Feature

Cardio-Oncology Opens New Pathways in Cath Lab

Guidance for managing patients with CVD and cancer may help an underserved population.

Over time, survival rates of patients with cancer have increased, but that has led to a quandary that was not well-characterized until recently: Many cancer treatments are cardiotoxic and, as a result, many cancer survivors develop and eventually die from some form of heart disease.

As part of a trend toward proactivity for CV issues in patients with cancer, the Society for Cardiovascular Angiography and Interventions this year released an expert consensus statement that focuses on treatment and management strategies for patients in the cath lab with CVD and cancer.

Until now, interventionalists lacked guidance on special considerations for such patients, despite an estimated 14.5 million cancer survivors in the United States — a number that is projected to increase to 20 million survivors by 2020. Further, more than two-thirds of people with cancer are still alive 5 years after their diagnosis.

“This means that they have time for potential CV side effects of chemotherapy agents to manifest. Also, these patients are becoming older and, as they get older, their risk for CVD also becomes greater,” Gagan Sahni, MD, FACC, FACP, director of cardio-oncology and cardiology consult services at Mount Sinai Hospital, said in an interview.

Gagan Sahni

Special Challenges

Patients with cancer bring special challenges when they present with CVD, but have traditionally been excluded from PCI-related clinical trials and registries. A document on best practices for these patients was needed, Cezar A. Iliescu, MD, FACC, FSCAI, director of the cardiac catheterization laboratory at The University of Texas MD Anderson Cancer Center and lead author of the SCAI document, told Cardiology Today’s Intervention.

“What [SCAI] realized was that in the community, there was an obstacle to tackling patients with both cancer and heart disease because of the complexity of them as well as factors such as anemia and thrombocytopenia,” he said. “SCAI looked at centers and operators that had experience in doing these procedures, and saw how they did them safely. The beauty of this document is that it encourages interventionalists throughout the country to help patients who have cancer in the effort to overcome CV problems.”

The statement reviews the mechanisms of vascular toxicities in patients with cancer, including vascular toxicities induced by chemotherapy and coronary and peripheral artery disease induced by radiation. The authors identified 20 chemotherapeutic agents that have been associated with myocardial ischemia.

Iliescu and colleagues offer recommendations for prevention of CVD in patients with cancer. Pre-chemotherapy cardioprotection with agents such as beta-blockers, ACE inhibitors and statins is recommended, “although data are limited and such approach remains controversial,” according to the statement. Pre-radiation therapy cardioprotection with aspirin and statins for patients with CAD or at high risk for atherosclerotic CVD is also recommended.

The statement lists a number of CV screening recommendations for patients with cancer, including performance of transthoracic echocardiography on patients with significant exposure to anthracycline or chest radiation starting within 2 years of completion of therapy, and screening within 2 years after radiation therapy in patients with known CAD, patients older than 60 years and those with at least one CVD risk factor.

Advice on Revascularization

The authors recommend the revascularization approach used at MD Anderson Cancer Center, which calls for medical management of patients with ACS and a modified TIMI risk score less than 3 (one point is added for patients who have received chest radiation, and one point is added for patients taking a prothrombotic chemotherapy drug), and invasive therapy or medical management for patients with ACS and a modified TIMI risk score of at least 3, depending on severity of disease and platelet count.

The statement also includes recommendations on vascular access, favoring transradial access in cases in which the patient is a candidate for transradial or transfemoral access because of less risk for bleeding and higher patient satisfaction.

For patients with cancer with expected survival of less than 1 year being considered for non-urgent PCI, fractional flow reserve should be performed to justify revascularization; for patients with cancer with expected survival of less than 1 year and stable angina, medical management should be optimized before resorting to invasive therapy; and for patients with cancer with expected survival of less than 1 year and STEMI or high-risk non-STEMI, percutaneous revascularization may be considered. For patients with cancer with a better prognosis, general revascularization criteria may be applied, but revascularization should be performed in only the most appropriate cases.

