Cardio-Oncology Patients in the Cardiac Catheterization Laboratory

Authors:
Iliescu CA, Grines CL, Herrmann J, et al.
Citation:
SCAI Expert Consensus Statement: Evaluation, Management, and Special Considerations of Cardio-Oncology Patients in the Cardiac Catheterization Laboratory. Catheter Cardiovasc Interv 2016;87:E202-E223.

Patients with cancer have greatly improved survival with current chemotherapy and radiation therapies. This has resulted in many patients developing heart disease that may need to be diagnosed or treated in the cardiac catheterization laboratory. The following are key points to remember from this expert consensus document on management of cardio-oncology patients in the catheterization laboratory:

  1. In addition to known effects on ventricular function, certain chemotherapeutic agents may injure the vascular system, causing acute endothelial damage, abnormal vasoreactivity, vasospasm, and platelet activation and aggregation.
  2. Clinical manifestations may include unstable angina, ST-segment elevation myocardial infarction, coronary thrombosis, Prinzmetal's angina, Takotsubo cardiomyopathy, hemorrhagic perimyocarditis, and acute limb ischemia, as well as later progression of coronary and peripheral arterial disease.
  3. Hormonal therapies are also associated with increased thrombotic events.
  4. Radiation therapy also damages endothelial cells and may result in deposition of cholesterol plaques and thrombus formation within days. Progression to significant coronary, carotid, and peripheral arterial disease (depending on the area radiated) can occur as early as 5 years after radiation therapy.
  5. Symptomatic patients treated with chemotherapy known to have vascular toxicity and/or radiation therapy to the chest or other vessels should undergo screening with an ankle-brachial index test, carotid ultrasound, stress test, or coronary computed tomography angiogram every 5 years.
  6. Radiation of the chest and anthracycline chemotherapies may cause myocardial fibrosis and dysfunction, and radiation can also cause constrictive pericarditis and thickening of the valves. Transthoracic echocardiography is recommended before treatment, 2 years after treatment, and every 5 years thereafter.
  7. Before chemotherapy or radiation therapy, one may consider "cardioprotection" with aspirin, statin, angiotensin-converting enzyme inhibitors, and beta-blockers (especially carvedilol or nebivolol). However, data are limited.
  8. Thrombocytopenia is associated with an increased propensity for thrombus formation. Withholding aspirin from patients with cancer with acute coronary syndromes is associated with worse outcomes.
  9. Diagnostic catheterization can be performed at any platelet level. Aspirin may be given if the platelet count is >10,000, and clopidogrel can be given if the platelet count is >30,000. Prasugrel or ticagrelor should not be given if the platelet count is <50,000.
  10. During percutaneous coronary intervention, these bleeding-avoidance strategies are recommended: radial access, bivalirudin, or low-dose heparin.
  11. Appropriate use of fractional flow reserve to justify the need for revascularization and intravascular ultrasound or optical coherence tomography to ensure optimal stent deployment is recommended. Optimal stent deployment may allow earlier discontinuation of dual antiplatelet therapy (DAPT) if necessary.
  12. When percutaneous revascularization is indicated:
    • Balloon angioplasty should be considered for patients with cancer who are not candidates for DAPT (platelets counts = 10,000-30,000/ml) or when a noncardiac procedure or surgery is planned <4 weeks.
    • Bare-metal stents with short-term DAPT should be considered for patients with platelet counts >30,000/ml who need a noncardiac procedure, surgery, or chemotherapy that can be postponed for >4 weeks.
    • Newer-generation drug-eluting stents with longer-term DAPT should be considered for patients with platelet counts >30,000/ml who are not in immediate need for a noncardiac procedure, surgery, or chemotherapy.
  13. When urgent surgery is needed after stenting, at least one antiplatelet agent should be continued.
  14. Patients with cancer may also require noncoronary interventional procedures, as shown in the following Table:

Procedure

Indications

Right heart catheterization

Evaluation of heart failure, constrictive or restrictive cardiomyopathy, valvular heart disease, pulmonary hypertension, and pericardial disease.

Endomyocardial biopsy

Evaluation of intracardiac tumors, unexplained heart failure associated with suspected anthracycline cardiomyopathy, infiltrative cardiomyopathies, and myocarditis.

Pericardiocentesis

Evaluation of pericardial effusion and symptomatic relief.

Balloon pericardiotomy

Prevention of large malignant pericardial effusion,especially in poor surgical candidates.

Balloon aortic valvuloplasty and transcatheter aortic valve replacement

Palliative measure of symptomatic aortic stenosis (or as a bridge for surgical or transcatheter aortic valve replacement).

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Cardio-Oncology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Pulmonary Hypertension and Venous Thromboembolism, Stable Ischemic Heart Disease, Valvular Heart Disease, Anticoagulation Management and ACS, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound

Keywords: Acute Coronary Syndrome, Angina, Unstable, Angioplasty, Balloon, Coronary, Anticoagulants, Aspirin, Cardiac Catheterization, Cardiotoxicity, Coronary Thrombosis, Drug-Eluting Stents, Echocardiography, Heart Failure, Heart Valve Diseases, Hypertension, Pulmonary, Ischemia, Myocarditis, Neoplasms, Percutaneous Coronary Intervention, Pericardiocentesis, Peripheral Arterial Disease, Platelet Aggregation Inhibitors, Radiation Oncology, Stents, Takotsubo Cardiomyopathy, Tomography, Thrombocytopenia, Transcatheter Aortic Valve Replacement


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