B P6 C57 Cardio-Oncology: Approach to the Patient Flashcards
(73 cards)
One intuitive and practical approach to the cancer patient with CVD can be summarized under the acronym _____.
SCI-FI
CV Subject
Oncology Context
Cardio-Oncology Interaction
Follow-up on Intervention
The three CVD groups to be attentive to in particular are _____.
Vascular disease
Arrhythmias
Cardiomyopathy/heart failure (HF)
Patients who were diagnosed with cancer and are about to undergo oncological or hematological treatment are referred for a cardiology consultation most commonly out of concern that the _____ could pose a threat to the completion of cancer therapy and the patient
Presence or risk of CVD
The key concept is that ______ add to any pre-existing impairment of CV function decreasing the CV reserve to the point of its exhaustion and eventually the clinical appearance of disease states.
Injuries from cancer therapies
Moreso, two subtypes had been proposed on the basis of the cardiotoxicity reversibility pattern (_______), and the 2014 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACI) consensus document assigned all (potentially) cardiotoxic medication to one of these two groups.
Irreversible cardiac injury - type 1
Reversible cardiac dysfunction - type 2
Alternative classification systems have been proposed, and in the general approach to cancer patients at risk of cardiac dysfunction it might be useful to consider the mechanisms that can account for the decrease in cardiac function:
(1) Directly harmful effects on the myocardium
(2) Indirectly harmful effects on the myocardium, for example, via progression of coronary artery disease (CAD), ischemia, metabolic derangement
(3) Mediated by inflammation
Patients with a history of CAD and myocardial infarction (MI) in particular should be informed about the risks and benefits of undergoing chest radiation therapy.
An increased risk of acute coronary events was seen in particular in this subgroup of women who underwent _____ therapy for breast cancer. The risk of these events is not immediate but within the timeline of years.
Radiation therapy - years
_____ of dose exposure is the best preventive strategy and several techniques are available.
Reduction of dose exposure
Based on pathophysiology, one may propose three main vascular toxicity types:
Acute thrombosis
Acute vasospasm
Accelerated atherosclerosis
The risk of venous thrombosis in cancer patients relates not to a single but several factors (patient-, cancer-, and treatment-related). These are captured in risk prediction models such as the most widely used _____ risk score
Khorana risk score
Based on data indicating a ___% reduction in VTE and/or VTE-related deaths, practice guidelines of various societies suggest the use of direct oral anticoagulants (DOACs) as primary thromboprophylaxis in ambulatory cancer patients who are about to start chemotherapy and have a Khorana score >/= ___, if there are no drug-drug interactions and no high-risk scenario for bleeding.
60%
> /= 2 score - DOAC
_____ remains an option for outpatient thromboprophylaxis in high-risk patients.
Low-molecular-weight heparin (LMWH)
For patients with multiple myeloma receiving “IMiD”-based combination therapy, current guidelines recommend _____ mg daily if none or only one individual/myeloma risk factor, otherwise _____
Myeloma risk factor:
0 or 1: Aspirin 81 to 325
> 1: LMWH equivalent to 40 mg enoxaparin daily or full-dose warfarin
In hospitalized patients with major surgery or acute medical illness, thromboprophylaxis with _____ is recommended per standard recommendations with consideration for ___ weeks extension in high-risk post- operative patients in the setting of abdominal and pelvic surgery for malignancy.
Heparin or LMWH
High risk post-operative patients in Abdominal or pelvic surgery for malignancy: Extend for 4 weeks
Regarding arterial thromboembolic events (ATEs), the highest risk period is within ____ month before and after cancer diagnosis, thereafter declining by persisting for at least 12 months.
1 month
_____ pose the highest malignancy-related risk categories for ATEs, similar to VTE
Advanced (stage 3 and 4) Cancers
Gastrointestinal tract Cancer
Lung Cancer
A therapy-related risk of ATEs is seen in particular with _____.
VEGF inhibitors
Platinum drugs
____ should be anticipated for patients to be started on 5-fluorouracil (5-FU), capecitabine, paclitaxel, cisplatin, bleomycin, VEGF inhibitors such as sorafenib,a nd Bcr-Abl inhibitors such as dasatinib
Acute vasospasm
Accelerated atherosclerosis in cancer patients is most commonly associated with radiation therapy but has received attention with the use of _____ in recent years; it may also be seen with_____.
Bcr-Abl (Nilotinib and ponatinib)
VEGF inhibitors
Cisplatin
Main goals of consultation before treatment
Determine and mitigate CV risk with cancer therapy (chemotherapy, radiation, surgery)
* Optimize CV health and disease
* Enable best and safest cancer care
(prevention and surveillance plan)
Main goals of consultation after treatment
- Recognize and reduce CV risk, preferably early through surveillance efforts
- Optimize CV health and disease
- Contribute to optimal survivorship
care
Main goals of consultation during treatment
- Define severity (acuity) and treatment
- Determine causality with cancer therapy
and need for change in cancer therapy - Co-manage CVD for best outcomes
Patients with cancer who have _____ should be assumed to be more susceptible to cancer therapy-induced arrhythmias, as are those undergoing treatment regimens with known cardiotoxicity potential.
Therefore, as a general rule, comorbidities that could represent a possible arrhythmogenic substrate should be identified and treated aggressively before and during cancer therapy
Electrocardiogram (ECG) abnormalities
Impaired exercise capacity
CVD at baseline
Early identification and appropriate management of _____ is also likely to be the best strategy to modulate the arrhythmogenic substrate and improve outcomes in patients with cancer therapy-induced arrhythmias
Cardiac ischemia, dysfunction, and remodeling