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Cancer Treatments and Your Heart (Dr. Tamarappoo 10/06/14)

Dr. Tamarappoo

Balaji Tamarappoo, MD, PhD
Co-Director, Cardio-oncology Center

October 6, 2014 - Noon

Description

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. Dr. Tamarappoo answers your questions about cancer treatments and your heart.

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Imaging Studies During and After Cancer Treatment

Moderator: Dr. Tamarapoo, often people have questions about the imaging tests we do for patients who are undergoing cancer treatment. Can you talk about those tests and what patients should ask their doctor?

Balaji_Tamarappoo,_MD,_PhD: The most simple test that would give us information about the performance of the heart muscle, the valves and the aortic root is an echocardiogram. At Cleveland Clinic, we also measure left ventricular strain, which is a more sensitive way to look at the heart muscle. This can be accomplished within 45 minutes and we would recommend an echocardiogram with strain measurement for all patients who are undergoing cancer chemotherapy or radiation therapy. If patients undergo treatment with anthracycline or herceptin based chemotherapy we would also recommend an echocardiogram at either the midpoint or at conclusion of therapy to ensure there has not been damage to the heart. The reason for doing this is because in some patients damage to the heart muscle may be silent and may present at a much later time point. Detection of changes in cardiac function may prompt the oncologist to seek the help of a cardio-oncologist for medical treatment options. Early detection of cardiac damage, may also prompt the oncologist to consider other chemotherapy alternatives or dosage changes.

Kim: If you have LV dysfunction and on medications with normal strain echoes since the medications have been initiated, how frequently is it recommended that the echo be repeated, since I am no longer on chemotherapy?

Balaji_Tamarappoo,_MD,_PhD: An annual echocardiogram is all you would need. You would also want to monitor your clinical symptoms so that your cardiologist can adjust the medications appropriately.

sharon123: Hello: Treated with six cycles of ABVD two years ago. I had a MUGA 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 six cycles of treatment?

Balaji_Tamarappoo,_MD,_PhD: The MUGA is a relatively reliable test of cardiac function however, a cardiac MRI or an echocardiogram can give better images and even more accurate information regarding LV function. If you don't have clinical symptoms of heart disease and your MUGA tests were normal I would not recommend further cardiac testing. At this time, there are no good studies that have shown the benefit of the use of supplements or medications in patients with normal heart function.

Suzanne53: If I am having chemotherapy for breast cancer and I go through testing on my heart and find something - won't that risk the success of my chemotherapy?

Balaji_Tamarappoo,_MD,_PhD: We would not stop your chemotherapy based on echocardiographic information, however we would recommend the use of medications such as beta blockers, ace inhibitors and statins along with your chemotherapy to provide potential cardiac benefit.

AnnS61: I have a friend that recently had cancer treatment. She had echoes during the treatment but not the special strain imaging you talk about on the website. Is that enough to monitor her for heart problems?

Balaji_Tamarappoo,_MD,_PhD: If the echocardiograms did not reveal significant changes in cardiac function, and your friend has not had any clinical symptoms of cardiac damage such as heart failure or chest pain, I do not recommend further non-invasive cardiac testing to monitor her for cardiac problems.


Radiation Heart Disease

Nissa: What effect if any could seven weeks of radiation for breast cancer to sternal area have on heart? Also, has five years of Tamoxifen therapy been found to have any effect on the heart?

Balaji_Tamarappoo,_MD,_PhD: The two classes of medications that have the most profound effect on the heart are anthracyclines and herceptin. Taxol effects microtubules in cancer cells and does not have significant cardiac side effects. The effect of radiation may cause calcification and atherosclerosis in the coronary arteries. It may also cause stiffening of the heart valves; and the heart muscle. However, if you are not having symptoms such as chest tightness, chest pressure or shortness of breath, it is less likely that you are experiencing clinical signs of significant damage.


