Cardio-Oncology (Drs Plana and James)
Current treatments for cancer are saving lives and have been one of the greatest achievements in modern medicine. However, many of the life saving cancer therapies can have significant and serious cardiovascular side effects, such as heart failure, thromboembolism, severe hypertension and lethal arrhythmia. Learn more about cancer treatments and the effect on heart disease by experts from Cleveland Clinic.
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Cleveland_Clinic_Host: Let's begin with the questions.
Symptoms of Heart Disease after Cancer Treatment
FranW: I have idiopathic ventricular tachycardia. I am taking Flecainide twice a day and Toprol once a day for that. I had breast cancer in 2009, a lumpectomy, chemo, and radiation. I am currently taking Femara - have been on it since 2009. I had a VT attack last May (2010). Dr. didn't know what brought it on, but he changed my medication to what I am taking now. (I had been on Flecainide once a day with Verapamil.) Still have some fainting feelings occasionally. My heart rate is rally low. Doc's say Femara is not conflicting with my heart meds, but I wonder. What do you think? Also, is there any update on VT treatment? I had an ablation in 2006 when it first showed up, but it was not successful, so am using medication. Cardiologist says I am not perfect, but doing OK for now. But, I can't "over do" anything without getting fainting feelings. Thanks! Fran
Dr__Plana: Having received chemotherapy and radiation, the questions I have for you is what your ejection fraction is, and do you have any blockages in the coronary arteries (arteries of the heart) - we would recommend a special type of echo that we offer here at the Cleveland Clinic as well as evaluation for coronary artery disease.
CarolynK: I have a friend who had chemotherapy for ovarian cancer. She is now having high heart rates and chest discomfort. Is it possible to treat this and will she need to be on heart meds for life.
Dr__James: Your friend may possibly have some cardiac toxicity, depending on what chemotherapy medications she received. She should undergo an echocardiogram to start, as well as possibly other testing to assess her heart rhythm and chest discomfort.
Gilles: What is best treatment for SVT? Is it Toprol, Digoxin, or ablation with "twilight sleep" anesthesia?
Dr__James: SVT is not a frequent side effect of chemotherapy, although it can occasionally occur. The optimal treatment for SVT varies from patient to patient, whether it is medications or ablation. This decision is ideally made by an electrophysiologist, a doctor that specializes in heart rhythm problems.
benlomondeast: I was treated for Hodgkin's in "82" with mediastinal RT. Subsequent valvular and myocardial damage have progressed to symptomatic heart disease, afib, and failure, what are my best options?
Dr__James: The best starting point would be to see one of us to perform cardiac testing to determine what your options may be.
Damage to the Heart after Cancer Treatment
MargeK: I had breast cancer, lumpectomy, chemo and radiation back in 2008. I have been doing very well. I read that chemo can cause heart failure and muscle damage even up to 10 years after treatment. Do you have statistics as to how often damage occurs?
Dr__Plana: The data that we now have is that LV dysfunction can occur in up to 32% of patients and heart failure in up to 7%. We recommend an echo using a special technology called strain echocardiogram. This new technology that we are pioneering here at the Cardio-Oncology Center allows for very early detection of toxicity.
DaleT: How does chemotherapy damage the myocardium? How do you prevent side effects of chemotherapy from damaging the heart?
Dr__James: Chemotherapy can damage the heart in many ways. A class of chemotherapy medications known as anthracyclines, including the commonly used drug Adriamycin, causes death of heart muscle cells in ways that are not fully elucidated. Higher Adriamycin doses cause more heart muscle cell death. This cell death may be difficult to detect by usual cardiac tests such as standard echocardiography or nuclear MUGA scans. As noted by Dr. Plana, our Cardio-Oncology Center uses stain imaging echocardiography to detect toxicity from chemotherapy at a much earlier stage. When early signs of toxicity are found, we can take steps to minimize cardiac damage. One medication we often use is carvedilol, a beta blocker which is a commonly used heart drug. It has been shown to prevent myocardial cell death experimentally.
PemberKim59: Having had multiple chemotherapies over the last 12 years, I was diagnosed with LV dysfunction and heart muscle damage at your center. I have since been on medications and my strain echoes have been good since the medications have been initiated. How frequently is it recommended that the echo be repeated, since I am no longer on chemotherapy?
