Cardio OncologyNeeds and Opportunities

Charleston, SC

November 23rd, 2019

William B. Ellison, Jr MD FACC

• What is it ?

• Why are we here?

• Why does it matter?

• How many people are affected ?

• What types of cardiovascular pathology are we talking about?

• What strategies are effective in reducing the incidence of the problems and/or mitigating the effects ?

Cardio Oncology

Cardiovascular Complications of Cancer Therapy

Forms of Cardiotoxicity

L.F. Nhola, H.R. Villarraga / Rev Esp Cardiol. 2017;70(7):583–589

Mechanisms of Coronary Artery Disease in Cancer Therapy

Cancer Treatment Induced Cardiac Arrhythmias

(Circ Arrhythm Electrophysiol. 2017;10:e005443. DOI: 10.1161/CIRCEP.117.005443

Radiation Induced Heart Disease

Time Course of ToxicityTime frame Agent CV Toxicity

Minutes Paclitaxel Bradycardia

Days

VEGF inhibitors(bevacizumab, lenvatinib, aflibercept, sunitimib)

Hypertension

Tyrosine Kinase Inhibitors (sunitinib, vandetanib)

QT prolongation

Weeks

Checkpoint Inhibitors(nivolumab, pembrolizumab)

Myocarditis

Proteasome inhibitors(carfilzomib)

Heart Failure (HFpEF)

Months

Trastuzumab Heart Failure (HFrEF)

Tyrosine Kinase Inhibitors(nilotinib, ponatinib)

Peripheral Arterial Disease (PAD)

YearsAnthracyclines(doxorubicin)

Heart Failure (HFrEF)

Decades Radiation Restrictive cardiomyopathy

Common Risk Factors

Clonal Hematopoiesis of Indeterminate Potential (CHIP)

• Prevention of CV complications

• Optimization of CV health for CV patients and the facilitation of anticancer treatment

• Early identification of CV complications

• Surveillance for late complications

Who Needs a Cardiologist?

European Heart Journal (2018) 00, 1-8

•63 y.o. male with metastatic rectal cancer treated with FOLFOX beginning June 2018-last dose 9/24/2018

• FOL- folinic acid (leucovorin)

• F- 5-fluorouracil

•OX- oxiliplatin

FOLFOX

Admitted 9/26 with abdominal and chest pain thought to represent indigestion. trop 0.039

Repeat EKG after pain resolution. Discharged on antacids

Admitted to hospital in another city 11.2018with anterior MI

FOLFOX restarted 1.9.2019- stopped 1.23.2019. Readmitted to Roper 1.25 with chest pain and trop of 0.052. Cath showed patent stents in LAD and D1

Cardio Oncology Team

Cardio Oncology Team

• What protocols are helpful in cardiovascular care?

• Role of biomarkers

• Echo and other determinants of EF• How often

• What if it drops

• When to resume

• What medications if any are useful for cardioprotection?• ACEs, beta blockers, aspirin, statins

• What cardiac surveillance is appropriate before, during, and after treatment and for how long?

• What do we do about survivors of childhood cancers in our system?

Cardio Oncology Team