Cardio-Oncology Topics From AHA 2019

Introduction

To keep our readers up to date with the latest research in the exponentially growing field of cardio-oncology, we have compiled summaries of relevant abstracts presented at the American Heart Association's Scientific Sessions 2019. Our hope is to educate but also promote interest and the formation of new collaborations. Abstracts are categorized by the following headings:

  1. Cardiovascular Imaging
  2. Biomarkers
  3. AF and Other Arrhythmias
  4. Breast Cancer
  5. Other Outcomes
  6. ACS, PCI, TAVR, and Other Procedures
  7. Epidemiology

Our hope is that this serves as a good reference for new research coming out, and, if you're interested in one of these topics, leads you to do further reading.

I. Cardiovascular Imaging

I.A. Early Captopril Treatment Mitigates Doxorubicin Cardiomyopathy in Mice: A Cardiac MRI Pilot Study
By George M. Cater

  • The authors analyzed the impact of early versus late angiotensin-converting enzyme inhibitor (ACEi) therapy, using serial cardiac magnetic resonance imaging (CMRI) in preventing the adverse cardiac effects of anthracycline cardiomyopathy in a murine anthracycline cardiomyopathy model. The authors report an equivalent 10-week survival in the early ACEi and sham mice, while all late ACEi mice died before 10 weeks (60% vs. 0%; p < 0.05). In surviving mice (n = 3/group), there was a trend toward improvement of left ventricular ejection fraction (LVEF) (16% vs. 1.4%; p = 0.5), recovery of myocardial mass (16 vs. 14 mg; p = 0.02) and improved left ventricular (LV) radial, circumferential, and longitudinal strain in early ACEi mice during weeks 5-10.

I.B. The Impact of Speckle Tracking Echocardiography in Patient With Lymphoma Receiving Chemotherapy
By Yen-Wen Liu

  • The authors investigated the utility of LV global longitudinal strain (GLS) by speckle-tracking echocardiography to detect subclinical LV systolic dysfunction in patients  with lymphoma receiving chemotherapy. In their prospective analysis of 80 patients with lymphoma, the authors report a significant decrease in LV GLS in 18 (27%) patients after 3rd cycle of chemotherapy (-19.6 ± 2.5% vs. -18.5 ± 2.5%; p < 0.001) despite a low cumulative dose of chemotherapy and no significant change of LVEF (69.5 ± 7.1% vs. 70.0 ± 6.9%; p = 0.869). In addition, patients with subclinical LV dysfunction had impaired exercise capacity on cardiopulmonary exercise test: lower VO2/Kg (13.9 ± 3.1 ml/kg/min vs. 16.8 ± 3.9 ml/kg/min; p = 0.025) and lower VO2/Kg at anaerobic threshold (7.0 ± 1.5 ml/kg/min vs. 9.7 ± 3.2 ml/kg/min; p = 0.02).

I.C. The Impact of Anthracycline-Based Chemotherapy on Left Ventricular Function: All Doses Matter
By Hua Zhong

  • In a cross-sectional study, the authors analyzed the impact of anthracycline-based chemotherapy (42 patients, mean age 62.5 ± 11.8 years) and non-anthracycline-based chemotherapies (46 patients, mean age 67.5 ± 11.6 years) on LV function in comparison to a healthy control group (18 patients, mean age 61.3 ± 7.1 years). The authors report significantly decreased two-dimensional (2D) LVEF, three-dimensional (3D) LVEF, and GLS in patients treated with anthracycline-based chemotherapy versus non-anthracycline-based chemotherapies (58.6 ± 4.8% vs. 61.3 ± 5.8%; p = 0.028; 57.7 ± 4.1% vs. 61.5 ± 4.5%; p = 0.001; -18.1 ± 2.6% vs. -20.0 ± 3.0%; p = 0.004, respectively) and versus healthy controls (p < 0.01 for 2D LVEF, 3D LVEF, and GLS). Even among patients with low cumulative doxorubicin doses (<240 mg/m2), 2D LVEF, 3D LVEF, and GLS were significantly decreased compared to the non-anthracycline-based chemotherapies (57.8 ± 4.9% vs. 61.3 ± 5.8%; p = 0.03; 58.1 ± 4.2% vs. 61.5 ± 4.5%; p = 0.02; -18.3 ± 2.2% vs. -20.0 ± 3.0%; p = 0.03, respectively) and control group (p < 0.01 for all 3 measures of systolic function).