“We have included our conservative approach [involving] fractional flow reserve,” Iliescu told Cardiology Today’s Intervention. “In our limited experience so far, we are deferring intervention by 40% to 50%, and patients can still continue to do well, as seen in the DEFER and FAME trials. We try to avoid stenting if possible because being on dual antiplatelet therapy [during] cancer therapy may be challenging.”

Cezar A. Iliescu

When an invasive approach is required, angioplasty and stenting strategies should be based on platelet counts, bivalirudin should be considered to reduce bleeding risk, and IVUS or OCT should be performed after stenting, according to the statement.

Iliescu noted that the document also covers special considerations that must be given to patients with thrombocytopenia.

“It describes how to do cardiac catheterization safely in those patients, using a micropuncture technique,” he said. “We prefer the radial approach because we will probably have less anticoagulation in the procedure, and close monitoring, because despite the fact that they have thrombocytopenia, they can still thrombose and have ACS.”

Moreover, transcatheter aortic valve replacement “may be a viable option in cancer patients with acceptable prognoses and severely symptomatic [aortic stenosis],” Iliescu and colleagues wrote.

“We’re trying not to intervene and interfere with cancer therapy as much as possible. But on the other hand, [the document] gives interventional cardiologists the tools in such a situation. ... [PCI] is a little more meticulous in such a situation because of the increased frailty of the patient population and the added comorbidities,” Iliescu said.

Vascular Disease and Cancer

It is important to have a plan for patients with cancer and peripheral vascular disease, because sometimes a patient’s cancer prognosis makes revascularization inappropriate and other times the treatment for vascular disease will have to be delayed until the treatment for cancer is complete, Mark W. Burket, MD, professor of medicine, chief of the division of cardiovascular medicine and director of vascular medicine at University of Toledo Health, Toledo, Ohio, whose practice includes cardiac and endovascular interventions, said in an interview.

Mark W. Burket

However, “with a treatable cancer and significant vascular disease, the best strategy may be simultaneous treatment,” he said. “We usually favor endovascular as the preferred approach. It’s vitally important to communicate with the oncologist to ensure that whatever antiplatelet medications are needed will be compatible with the planned chemotherapy. This is especially important if thrombocytopenia is likely to develop.”

Another significant consideration, he said, is whether the patient has ever had radiation therapy, especially with older technologies.

“Virtually any vessel within the radiation port is vulnerable, with well-documented reports of carotid, subclavian, renal and lower-extremity arterial obstruction,” he said. “In this setting, an endovascular-first approach is strongly preferred because radiation-induced scarring and small vessel damage make surgery difficult, and wound healing poor. Statin therapy and antiplatelet therapy should be considered lifelong if possible.”

Burket also said radiation injury can have implications for venous intervention, such as triggering of lower-extremity deep vein thrombosis by radiation-induced pelvic vein injury. “Complete treatment involves not only thrombolysis, but also correction of the underlying stenosis, usually with a stent,” he said.

Closer Collaboration

Now that the implications of oncology treatments on patients with CVD are better known, it is crucial to foster collaboration between interventional cardiologists and oncologists, experts said.

“It has become too complex for every [CV] specialist to know all the potential complications and interactions of the drugs used to treat cancer,” Burket said. “Since some of these drugs have been shown to cause acute vessel injury and/or thrombosis, it’s great to have a readily accessible expert to provide advice. In 2016, it seems appropriate for any large center to cultivate this kind of practice.”

One consequence has been that in many centers, emphasis is shifting from focusing on CV issues of patients with cancer when they are far enough along to require a visit to the cath lab to handling them proactively, before revascularization is required.

“This collaboration is moving from where we were treating people who were decompensating — in many cases the battle was already lost — to preventing, screening, detecting and facing these problems, and trying to prevent them by CV therapies,” Iliescu said. “In a way, it brings more complex decisions, but in the long run, it will definitely translate to better outcomes for patients.” — by Erik Swain

Disclosures: Burket, Iliescu and Sahni report no relevant financial disclosures.