Chemotherapy and Heart Disease

dbvido28: If you have had treatment - mine was in 2005 - what should you be looking out for? Should I be monitored for this....if there is a problem, is there a solution???? Denise

Balaji_Tamarappoo,_MD,_PhD: The first issue is - what medications were used for treatment? If you were treated with anthracyclines (a common medication is doxorubicin) or herceptin, you would have a higher likelihood of developing cardiac disease. However, only about five percent of patients have sustained cardiac dysfunction after undergoing chemotherapy. A simple test such as an echocardiogram along with measurement of left ventricular strain should be adequate to screen for damage to the heart muscle. If you develop symptoms such as shortness of breath, leg swelling, chest tightness or pressure, you might consider seeking medical attention and treatment with medications such as beta blockers and ace inhibitors. We would normally treat you with these medications if you had heart disease from blockages to your coronary arteries and treatment for chemotherapy induced heart disease is similar.

dbvido28: I previously asked a question but didn't put specifics in. I was treated in 2005 with Adriamycin and Cytoxan. It looks like 116.4 mg of Adria and 116.4 mg of Cytoxan every three weeks - I think it was four cycles. I also had radiation. I have had heart tests as I thought I was having a heart attack but it was GERD. Both times everything was fine with my heart. ECHO, Stress Tests. What would you do if anything?

Balaji_Tamarappoo,_MD,_PhD: I would not recommend routine cardiac testing unless you had recurrence of the symptoms that I mentioned in the previous response to your question submitted.

Dale-T: How does chemotherapy damage the myocardium? How do you prevent side effects of chemotherapy from damaging the heart?

Balaji_Tamarappoo,_MD,_PhD: Chemotherapy is thought to affect the heart by creating "free oxygen radicals" and it also interferes with the way the heart muscle repairs itself. Preliminary studies show that patients who have been treated with beta blockers and with statins may have less cardiac damage. However large scale clinical trials are being planned to examine what cardio-protective medications provide the most benefit.

Melissa: Do all types of chemotherapy put you at risk for heart disease - if not - what types?

Balaji_Tamarappoo,_MD,_PhD: The most common type of chemotherapy used for treatment of lymphoma, sarcoma and breast cancer is anthracycline (doxarubicin, daunorubicin, idarubicin). Anthracyclines can cause myocardial dysfunction. The other chemotherapy agent is herceptin, commonly used for treatment of breast cancer and this can cause cardiac dysfunction, however, this is reversible. Cyclophosphamide can also cause myocardial dysfunction.

Laura1969: 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?

Balaji_Tamarappoo,_MD,_PhD: You should go ahead with the recommendations of your oncologist for treatment of your breast cancer. However, I would request your oncologist to obtain a baseline echocardiogram and if you are being treated with anthracycline or herceptin to also obtain an echocardiogram at midpoint or at the end of treatment to ensure you have not suffered any cardiac damage. If you were to be seen at Cleveland Clinic in the Cardio-Oncology Center we would perform the echocardiogram with measurement of LV strain which is a sensitive indicator of your cardiac function. Dramatic changes in LV strain with treatment would prompt us to consider the use of beta blockers, ace inhibitors and statins (these medications are thought to provide cardio-protection in patients undergoing chemotherapy).


Heart Changes after Cancer Treatment

MargeK: I had breast cancer, lumpectomy, chemo and radiation. 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?

Balaji_Tamarappoo,_MD,_PhD: Overall, 5% of patients who have undergone chemotherapy suffer cardiac dysfunction. With radiation therapy, the damage can take the form of valve disease or damage to the heart muscle itself. With radiation therapy up to 25% of patients can experience some cardiac dysfunction however this would also depend upon how much of the heart was exposed to the radiation field. The largest group of patients who present with cardiac disease after radiation are those who have been treated for lymphoma in the chest. We can perform an exercise treadmill test along with an echocardiogram to assess if you have had any detectable changes in how your heart or heart valves function.

dbvido28: So are you saying that 95% of patients do not have sustained cardiac dysfunction? If so, that is good news.

Balaji_Tamarappoo,_MD,_PhD: Yes - you are correct. However, at this time, we do not have a good handle on who the 95% of patients are and we do not have a clear picture of all the risk factors that predispose a patient to experience chemotherapy induced cardiac dysfunction. This is why we recommend a baseline echocardiogram in all patients who undergo chemotherapy or radiation therapy.

MaryK: I have a friend who had breast cancer treatments 10 years ago and out of the blue this past week, she started having chest pains and shortness of breath with minimal activity. She is seeing a cardiologist next Monday. Her family doc thinks she may have heart damage from her chemo. Is it possible that she can be treated and get back to being an active person again. Right now she is very limited.