Dr__Plana: It is great to know that your strain values have been stable while on therapy. I would follow the advice of your treating physician as to the adequate interval for follow-up testing.
Prevention of Heart Problems with Cancer Treatment
Lara1974: If one is diagnosed with breast cancer and looking into different possibilities for treatment and has a strong family history of heart disease, what is the best way to go for treatment? What should I be looking for?
Dr__James: I would recommend seeking treatment of breast cancer based on medically and scientifically established guidelines. A breast cancer oncology specialist can advise what are the best options for any given patient.
When someone is starting treatment for breast cancer and also has a family history of heart disease, it is important to be evaluated by a cardiologist experienced in cancer therapy. This can allow your oncologist and cardiologist to work together to plan the safest regimen for you.
JennyP: What is the risk to my heart with being treated with adriamycin for breast cancer? Is radiation worse or chemo worse for the heart? Does it make a difference if I am diabetic?
Dr__Plana: The risk of heart failure for a patient receiving adriamycin only is 5%. It goes up if used in combination with other chemotherapeutic agents. The risk of heart failure associated with adriamycin is dose dependent. Chemotherapy and radiation can cause heart toxicity and the fact that you are a diabetic increases the risk for both. I will recommend a thorough evaluation of both your heart function and the status of your heart arteries before initiation of treatment.
shaneme123: Hello: treated for Hodgkins IV with 6 cycles of ABVD two years ago (46 years old); last year valve aortic replacement. What have studies stated about longevity? I had a MUGA (sorry for spelling) test done prior to ABVD treatment; at end had another. No issues found but is the MUGA test accurate/reliable? are there any supplements/drugs that can help the heart and vascular functions after ABVD 6 cycles of treatment?
Dr__Plana: You received adriamycin as part of your chemotherapy. Your longevity will be determined by whether your heart muscle had toxicity secondary to the adriamycin and if the cancer recurs. Although your MUGA scan did not reveal the presence of issues, I will recommend that your heart gets tested with the state of the art technology (strain echocardiogram). If LV dysfunction is encountered, cardioprotective medications can be initiated.
Cleveland_Clinic_Host: Can you please tell us a little more about your program and some new research that has been coming out about the effects of chemotherapy on the heart?
Dr__Plana: We have put together a multidisciplinary center to address the cardiac complications of cancer therapy. The center includes cancer radiotherapy, heart failure and cardiac imaging experts. The goal of the center is to allow the patients to complete their cancer treatments minimizing the cardiac complications.
For patients that have received cardiotoxic chemotherapy and radiation, we offer new technology to detect toxicity that will allow us to initiate treatment and to prevent the development of heart failure.
Dr__James: There is a full spectrum of treatments available through the Cardio-Oncology Center. At the earliest stage, minimizing cardiotoxicity is key. The strain imaging echocardiography allows us to take steps early on to minimize heart damage.
For patients whose hearts have already sustained damage, their cardiomyopathy can be treated with medications and device therapy. For those with extensive damage, we can evaluate for the appropriateness of heart transplantation in some cases or mechanical assist devices. It has been found that patients with chemotherapy-induced cardiomyopathy have similar outcomes with heart transplant and assist devices to patients with other types of cardiomyopathies.
Dr__Plana: The state-of-the-art echo that we offer at the Cardio-Oncology Center includes 3D (three dimensional) calculation of ejection fraction after the administration of echo-contrast (not toxic to the kidneys). It also includes strain imaging. Strain imaging allows an accurate characterization of the function of each individual segments of the heart. When comparing the images obtained during treatment with the ones obtained at baseline, we can identify cardiac toxicity at very early stages.
MH6874: For primary heart cancer – is transplant an option?
Dr__James: Sometimes. Patients with active or recent cancer are not heart transplant candidates because anti-rejection medications can further decrease the body’s ability to fight cancer. However, some patients with primary heart cancer are offered auto-transplantation in select situations. Auto-transplantation is a surgery at Cleveland Clinic whereby the heart is removed from the chest, the cancer removed, and then the heart is placed back into the chest.
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