Over time, survival rates of patients with cancer have increased, but that has led to a quandary that was not well-characterized until recently: Many cancer treatments are cardiotoxic and, as a result, many cancer survivors develop and eventually die from some form of heart disease.

As part of a trend toward proactivity for CV issues in patients with cancer, the Society for Cardiovascular Angiography and Interventions this year released an expert consensus statement that focuses on treatment and management strategies for patients in the cath lab with CVD and cancer.

Until now, interventionalists lacked guidance on special considerations for such patients, despite an estimated 14.5 million cancer survivors in the United States — a number that is projected to increase to 20 million survivors by 2020. Further, more than two-thirds of people with cancer are still alive 5 years after their diagnosis.

“This means that they have time for potential CV side effects of chemotherapy agents to manifest. Also, these patients are becoming older and, as they get older, their risk for CVD also becomes greater,” Gagan Sahni, MD, FACC, FACP, director of cardio-oncology and cardiology consult services at Mount Sinai Hospital, said in an interview.

Gagan Sahni

Special Challenges

Patients with cancer bring special challenges when they present with CVD, but have traditionally been excluded from PCI-related clinical trials and registries. A document on best practices for these patients was needed, Cezar A. Iliescu, MD, FACC, FSCAI, director of the cardiac catheterization laboratory at The University of Texas MD Anderson Cancer Center and lead author of the SCAI document, told Cardiology Today’s Intervention.

“What [SCAI] realized was that in the community, there was an obstacle to tackling patients with both cancer and heart disease because of the complexity of them as well as factors such as anemia and thrombocytopenia,” he said. “SCAI looked at centers and operators that had experience in doing these procedures, and saw how they did them safely. The beauty of this document is that it encourages interventionalists throughout the country to help patients who have cancer in the effort to overcome CV problems.”

The statement reviews the mechanisms of vascular toxicities in patients with cancer, including vascular toxicities induced by chemotherapy and coronary and peripheral artery disease induced by radiation. The authors identified 20 chemotherapeutic agents that have been associated with myocardial ischemia.

Iliescu and colleagues offer recommendations for prevention of CVD in patients with cancer. Pre-chemotherapy cardioprotection with agents such as beta-blockers, ACE inhibitors and statins is recommended, “although data are limited and such approach remains controversial,” according to the statement. Pre-radiation therapy cardioprotection with aspirin and statins for patients with CAD or at high risk for atherosclerotic CVD is also recommended.

The statement lists a number of CV screening recommendations for patients with cancer, including performance of transthoracic echocardiography on patients with significant exposure to anthracycline or chest radiation starting within 2 years of completion of therapy, and screening within 2 years after radiation therapy in patients with known CAD, patients older than 60 years and those with at least one CVD risk factor.

Advice on Revascularization

The authors recommend the revascularization approach used at MD Anderson Cancer Center, which calls for medical management of patients with ACS and a modified TIMI risk score less than 3 (one point is added for patients who have received chest radiation, and one point is added for patients taking a prothrombotic chemotherapy drug), and invasive therapy or medical management for patients with ACS and a modified TIMI risk score of at least 3, depending on severity of disease and platelet count.

The statement also includes recommendations on vascular access, favoring transradial access in cases in which the patient is a candidate for transradial or transfemoral access because of less risk for bleeding and higher patient satisfaction.

PAGE BREAK

For patients with cancer with expected survival of less than 1 year being considered for non-urgent PCI, fractional flow reserve should be performed to justify revascularization; for patients with cancer with expected survival of less than 1 year and stable angina, medical management should be optimized before resorting to invasive therapy; and for patients with cancer with expected survival of less than 1 year and STEMI or high-risk non-STEMI, percutaneous revascularization may be considered. For patients with cancer with a better prognosis, general revascularization criteria may be applied, but revascularization should be performed in only the most appropriate cases.

