Cardio-Oncology Topics From ACC.20/WCC Virtual

Introduction

The cardio-oncology subspecialty continues to advance at a remarkable pace, with extensive clinical and basic research moving the field forward. In this article, we summarize and highlight the key findings of the abstracts accepted for ACC's 2020 Annual Scientific Session Together with World Congress of Cardiology Virtual related to cardio-oncology topics. The abstracts are categorized as follows:

I. Cardiovascular Imaging
II. Biomarkers
III. AF and Other Arrhythmias
IV. Breast Cancer
V. Other Outcomes
VI. ACS, PCI, TAVR, and Other Procedures

We hope this will provide an overview of ongoing research in the field and serve as a quick guide to direct the readers to further readings on topics that interest them.

I. Cardiovascular Imaging

Intramyocardial Fast-SENC CMR Strain Is Less Impacted by Compensatory Mechanisms Than Echocardiography in Monitoring Cardiotoxicity: The PREFECT Study
By Henning Steen

  • The authors compared fast strain-encoded (fSENC) cardiac magnetic resonance (CMR) and echocardiographic parameters in measuring subclinical and clinical cardiotoxicity in 63 patients receiving anthracycline-based cancer treatment. fSENC detected early subclinical cardiotoxicity irrespective of loading conditions and prior to a decline in left ventricular ejection fraction (LVEF) by CMR. Echocardiography-derived LVEF and global longitudinal strain (GLS) did not accurately detect presence of cardiotoxicity. fSENC is a direct measure of intramyocardial contraction less impacted by loading conditions compared to LVEF and GLS based on tissue tracking.

Regional Fast-SENC Circumferntial Strain Assesses Cardiotoxicity Risk Before Initiating Cancer Therapy: The PREFECT Study
By Henning Steen

  • The authors evaluated the ability of baseline fSENC CMR to stratify cardiotoxicity risk in 63 patients undergoing anthracycline-based cancer treatment. Circumferential fSENC identified the risk for both subclinical and clinical cardiotoxicity, while longitudinal fSENC only identified clinical cardiotoxicity from absence of cardiotoxicity. Neither baseline CMR-derived nor echocardiography-derived LVEF and GLS were associated with development of cardiotoxicity.

Cardiotoxicity During Cancer Treatment Causes More Regional Than Global Dysfunction: The PREFECT Study
By Henning Steen

  • The authors compared midmyocardial fSENC CMR to endocardial and epicardial fSENC in detecting subclinical and clinical cardiotoxicity in 63 patients undergoing anthracycline-based cancer treatment. All myocardial layers detected subclinical and clinical cardiotoxicity with high accuracy. There were regional differences in the left ventricle (LV) where the lateral wall was least affected by cardiotoxicity compared to the septal, anterior, and inferior LV walls.

T1 Mapping and Myocardium Strain Evaluated Through Tissue Tracking in Patients With Lymphoma Treated With Anthracyclines
By Isabela Costa

  • Forty-eight patients with lymphoma undergoing treatment with anthracyclines were evaluated with CMR at baseline (time 1), at the end of the third cycle of chemotherapy (time 2), and 30 days after chemotherapy (time 3). At time 1, there was no significant difference between CMR parameters including LV volumes, native T1 mapping, or GLS. However, at time 3, patients with cardiotoxicity had similar diastolic volumes, higher systolic volumes, lower LVEF, and reduced GLS and radial strain compared to patients without cardiotoxicity. There was no significant difference in T1 mapping or extracellular volume between patients with and without cardiotoxicity at time 2 or time 3.

Global Longitudinal Strain as a Therapeutic Guide for Myocardial Dysfunction During Trastuzumab Treatment: A Randomized Single-Center Study
By Eliane Ramos

  • In a randomized controlled trial, 83 patients with breast cancer and no prior heart disease who showed a >15% decline in GLS during trastuzumab therapy with preserved LVEF were randomized to treatment with carvedilol and enalapril (group A) versus no treatment (group B). Trastuzumab therapy was not interrupted. Patients in group A had a significantly higher mean GLS compared to group B during the third month of intervention.