I.D. Cardiac Effects of Mitogen-Activated Protein Kinase Inhibitors in Children
By Jennifer A. Su

  • The authors analyzed the effects of MEK inhibitors on cardiac function by echocardiography in children (<21 years). Among 24 children on MEK inhibitor therapy with echocardiography follow-up, 3 of 24 (12.5%) patients developed both abnormal ejection fraction (ejection fraction <53%) and fractional shortening (fractional shortening <27%). Cardiac dysfunction was mild in all cases (lowest documented ejection fraction was 45%, and fractional shortening was 24.4%). Eleven of 24 (45.8%) patients developed borderline ejection fraction (ejection fraction of 53-57.9%) alone, and 6 of 24 (25%) developed borderline fractional shortening (fractional shortening of 27-28.9%) within 2 years of MEK inhibitor initiation. MEK inhibitor therapy was interrupted in 2 patients for cardiac dysfunction that subsequently resolved but with recurrence of fluctuating borderline cardiac dysfunction upon re-initiation of therapy. Symptomatic heart failure (HF) did not occur.

I.E. Subclinical Cardiotoxicity Post Anthracycline in an African Population
By Joseph O Abuodha

  • The authors evaluated the clinical and echocardiographic parameters associated with the development of cardiac dysfunction in a sub-Saharan African population of patients with cancer receiving anthracyclines. Among 141 anthracycline-treated patients (82% breast cancer), 39 (27.7%) developed subclinical LV dysfunction (LVEF or GLS). Mean doxorubicin dose was higher in cases compared with controls (237 vs. 217 mg/m2). Measures of diastolic dysfunction were also different between cases and controls.

II. Biomarkers

II.A. Soluble Urokinase Plasminogen Activator Receptor Levels Rise in Response to Cardiotoxic Chemotherapy Independent of Global Longitudinal Strain
By Maria Devanesan

  • Based on being a marker of chronic immune activation and a strong predictor of cardiovascular (CV) outcomes including HF, the authors investigated whether soluble urokinase-type plasminogen activator receptor increase with doxorubicin containing chemotherapy. The authors observed a significant 22% and 310% increase from baseline in soluble urokinase-type plasminogen activator receptor and N-terminal pro-B-type natriuretic peptide levels, respectively (p < 0.01), in the absence of significant changes in GLS or clinical signs of cardiotoxicity among 23 adult women <65 years of age (mean age 49 years; 30% African American), without baseline cardiac history, receiving 4 cycles of doxorubicin for newly diagnosed ER/PR-positive, HER2-negative, non-metastatic breast cancer. At 6 months post-doxorubicin, soluble urokinase-type plasminogen activator receptor returned to baseline levels, while N-terminal pro-B-type natriuretic peptide remained elevated (p < 0.01).

III. AF and Other Arrhythmias

III.A. Atrial Fibrillation, Heart Failure and Bleeding Risk in Patients on Bruton Tyrosine Kinase Inhibitor Therapy- Results From a Tertiary Care Center
By Manik Veer

  • The authors analyzed the incidence of atrial fibrillation (AF), HF, and bleeding in a retrospective cohort of 154 patients receiving Bruton tyrosine kinase inhibitor (ibrutinib) treatment from December 2013 to May 2018. Incident AF, HF, and bleeding occurred in 8.8%, 17.3%, and 12.4% of the entire cohort, respectively. There was no significant difference in cardiac risk factors between AF cases and controls. Among those with incident AF, subsequent HF (55% vs. 14%; p = 0.001) and bleeding (42% vs. 10%; p = 0.001) were more common than in those without HF.