Balaji_Tamarappoo,_MD,_PhD: With appropriate treatment of possible heart failure or coronary artery disease, your friend may be able to get back to her usual level of physical functioning. However, this would depend on a number of factors, including the extent of cardiac damage, as well as the type of treatment she might need to undergo. Surgery such as CABG may be associated with a longer duration of post-operative recovery.

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?

Balaji_Tamarappoo,_MD,_PhD: Adriamycin does have cardiac side effects, however the effect is dependent upon the dose. Your oncologist may be able to monitor the effect of your chemotherapy by referring you to a cardiologist who can perform echocardiogram at the initiation of treatment and at the midpoint of treatment. Diabetes is usually associated with an increased risk for coronary artery disease however, there are no studies that have shown that diabetics are at an increased risk of myocardial damage from radiation or chemotherapy. Radiation can be damaging to the heart if the heart is in the field of radiation treatment. It also depends on the dose of radiation and you should speak to your radiation oncologist about minimizing the effective dose of radiation to your heart.


Coronary Artery Disease and Cancer Treatment

Marty15: In 2000, I was treated for ovarian cancer with taxol and carboplatin. Since then, I have lived a very healthy lifestyle (i.e., no smoking, healthy weight, regular exercise, vegetarian diet (no dairy, no meat)). All tests were normal (low BP, good cholesterol, good CRP), and yet, at 69, I recently was treated with angioplasty and stent for blockage of the LAD artery. Can I assume that the cancer treatment put me at high risk? If so, is there anything I can do to avoid future blockage?

Balaji_Tamarappoo,_MD,_PhD: Cancer chemotherapy usually affects the myocardium. More often radiation therapy affects the blood vessels. CAD is mainly related to environmental and genetic factors. Therefore, it is highly likely that the CAD is a result of inherited factors. We would recommend a healthy lifestyle in addition to medical therapy such as statins to reduce the progression of atherosclerosis.

Mary Elizabeth: I had cancer of right breast in 1993, treatment was lumpectomy followed by radiation. I was diagnosed with CAD in 2004. My LAD was 100% occluded just after the large first diagonal branch and first of the perforated branch took off, it was also small and opened with two stents. The left circumflex artery was large with 99% stenosis in the mid portion, one stent was placed there. At times I become short of breath, more like a pressure, with exercise. I exercise at least three times a week. I had a chemical stress test which was normal. Could you please tell me if all my problems were caused by radiation and if there is anything I should watch for. My current meds are Plavix,81mg ASA, Lipitor, Isosorbide, Atenolol. Any answers would be greatly appreciated. Thank You.

Balaji_Tamarappoo,_MD,_PhD: The medical therapy that you are on appears to be optimal for preventing progression of your coronary artery disease. Your shortness of breath may be secondary to the effects of radiation on your lungs. You may also have some limitations of myocardial performance due to previous radiation, however, if your stress test showed that your exercise capacity was appropriate for age and gender, then we would be less concerned about the effect of radiation on your heart. The things to watch out for: The symptoms to watch for are difficulty breathing when lying down, leg swelling, abnormal fluid accumulation in the abdominal area and inability to perform physical activities that you are currently able to do.

Chuck24: What if you developed CAD which required CABG several years after a rigorous chemo regimen. How do you prevent future disease if all other traditional risk factors are minimized?

Balaji_Tamarappoo,_MD,_PhD: The two major determinants of coronary artery disease are environmental factors such as your diet, amount of exercise and exposures (including your chemotherapy or radiation). The other determinant which you do not have the ability to control is your genetic makeup. Besides following a healthy lifestyle, the other way to minimize progression of CAD is the use of medications such as statins.


Valve Disease and Radiation

dulcinea2020: I am 71 y/o female with severe mitral regurg with recommendation for replacement soon. Recently had lumpectomy for DCIS. The recommendation is also for radiation. Since the surgery was on left breast, I am reluctant to have radiation because of the effect on my heart. Is this reasonable?

Balaji_Tamarappoo,_MD,_PhD: This would depend on how soon you need the radiation treatment and if radiation is going to significantly improve your chance of getting complete cure of the cancer. If there are other alternatives to radiation I would recommend those strategies in order to minimize potential damage to your heart. The other advice would be to undergo the mitral valve surgery; allow time for recovery; and then proceed with radiation. If you would like to be seen by one of our cardiologists who treats patients with oncological problems, we would be glad to see you.