Variable Left Ventricular Ejection Fraction on Multigated Radionuclide Imaging Analyzed by Different Software Packages in Patients With Cancer
By Anoshia Raza

  • The study included 210 multigated acquisition scans in 123 patients (94% with cancer) processed using two software packages, showing that the mean difference in ejection fraction between the paired studies was 10.4%. Of the total number of scans, 105 (50%) showed a difference in ejection fraction greater than 10%. The study highlights that software packages are not interchangeable in measuring LVEF and the difference in measurement may lead to inappropriate decision-making in cancer treatment.

Multi-Parametric Cardiac Magnetic Resonance Markers of Angiogenesis Inhibitor-Induced Cardiotoxicity
By Stephen Dobbin

  • In this prospective study, 9 patients receiving vascular endothelial growth factor signaling pathway inhibitors for cancer treatment were enrolled and underwent stress-perfusion magnetic resonance imaging before treatment and after 4-6 weeks of treatment. The results showed that vascular endothelial growth factor signaling pathway inhibitor therapy is associated with early reduction in LVEF, T1, extracellular volume, and resting myocardial blood flow. Cardiac microvascular constriction and rarefaction may contribute to vascular endothelial growth factor signaling pathway inhibitor-associated LV systolic dysfunction.

Role of Speckle Tracking Echocardiography for Assessment of Ventricular Function in Children Treated With Anthracycline Chemotherapy
By Doaa Shahbah

  • This was a retrospective cohort study of 34 pediatric patients to assess change in GLS and traditional measures of systolic and diastolic function by echocardiography at baseline prior to start of anthracycline chemotherapy and at most recent follow-up. Time from diagnosis to follow-up was 21.7 ± 18 months. There was a significant drop in GLS after anthracycline therapy compared to baseline in the setting of normal ejection fraction, which implies presence of occult LV systolic dysfunction.

II. Biomarkers

The Clinical Relevance of Paraoxonase-1 Activity as a Novel Biomarker in Breast Cancer Patients Treated With Doxorubicin With or Without Trastuzumab
By Elizabeth Thompson

  • The authors investigated the potential role of paraoxonase-1, a cardioprotective enzyme, as a novel biomarker for the development of cancer therapy-related cardiac dysfunction. The study included 225 patients with breast cancer receiving doxorubicin or doxorubicin and trastuzumab from the Penn Cardiotoxicity of Cancer Therapy cohort study. Paraoxonase-1 activity was quantified based on the activity levels of its paraoxonase, arylesterase, and lactonase. Paraoxonase, arylesterase, and lactonase activity decreased after doxorubicin treatment. A decline in paraoxonase or lactonase activity was associated with a lower risk of cancer therapy-related cardiac dysfunction.

III. AF and Other Arrhythmias

Prevalence of Atrial Fibrillation With Cancers and Associated Mortality: A Retrospective Study
By Muhammad Khan

  • The authors investigated the association between different cancer types and incidence of atrial fibrillation (AF) based on data obtained from the National Inpatient Sample on 143,211,398 patients between 2012 and 2015. There was a significant association between prostate, lung, colon, breast, pancreas, leukemia, non-Hodgkin's, Hodgkin's, and intrathoracic cancer and presence of AF. Patients with prostate cancer had the highest incidence of AF. Patients with AF and prostate cancer, non-Hodgkin's lymphoma, or colon cancer had increased risk of mortality.

Atrial Fibrillation in Active Cancer Patients Who Develop Strokes
By Alia Khamis

  • In a case-control study of 318 patients, the authors compared patients with active cancer presenting to the emergency department with stroke or transient ischemic attack (TIA) between 2014 and 2018 at King Hussein Cancer Center to a computer-matched control group without stroke/TIA in order to evaluate the relationships among cancer, AF, and stroke. Patients presenting with stroke/TIA had higher rates of AF, distant cancer, history of stroke, coronary artery disease, chronic kidney disease, concurrent aspirin use, and higher CHADS2VASc and HAS-BLED scores. Although history of stroke, chronic kidney disease, and concurrent aspirin use were independent risk factors for stroke/TIA, AF on presentation was a weak predictor of stroke/TIA in the cancer population.