III.B. Anticoagulation Therapy for Atrial Fibrillation in Cancer Patients May Reduce the Incidence of Venous Thromboembolism
By Pengyang Li

  • Using the National Inpatient Sample database, the authors performed a propensity score-matched analysis of hospitalized patients with cancer 65 years of age and older with (n = 17,471) and without (n = 273,025) anticoagulation for AF to determine whether the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) was different in the 2 groups. Patients on anticoagulation for AF had a significantly lower incidence of acute PE (unmatched 1.9% vs. 2.6%; p < 0.001; matched 1.9% vs. 2.4%; p = 0.001) and acute DVT (unmatched 2.5% vs. 3.3%; p < 0.001; matched 2.5% vs. 3.1%; p < 0.001) than those not on anticoagulation for AF. Patients on anticoagulation for AF also had lower all-cause in-hospital mortality (unmatched, p<0.001; matched 5.8% vs. 6.7%; p < 0.001), total cost (unmatched p < 0.001; matched $16,476 ± 38,041 vs. $12,471 ± 19,115; p < 0.001), and length of hospitalization (unmatched p = 0.016; matched 5.2 ± 8.9 days vs. 4.6 ± 6.2 days; p < 0.001).

III.C. Prevalence and Impact of Atrial Fibrillation in Hospitalized Solid Organ Cancer Patients
By Srikanth Yandrapalli

  • The authors analyzed the prevalence of AF and its temporal trend, differences in CV disease burden, stroke rate, and age-adjusted mortality compared to those without AF in a retrospectively analysis of the US National Inpatient Sample for all hospitalizations from 2005 to 2014 in adult patients with the 4 most common solid organ cancers (prostate, breast, lung, and colorectal). Among 10,631,215 hospitalizations in patients with these 4 cancers, AF was present in 1,335,755 (12.6%). Rates of AF increased from 11.6% in 2005 to 14.7% in 2014, a 43% age-adjusted increase (odds ratio [OR] for 2014 compared to 2005 1.43; 95% confidence interval [CI], 1.39-1.48; p < 0.001). Compared to patients without AF, those with AF were older with more CV morbidity and had a significantly higher stroke rate (2.7% with than without 1.5%; p < 0.001) and inpatient mortality (10% vs. 5.8%; p < 0.001).

III.D. Impact of Financial Burden Associated With Atrial Fibrillation in Cancer: Insights From National Inpatient Sample
By Avirup Ghua

  • Using the US National Inpatient Sample between 2003 and 2015, the authors analyzed the trends of AF hospitalizations and percentage increase in overall cost associated with AF among adult patients with cancer and AF. Among the 51 million cancer admissions over 13 years, 8.2 million (16%) had comorbid AF. Patients with cancer experienced a temporal increase in the primary AF admissions (1.1% in 2003 to 1.5% in 2015) as well as prevalent AF (12.3% in 2003 to 21% in 2015) among hospitalized patients. An increase in costs associated with AF admissions over time was seen across 5 common cancers (e.g., $44.8/$16.9 million in 2003 to $87.2/$36.7 million for admissions among patients with breast cancer and lymphoma).

IV. Breast Cancer

IV.A. Understanding the Impact of Hypertension Among Breast Cancer Patients Treated With Contemporary Cancer Therapies: 9-Year Trends From Two National Registries
By Rebecca R Carter

  • The authors analyzed the incidence of hypertension (HTN) related admissions and adverse events among female patients with breast cancer using the National Inpatient Sample and Food and Drug Administration adverse event reporting system databases from 2007 to 2015. Among the 5,464,401 breast cancer admissions in the National Inpatient Sample cohort, 46,989 (0.8%) presented with HTN. The authors reported a greater relative increase in HTN admissions per 100,000 patients with breast cancer compared to per 100,000 non-cancer patients (26.4% vs. 9.2%). Among admitted patients with breast cancer with HTN, stroke occurred in 1% and in-hospital mortality in 0.3%. Among the Food and Drug Administration adverse event reporting system breast cancer cohort, those with HTN were more frequently hospitalized (40.1% vs. 36.7%; p < 0.001). HTN events were most commonly associated with chemotherapy (15.4% in 2007 to 32.1% in 2015), closely followed by HTN events in other targeted therapies over time.

