Cardiovascular Risk Assessment in a Hodgkin's Lymphoma Survivor

A 52-year-old female patient is referred to your cardio-oncology clinic for cardiovascular risk stratification and counseling from a cancer survivorship center. Her past medical history is significant for being diagnosed with Hodgkin's Lymphoma at the age of 17. Cancer treatment records, obtained through your affiliated cancer survivorship center, reveal that she received a total cumulative dose of 300 mg/m2 doxorubicin and mantle radiation with a total radiation dose of 40 Gy. No acute cardiotoxic events were documented during her treatment course, and she continues periodic follow-up with her hematologist with no evidence of recurrence or secondary malignancies.

She denies any symptoms of chest pain, palpitations, or unexplained episodes of presyncope or syncope. However, she is not physically active, does not regularly exercise, and ambulates as part of her work as an office administrator, stating she's "never been one to really exercise." She does note some mild dyspnea when climbing one to two flights of stairs, which has been stable. She denies any history of orthopnea, paroxysmal nocturnal dyspnea, claudication-like symptoms in her legs, or lower extremity edema. She has no neurologic symptoms.

Her past medical history is negative for risk factors such as hypertension and diabetes. She does not take any medications or vitamin or herbal supplements. Her family history is significant only for hypertension in her father and her older brother. She denies a history of tobacco or illicit drug use and drinks alcohol socially.

Her physical exam reveals a temperature of 98.2°F, heart rate of 95 bpm, blood pressure of 132/87, respiratory rate of 16 per minute, and an oxygen saturation of 98% on room air. Her height is 5'4" (64 inches), and her weight is 165 pounds with a body mass index of 28.3. She is a well-appearing individual, mildly overweight in no distress. Her head, eye, nose, and throat exam is unremarkable. Her neck exam reveals a jugular venous pressure of approximately 6 cm H20, with no cervical lymphadenopathy. Although not quite audible, you suspect a possible +1 carotid bruit heard in the region in her right carotid artery. Carotid impulses are not delayed, and upstrokes are brisk. Her heart exam reveals a regular rhythm, no S3 or S4 gallop, and a grade II/VI midsystolic murmur heard best at the left upper sternal border with radiation to the carotid arteries. Her lungs are clear to auscultation. Her abdominal exam is negative for ascites or hepatomegaly. Her lower extremity exam is negative for edema and arterial/venous insufficiency, with +2 dorsalis pedis pulses. No clubbing or cyanosis is noted in all four of her extremities.

Laboratory results are negative for any electrolyte and hematologic abnormalities. Her lipid profile consists of a total cholesterol of 216 mg/dL, a high-density lipoprotein level of 38 mg/dL, a low-density lipoprotein level of 142 mg/dL, and triglyceride level of 178 mg/dL. Her electrocardiogram shows normal sinus rhythm, normal axis, no criteria for ventricular or atrial hypertrophy, and nonspecific T wave flattening in the inferior leads. A transthoracic echocardiogram shows a left ventricular ejection fraction of 55-60%, normal wall thickness, and normal wall motion. Mild mitral annular calcification is noted without significant regurgitation. A moderately calcified aortic valve is noted with evidence of mild aortic stenosis with an aortic valve area of 1.6 cm2. Carotid ultrasound Doppler revealed a 50-69% stenosis of the right internal carotid artery with mild, <50% stenosis of the left internal carotid artery.

She asks you about her long-term cardiovascular risk given her history of chemoradiation treatment.

Which of the following is true regarding long-term cardiovascular risk of survivors of Hodgkin's Lymphoma with a history of chemotherapy and mediastinal radiation exposure?

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