“We have included our conservative approach [involving] fractional flow reserve,” Iliescu told Cardiology Today’s Intervention. “In our limited experience so far, we are deferring intervention by 40% to 50%, and patients can still continue to do well, as seen in the DEFER and FAME trials. We try to avoid stenting if possible because being on dual antiplatelet therapy [during] cancer therapy may be challenging.”

Cezar A. Iliescu

When an invasive approach is required, angioplasty and stenting strategies should be based on platelet counts, bivalirudin should be considered to reduce bleeding risk, and IVUS or OCT should be performed after stenting, according to the statement.

Iliescu noted that the document also covers special considerations that must be given to patients with thrombocytopenia.

“It describes how to do cardiac catheterization safely in those patients, using a micropuncture technique,” he said. “We prefer the radial approach because we will probably have less anticoagulation in the procedure, and close monitoring, because despite the fact that they have thrombocytopenia, they can still thrombose and have ACS.”

Moreover, transcatheter aortic valve replacement “may be a viable option in cancer patients with acceptable prognoses and severely symptomatic [aortic stenosis],” Iliescu and colleagues wrote.

“We’re trying not to intervene and interfere with cancer therapy as much as possible. But on the other hand, [the document] gives interventional cardiologists the tools in such a situation. ... [PCI] is a little more meticulous in such a situation because of the increased frailty of the patient population and the added comorbidities,” Iliescu said.

Vascular Disease and Cancer

It is important to have a plan for patients with cancer and peripheral vascular disease, because sometimes a patient’s cancer prognosis makes revascularization inappropriate and other times the treatment for vascular disease will have to be delayed until the treatment for cancer is complete, Mark W. Burket, MD, professor of medicine, chief of the division of cardiovascular medicine and director of vascular medicine at University of Toledo Health, Toledo, Ohio, whose practice includes cardiac and endovascular interventions, said in an interview.

Mark W. Burket

However, “with a treatable cancer and significant vascular disease, the best strategy may be simultaneous treatment,” he said. “We usually favor endovascular as the preferred approach. It’s vitally important to communicate with the oncologist to ensure that whatever antiplatelet medications are needed will be compatible with the planned chemotherapy. This is especially important if thrombocytopenia is likely to develop.”

Another significant consideration, he said, is whether the patient has ever had radiation therapy, especially with older technologies.

“Virtually any vessel within the radiation port is vulnerable, with well-documented reports of carotid, subclavian, renal and lower-extremity arterial obstruction,” he said. “In this setting, an endovascular-first approach is strongly preferred because radiation-induced scarring and small vessel damage make surgery difficult, and wound healing poor. Statin therapy and antiplatelet therapy should be considered lifelong if possible.”

Burket also said radiation injury can have implications for venous intervention, such as triggering of lower-extremity deep vein thrombosis by radiation-induced pelvic vein injury. “Complete treatment involves not only thrombolysis, but also correction of the underlying stenosis, usually with a stent,” he said.

PAGE BREAK

Closer Collaboration

Now that the implications of oncology treatments on patients with CVD are better known, it is crucial to foster collaboration between interventional cardiologists and oncologists, experts said.

“It has become too complex for every [CV] specialist to know all the potential complications and interactions of the drugs used to treat cancer,” Burket said. “Since some of these drugs have been shown to cause acute vessel injury and/or thrombosis, it’s great to have a readily accessible expert to provide advice. In 2016, it seems appropriate for any large center to cultivate this kind of practice.”

One consequence has been that in many centers, emphasis is shifting from focusing on CV issues of patients with cancer when they are far enough along to require a visit to the cath lab to handling them proactively, before revascularization is required.

“This collaboration is moving from where we were treating people who were decompensating — in many cases the battle was already lost — to preventing, screening, detecting and facing these problems, and trying to prevent them by CV therapies,” Iliescu said. “In a way, it brings more complex decisions, but in the long run, it will definitely translate to better outcomes for patients.” — by Erik Swain

Disclosures: Burket, Iliescu and Sahni report no relevant financial disclosures.