IV.B. Healthcare Utilization and Hospital Variation of Cardiac Surveillance During Breast Cancer Treatment
By Yvonne Koop

  • The authors evaluated cardiac surveillance practice patterns among women with breast cancer during and after cancer treatment. Among 16,040 patients with breast cancer from the Dutch Hospital data, only 4,376 (27.3%) received any type of cardiac care. Imaging procedures, such as CMRI and echocardiography, occurred in 0.4% and 11.6% of patients, respectively. Patients receiving cardiotoxic treatments received more cardiac care compared to the overall breast cancer population (36.6% vs. 27.3%). However, only small differences were seen for CMRI (0.4% vs. 0.7%) and measurements of troponin (5.1% vs. 4.2%). A large variation in cardiac care was seen between hospital types and individual hospitals (range 0.4-65%).

IV.C. Temporal Association Between Breast Cancer and Heart Failure in Postmenopausal Women
By Phillip H Lam

  • The authors analyzed the associations between prevalent HF and incident breast cancer and prevalent breast cancer and incident HF in postmenopausal women enrolled in the Women's Health Initiative between 1993 and 1998 and followed through 2017 with centrally adjudicated outcomes. Among a cohort of 44,174 women (mean age 63 ± 7 years), 2,688 participants developed incident breast cancer (of which 2,188 were invasive), and 2,417 developed incident HF (median follow-up 14 years and 15 years, respectively). When compared to a breast cancer-free and HF-free cohort, there was no association between prevalent HF and incident breast cancer (p = 0.98) or incident invasive breast cancer (p = 0.27). Similarly, there was no association between prevalent breast cancer and incident HF (p = 0.46) despite shared risk factors of age, obesity, alcohol use, physical inactivity, and elevated resting heart rate.

V. Other Outcomes

V.A. High Flow Oxygen to Improve Cardiac Autonomic Dysfunction During Exercise in Advanced Cancer: A Pilot Study
By Tushar Ramesh

  • The authors examined the effect of high-flow O2 during exercise on markers of cardiac autonomic dysfunction in patients with advanced cancer. Interbeat intervals of normal sinus beats were calculated as a surrogate measure of heart rate variability. Among 36 patients with cancer randomized to 4 treatment groups (high-flow O2, high-flow room air, low-flow O2, and low-flow room air), the authors report improved exercise time and a trend toward improvement in interbeat intervals of normal sinus beats with high-flow O2 that was not statistically significant. The pooled effect of O2 (n = 18) vs. room air (n = 18) increased exercise time by 102.8 ± 42.5 s (p < 0.05). The high-flow O2 group (n = 9) had exercise time 651.9 ± 264.0 s (p = 0.140), Δ exercise time 188.9 ± 218.6 s (p = 0.140), interbeat intervals of normal sinus beats 10.1 ± 2.2 ms (p = 0.325), and %Δ interbeat intervals of normal sinus beats 25.0 ± 37.4% (p = 0.202) compared to patients in the low-flow room air group (n = 9) who had exercise time 463.2 ± 82.5 s, Δ exercise time 23 ± 93.6 s, interbeat intervals of normal sinus beats 8.5 ± 2.0 ms, and %Δ interbeat intervals of normal sinus beats 5.0 ± 21%.

V.B. A Tumor Suppressive Circular RNA CircITCH Ameliorates Doxorubicin-Induced Cardiotoxicity by Reducing Oxidative Injury and DNA Damage Through Regulation of miR-330-5p/SIRT6 Axis
By Dong Han

  • Using quantitative polymerase chain reaction and RNA in situ hybridization, the authors report a downregulation of circITCH, a tumor suppressor, in doxorubicin-treated human-induced pluripotent stem cell-derived cardiomyocytes as well as in the autopsy specimens of patients with cancer with doxorubicin-induced cardiomyopathy. In addition, they report amelioration of doxorubicin-induced cardiomyocyte injury by circITCH through reduction of cellular/mitochondrial oxidative stress and DNA damage induced by doxorubicin. In human-induced pluripotent stem cell-derived cardiomyocytes, circITCH mediated these effects by regulating downstream proteins through the miR-330-5p/SIRT6 axis. Overexpression of circITCH in mice partially prevented doxorubicin-induced cardiotoxicity.

