penetrating trauma (i.e., ribs, foreign bodies, sternum), nonpenetrating trauma (or blunt cardiac injury), massive chest compression (or crush injury), deceleration, traction, or torsion of the heart or vascular structures, and…
1 What is the word syncope derived from? According to text in the European Society of Cardiology (ESC) Guidelines on the Management of Syncope, the word syncope is derived from the Greek words syn , meaning “with,” and the verb kopto , meaning “I cut” or “I interrupt.” 2 What is syncope? An abrupt, transient, and complete loss of consciousness with spontaneous recovery associated with inability…
1 What is the definition of pulmonary hypertension and pulmonary arterial hypertension? At the Sixth World Symposium on Pulmonary Hypertension (PH), held in Nice, France, in 2018 and subsequently published in 2019, a consensus expert panel reestablished the definition of PH as mean pulmonary arterial pressure (mPAP) greater than 20 mm Hg as measured during invasive hemodynamic testing and emphasized the role of measuring pulmonary vascular…
1 What is the natural history of perioperative cardiac morbidity? Perioperative cardiac morbidity occurs most commonly during the first 3 postoperative days and includes perioperative myocardial infarction (PMI), unstable angina, congestive heart failure, cardiac death, and nonfatal cardiac arrests. Studies suggest a peak incidence of PMI within the first 48 hours or earlier. Among patients with known ischemic heart disease, incidence of PMI is approximately 5%,…
1 The pericardium is not necessary for life. What does it do? Why is it important? The pericardium serves many important but subtle functions. It limits distension and facilitates interaction of the cardiac chambers, influences ventricular filling, prevents excessive torsion and displacement of the heart, minimizes friction with surrounding structures, prevents the spread of infection from contiguous structures, and equalizes gravitational, hydrostatic, and inertial forces over…
1 How does warfarin work? Warfarin (and related coumarin compounds) inhibits the activity of hepatic vitamin K-2,3 epoxide, which is used to recycle the active form of vitamin K, vitamin K hydroquinone. Without sufficient vitamin K hydroquinone, clotting factors II, VII, IX, and X fail to be carboxylated, leaving them in an inactive state. The onset of warfarin anticoagulation is gradual and related to the elimination…