Arrhythmias and Cancer Treatment

Jennifer23: What is the relationship between arrhythmias and chemotherapy. I have had an irregular heart rhythm since my chemo - is that related?

Balaji_Tamarappoo,_MD,_PhD: Arrhythmias may result from chemotherapy although they are not the most common presentation of cardiac dysfunction in chemotherapy patients. We would recommend that you be seen by one of our cardiologists at the Cardio-Oncology Center to determine if there are appropriate treatment options and if your arrhythmia requires medical treatment.


Myxoma

RobinV: My wife had an atrial myxoma removed in July, 2012. The surgery was performed by open heart surgery. She is experiencing some of the same symptoms as she did prior to her surgery. Although we know that the likelihood of the reoccurrence of the tumor is not great it is of great concern. From the little research we have done it indicates that up to 25% of the tumors return. She is scheduled to have a stress echo test this coming Wed. Is this type of surgery eligible for the robotic surgery, if necessary?

Balaji_Tamarappoo,_MD,_PhD: In addition to stress echo, a cardiac MRI may be useful to look for recurrence of the myxoma. Robotic surgery at Cleveland Clinic is usually used for mitral valve repair. However for the atrial myxoma, you would have to speak to our cardiothoracic surgeon in terms of performing a second surgery robotically assisted.


Vasovagal Symptoms

donnatriolo: Are there any cardio-oncology patent support groups in Maryland? Can you recommend any therapy for maintaining a balanced day with chronic cardio (undiagnosed) symptoms after completing chemotherapy topical cream skin cancer treatment? Since 2007, after using (over a five yr. period) Aldara / 5% Imiquidmod - chemotherapy cream to treat basil cell and squamis cell skin cancer on my chest and face, I suffer from "episodes" that start with chest thickness and pain - triggering a physiological - vasil vagal -like seizure lasting five minutes - almost passing out, low hr and blood pressure, involuntary tears, talk in whisper, thoughts slowing, little to no energy, or muscle activity in arms and legs. Followed by two days of lethargic - no energy - slow thinking. - My cardio-oncology strain test where negative, my cardiology stress test and sonogram of heart report strong heart. For the past six yrs. I suffer from this. First year, five episodes a year, now in the sixth year, five episodes a month. My spleen was removed when I was seven from a car accident, and with a low immune system, and not realizing - injured host user immune system and bodily physiological functions as a whole from using Aldara/ 5%imiquimod - topical chemotherapy with the capability of stimulating immune activity to induce “unknown levels”.

Balaji_Tamarappoo,_MD,_PhD: If your symptoms are vasovagal you might benefit from being seen by a cardiologist who specializes in patients with syncope. We have a syncope clinic where we see patients such as you with our neurology department. I am not aware of specific cardio-oncology support groups in Maryland.


Research

Moderator: Dr. Tamarappoo, are there any research studies going on regarding this topic?

Balaji_Tamarappoo,_MD,_PhD: We are performing a large scale retrospective study to identify risk factors associated with chemotherapy induced cardiac disease. We are also examining the use of left ventricular strain measurements in guiding therapy of patients who are at risk of chemotherapy induced cardiac disease.


Cardio-Oncology CenterM

Moderator: Dr. Tamarappoo - many people are confused by the term Cardio-Oncology. What is a Cardio-Oncology Center? Who should go there and what are the benefits?

Balaji_Tamarappoo,_MD,_PhD: A Cardio-Oncology center refers to cardiology practice with special focus on treating patients who have had previous or current oncology issues. The cardiologist at our Cardio-Oncology Center are trained in early identification of patients who are at risk for cardiac dysfunction as a result of chemotherapy and radiation therapy. Not all cancer patients need to be seen by a cardiologist however, those patients who experience symptoms are strongly recommended to be under the care of a cardiologist. The benefits of being seen by a cardio-oncologist at a Center like ours is that you would relieve integrated care between the cardiologist and oncologist. Furthermore, with the use of imaging tests we would be able to identify cardiac damage early during the course of your chemotherapy treatment.

Reviewed: 10/14

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