V.C. Statin Use is Associated With Increased Overall Survival in Patients With Colorectal Cancer: Findings From a Cohort of 29,498 United States Veterans
By Chiara Melloni

  • Using data from the National Veterans Affairs Central Cancer Registry from 2001 to 2011, the authors studied the association between statin use and overall survival of patients with colorectal cancer. Of the 29,498 patients with colorectal cancer identified, 11,340 (38%) were statin users. The authors report a significantly improved 10-year overall survival rate (40% vs. 34%; p < 0.001) and the cancer-specific survival rate (68% vs. 56%; p < 0.001) in statin users compared with non-statin therapy patients, respectively. This association persisted regardless of cancer stage, location, and presence of other CV comorbidities.

V.D. Effect of Aspirin on Venous Thromboembolism in Older Patients With Cancer
By Pengyang Li

  • The authors investigated whether aspirin might prevent venous thromboembolism development in older patients with cancer using the National Inpatient Sample from 2016. Compared to the non-aspirin group (31,654 patients with cancer) the aspirin group (31,654 patients with cancer matched on age, gender, race, insurance, and hospital demographics) had significantly lower incidences of acute PE (unmatched 2.1% vs. 2.6%; p < 0.001; matched 2.1% vs. 2.5%; p < 0.001) and acute DVT (unmatched 2.3% vs. 3.3%; p < 0.001; matched 2.3% vs. 3.2%; p < 0.001), lower in-hospital mortality (unmatched 4.0% vs. 6.8%; p < 0.001; matched 4.0% vs. 6.7%; p < 0.001), shorter length of stay (unmatched 5.29 ± 5.01 vs. 6.26 ± 6.96; p < 0.001; matched 5.29 ± 5.01 vs. 6.24 ± 7.11; p < 0.001), and lower total costs (unmatched $14,700 ± 15,031 vs. $16,545 ± 21,125; p < 0.001; matched $14,700 ± 15,031 vs. $16,261 ± 20,287; p < 0.001).

V.E. Burden and Impact of Takotsubo Cardiomyopathy in Patients Who Previously Underwent Mediastinal/Intrathoracic Radiation Therapy
By Rushik Bhuva

  • The authors analyzed the burden and related inpatient outcomes of takotsubo cardiomyopathy in adult patients with and without prior intrathoracic/mediastinal radiation therapy. Among 7,633 hospitalized patients with prior mediastinal/intrathoracic radiation therapy, the authors report an increasing trend in takotsubo cardiomyopathy per 100,000 hospitalizations in patients with prior mediastinal/intrathoracic radiation therapy compared to those without (from 31 to 241 vs. from 19 to 104; p < 0.001). In-hospital outcomes including all-cause mortality (4.6% vs. 2.8%; OR 1.45; 95% CI, 1.29-1.63; p < 0.001), cardiogenic shock (4.3% vs. 0.2%), cardiac arrest (3.1% vs. 0.9%), arrhythmia (34.3% vs. 24.6%), stroke (3.6% vs. 2.8%), respiratory failure (14.5% vs. 4.6%), length of stay, and hospital charges were significantly higher with takotsubo cardiomyopathy compared with non-takotsubo cardiomyopathy cohorts with prior radiation therapy.

V.F. Association of Ibrutinib and Development or Worsening of Hypertension
By Dae Hyun Lee

  • The authors assessed the incidence and risk factors of new or worsening HTN among patients treated with ibrutinib. In a retrospective cohort study of 106 patients treated with ibrutinib, 52.7% had HTN at baseline and 70% (n = 35) demonstrated an increase in blood pressure from baseline, with 34% (n = 18) developing criteria for new-onset HTN. One third of patients did not have adequate blood pressure control. Factors associated with interval increase in blood pressure included prior AF (p = 0.015) and baseline HTN (p = 0.063).

V.G. Fluoropyrimidine-Associated Cardiotoxicity: Patient Characteristics and Clinical Outcomes
By Inbar Raber

  • The authors analyzed the phenotypic variation in the presentation of fluoropyrimidine-associated CV toxicity. In a retrospective single-center cohort study of 1,844 patients who received either 5-FU or capecitabine from 2008 to 2018, 1.1% of the cohort (20 patients) met the criteria for CV toxicity. The authors report that CV toxicity phenotypes associated with fluoropyrimidine use are not limited to coronary vasospasm. Chest pain was the most common presentation of CV toxicity (90%). Two patients had new LV systolic dysfunction in the absence of ischemia. There was one case of myocarditis, as determined by endomyocardial biopsy. The fluoropyrimidine was discontinued in more than half of patients after the CV toxicity event.

V.H. Orthostatic Hypotension and Tachycardia Syndrome in Patients Undergoing Hematopoietic Cell Transplantation
By Alessandra Vecchie

  • The authors assessed the incidence and prevalence as well as potential risk factors for autonomic nervous system dysfunction (defined as a reduction of >20 mmHg in systolic blood pressure, orthostatic hypotension and/or an increase in heart rate of >30 bpm, [tachycardia syndrome] going from the sitting to the standing position not attributed to dehydration or medications) in patients undergoing hematopoietic cell transplantation. Among 136 patients treated with hematopoietic cell transplantation, pre-existent autonomic dysfunction was present in 3% (4 patients), and new autonomic dysfunction developed in 32% (43 patients). There was no significant difference between autologous or allogenic hematopoietic cell transplantation (p = 0.54). Chronic kidney disease and certain antineoplastic agents were associated with higher odds of developing autonomic dysfunction.

V.I. Cardiac Toxicity and Cardiovascular Events Among Adult Patients Treated With Chimeric Antigen Receptor T-Cells: A Multi-Center Registry
By Raza M Alvi

  • The authors studied the cardiac toxicity (defined as increased troponin or a decreased LVEF) and CV events among adults treated with chimeric antigen receptor-redirected T-cells (CAR-T) targeted cancer therapy. Among a registry of 137 patients who received CAR-T, cytokine release syndrome was noted in 59%; 39% were ≥grade 2. Tocilizumab was administered to 56 patients (41%) with cytokine release syndrome. An elevated troponin occurred in 29 of the 53 tested (54%) and decreased LVEF in 8 of 29 (28%), both occurring only in patients with ≥grade 2 cytokine release syndrome. There were 17 CV events (12%; 6 CV deaths, 6 decompensated HF, and 5 arrhythmias; median time to event was 21 days), all occurring in patients with ≥grade 2 cytokine release syndrome (31% patients with ≥grade 2 cytokine release syndrome). An elevated troponin and a longer duration between cytokine release syndrome onset and tocilizumab administration were both associated with CV events, where the risk increased 1.7-fold with each 12 hours from onset of cytokine release syndrome to tocilizumab administration.

V.J. Predictors of Mortality Among Cancer Patients Treated With Checkpoint Inhibitors
By Ali M Agha

  • The authors analyzed the predictors of mortality among patients with cancer treated with checkpoint inhibitors. Among a cohort of 1,075 patients with cancer receiving treatment with checkpoint inhibitors, the authors report that underlying CV conditions such as coronary artery disease (p = 0.0142) and elevated brain natriuretic peptide (p = 0.0456) as well as use of the checkpoint inhibitor atezolizumab were associated with higher incidence of death. In multivariate analyses, lower weight, lower platelet count, higher cancer stage, diabetes, and the use of atezolizumab were associated with death.

VI. ACS, PCI, TAVR, and Other Procedures

VI.A. Coronary Microvascular Dysfunction is Associated With Worse Outcomes in Patients With Thoracic Malignancy
By Sanjay Divakaran

  • The authors analyzed the prognostic usefulness of cardiac positron emission tomography (PET) derived coronary flow reserve (CFR) as a measure of coronary microvascular dysfunction in patients with thoracic malignancy. A total of 191 patients with various thoracic malignancies (46% breast cancer, 23% lung cancer) who had undergone cardiac PET assessment for chest pain or preoperative assessment was included (excluding individuals with known coronary artery disease, abnormal perfusion, or LVEF <45%). There was no difference in mean CFR between cancer type or treatment groups. Over a median follow-up of 6.68 years after PET, the lowest CFR tertile (CFR <1.71) was associated with higher all-cause mortality after adjusting for age; sex; diabetes; body mass index; metastatic disease; recurrent disease; time between cancer diagnosis and PET; and treatment with chemotherapy, chest irradiation, or surgery (hazard ratio [HR] 2.68; 95% CI, 1.55-4.63; p < 0.001).

VI.B. Thromboembolic and Bleeding Risks in Acute Myocardial Infarction Patients With Cancer Who Received Drug-Eluting Stent Implantation and Dual-Antiplatelet Therapy
By Hiroya Hayashi

  • The authors analyzed the thromboembolic and bleeding risks in a retrospective analysis of 443 patients with acute myocardial infarction treated by primary percutaneous coronary intervention with drug-eluting stent and dual-antiplatelet therapy between 2007 and 2015. Cancer was identified in 11.7% of study subjects. Of these, around 40% had gastrointestinal cancer. Patients with cancer were more likely to be older with history of AF, chronic kidney disease, anemia, and higher Killip class. During the 3-year observational period, cancer was associated with more frequent thromboembolic events (8% vs. 3%; p = 0.03) and higher all-cause mortality (20% vs. 9%; p = 0.03). Moreover, a significantly elevated bleeding risk was observed in subjects with acute myocardial infarction with cancer (10% vs. 3%; p = 0.03).

VI.C. A Risk Prediction Model for Hemorrhagic Events in Elderly Patients With Coronary Artery Disease and Malignant Gastrointestinal Tumors
By Nandi Bao

  • The authors derived a risk prediction model for bleeding events in elderly patients with coronary heart disease and malignant digestive tract tumor. Using logistic regression with stepwise proposed variable method for model selection, the authors identified 15 risk factors (in order of their coefficient of determination: mean blood pressure during hospitalization, platelet count, lymphocytes, carcinoembryonic antigen, CA724, hematocrit, CA125, international normalized ratio, red blood cell count, total protein, hemoglobin, alanine aminotransferase, and serum albumin) associated with increased bleeding events. The area under the receiver operating characteristic curve of this model was 0.756, and the accuracy of predicting bleeding events in elderly patients with coronary heart disease and digestive tract malignancy was 87.6%, with a precision of 0.834 and an F1 value of 0.831.

VI.D. Is HEART Score Adequate for Triaging Acute Chest Pain in Cancer Survivors?
By Ahmad Mahmoud

  • The authors analyzed the prevalence of cancer in patients evaluated for chest pain in emergency department and assessed the performance of the HEART score in predicting major adverse cardiac events (MACE) in patients with or without a history of cancer. In a prospective observational cohort study of 750 patients with chest pain transported to 3 tertiary-care hospitals in the United States, 69 patients (9.1%) had a history of cancer. Overall, 145 MACE events (19%) occurred during the 30-day follow-up period. The authors report no significant difference in the incidence of MACE between those with and without cancer history (18.1% vs. 17.4%; p = 0.89). Patients with a history of cancer had a higher HEART score in the emergency department (4.6 ± 1.8 vs. 3.9 ± 2.0; p = 0.006). The HEART score performed equally well with no difference in predicting MACE in patients with or without a history of cancer (area under the curve = 0.86 vs. 0.84; p = 0.76).

VI.E. Myocardial Infarction in Patients With Concomitant Cancer
By Fangcheng Wu

  • The authors analyzed the effects of concomitant cancer on therapy selection and in-hospital outcomes in patients hospitalized for MI. In a retrospective cohort of 650,975 patients with a principal diagnosis of MI (180,040 STEMI, 470,935 NSTEMI) in the 2016 Nationwide Inpatient Sample, the authors reported concomitant cancer in 3.29%. Patients with cancer were less likely to undergo stenting for STEMI (55.37% vs. 73.88%, OR 0.44, P<0.001) and NSTEMI (22.91% vs. 35.34%, OR 0.54, P<0.001, had lower rates of CABG for STEMI (4.11% vs. 5.78%, OR 0.70, P=0.039) and NSTEMI (5.86% vs. 10.09%, OR 0.55, P<0.001) and were less likely to be treated with drug-eluting stents (DES) for STEMI (34.84% vs. 63.24%, OR 0.31, P<0.001) and NSTEMI (17.48% vs. 31.8%, OR 0.45, P<0.001). In a multivariate logistic regression adjusting for patient demographics and comorbidities, cancer patients had higher in-hospital mortality (9% vs. 4.56%, OR 1.36, P<0.001) and a lower revascularization rate (37.2% vs. 56.56%, OR 0.59, P<0.001) compared with non-cancer patients.

VII. Epidemiology

VII.A. Cancer Survivorship and Incident Cardiovascular Events in the ARIC Study
By Roberta Florido

  • The authors analyzed the CV disease risk among cancer survivors in a prospective cohort of 12,414 participants of the ARIC (Atherosclerosis Risk in Communities) study who were free of CV disease or cancer at baseline (1987-1989). Cancer survivors (n = 2,932; 24%) were older, more likely males, and had more adverse CV disease risk profiles. In multivariable analyses, compared to persons without cancer, cancer survivors had higher risk of CV disease (HR 1.43; 95% CI, 1.30, 1.58), coronary heart disease, (HR 1.11; 95% CI, 0.96, 1.29), HF (HR 1.57; 95% CI, 1.41, 1.75), and stroke (HR 1.25; 95% CI, 1.05, 1.50) after adjusting for baseline and time-varying CV disease risk factors.

VII.B. Trends in Reported Cardiovascular Disease and Hospitalizations in Cancer Patients - Cardio-Oncology Patterns Over 14-Year From Two Nationally Representative Datasets
By Avirup Guha

  • The authors estimated the burden of acute and chronic CV disease in community-dwelling National Health Interview Survey patients with cancer and hospitalized National Inpatient Sample patients with cancer over time from 2004 to 2017. The authors report a prevalence of 18% for CV disease among those reporting cancer in the study participants from National Health Interview Survey, though there was no change in trends of proportions of reported cardiac disease among those with cancer across the years (p-trend 2004-2017 = 0.41). In hospitalized patients from the National Inpatient Sample, from 2004 to 2014, the proportion of primary cardiac hospitalizations reduced significantly over time in patients with cancer from 17% to 14.1% (p-trend 2004-2014 < 0.0001).

VII.C. The Association of Cardiovascular Disease and Future Cancer
By Emily Lau

  • The authors investigated the association of traditional CV risk factors, 10-year atherosclerotic CV disease risk score, and CV biomarkers with incident cancer in the Framingham Heart Study participants. Among 12,712 participants free of CV disease or cancer at baseline, 1,670 incident cancer cases occurred over a median follow-up of 14.6 years. The authors report that CV risk as captured by traditional CV risk factors (p < 0.05 for all), 10-year atherosclerotic CV disease risk score (HR 3.53; 95% CI, 2.84-3.94; p < 0.0001, in individuals with high vs. low atherosclerotic CV disease risk) and brain natriuretic peptide (brain natriuretic peptide tertile 3 vs. 1 [HR 1.62; 95% CI, 1.04-2.51; p = 0.03]) were associated with incident cancer. The development of interim CV events was associated with a >sevenfold higher hazard of subsequent cancer (HR 7.8; 95% CI, 6.44, 9.44).

Clinical Topics: Arrhythmias and Clinical EP, Cardio-Oncology, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Heart Failure and Cardiac Biomarkers, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: AHA Annual Scientific Sessions, AHA19, Alanine Transaminase, American Heart Association, Anaerobic Threshold, Anthracyclines, Atrial Fibrillation, Blood Pressure, Breast Neoplasms, Captopril, Carcinoembryonic Antigen, Cardio-oncology, Cardiotoxicity, Cardiovascular Diseases, Cohort Studies, Complement Factor B, Control Groups, Coronary Artery Disease, Cross-Sectional Studies, Drug-Eluting Stents, Exercise Test, Factor X, Follow-Up Studies, Hematocrit, Heart Rate, Hospital Mortality, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Independent Living, Incidence, Inpatients, International Normalized Ratio, Logistic Models, Myocytes, Cardiac, Natriuretic Peptide, Brain, Myocardial Infarction, Odds Ratio, Percutaneous Coronary Intervention, Pilot Projects, Platelet Count, Platelet Aggregation Inhibitors, Prevalence, Propensity Score, Prospective Studies, Reading, Receptors, Urokinase Plasminogen Activator, Retrospective Studies, Risk Factors, ROC Curve, Serum Albumin, ST Elevation Myocardial Infarction, Stroke Volume, Survival Rate, Urokinase-Type Plasminogen Activator, Venous Thromboembolism, Ventricular Function, Left


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