IV. Breast Cancer

Making Survivorship Matter: Predicting Cancer Therapy-Related Cardiac Dysfunction in Women With Her2+ Breast Cancer Through Integrative Diagnostic Approaches
By Dakota Gustafson

  • The authors investigated the role of circulating extracellular vesicles as predictors of subclinical cardiac injury and cancer therapy-related cardiac dysfunction in a cohort of patients with breast cancer. Patients were stratified by presence (n = 36) or absence (n = 76) of cancer therapy-related cardiac dysfunction. Patients with breast cancer who develop cancer therapy-related cardiac dysfunction had distinct plasma extracellular vesicles before and following anthracycline therapy. Patients who develop cancer therapy-related cardiac dysfunction demonstrated distinct microRNAs associated with angiogenesis and cardiac proteins pre- treatment and microRNAs associated with oxidative stress post-treatment.

The Impact of Cardiotoxicity and Trastuzumab Interruption on Breast Cancer Outcomes
By Robert S. Copeland-Halperin

  • In a retrospective study of 1,396 patients with stage I-III HER2+ breast cancer receiving trastuzumab at Memorial Sloan Kettering Cancer Center, the authors found that cardiotoxicity was a common reason for interruption of therapy (13%). Interruption of trastuzumab therapy was associated with worse recurrence-free survival, particularly when interruption occurred at trastuzumab doses <56 mg/kg.

Cardiotoxicity Surveillance and Risk of Heart Failure During Targeted-Her2 Therapy: A Case-Control Studyq
By Anthony F. Yu

  • In a case-control study including 53 cases of patients who developed HER-2 therapy-related cardiotoxicity and 159 controls, adherence to cardiotoxicity surveillance guidelines (LVEF assessment every 3 months) was not associated with a lower risk of heart failure (HF) defined as New York Heart Association Class III or IV symptoms. An LVEF <55% at any point during treatment was predictive of a HF event.

Prognosis of Heart Failure Following Cardiotoxic Breast Cancer Chemotherapy: A Retrospective Matched Cohort Study
By Felicia Tai

  • Using administrative databases, 804 patients with early breast cancer who developed HF after receiving cardiotoxic treatment were compared to 2,411 age-matched cancer-free women developing HF in the same year. The study found that women developing HF after chemotherapy for early breast cancer have fewer comorbidities at the time of HF diagnosis and better outcome than the women developing HF from other causes.

Statins Are Associated With Lower Risk of Heart Failure After Anthracycline and Trastuzumab Chemotherapy for Early Stage Breast Cancer
By David Bobrowski

  • Linked administrative databases were utilized to conduct a population-based retrospective cohort study of 2,545 anthracycline-treated women, of whom 953 were statin-exposed at the index date, and 1,345 trastuzumab-treated women, of whom 568 were statin-exposed at the index date. Statin-treated women were matched with untreated women (1:1). Results showed that statin exposure is associated with lower rates of HF after anthracycline- and trastuzumab-based chemotherapy for early breast cancer.

Racial Differences in Incidence of Cardiotoxicity in Breast Cancer Patients: A Real-World Study
By Mary Branch

  • This study evaluated 112 women (23 African American and 89 Caucasian) with stage I-IV breast cancer treated with anthracycline and/or trastuzumab. African American race was associated with higher incidence of cardiotoxicity, though not statistically significant, and this association was not attenuated by cardiovascular risk factors.

Cardiologist Involvement in Breast Cancer Patients Treated With Trastuzumab-Based Cancer Therapy Regimen
By Biniyam G. Demissei

  • This is a retrospective cohort study of 1,047 patients with breast cancer treated with trastuzumab therapy to determine the impact of cardiologist involvement. The results showed that cardiologist involvement is associated with a higher rate of guideline-adherent cardiac function monitoring and modest improvements in the control of cardiovascular risk factors such as systolic blood pressure (BP) and body mass index (BMI). The findings do not suggest an association between cardiologist involvement and overall survival.

Carvedilol for Prevention of Chemotherapy-Induced Cardiotoxicity: Final Results of the Prospective, Randomized, Double-Blind, Placebo Controlled CECCY Trial
By Silvia M M. Ayub-Ferreira

  • This randomized double-blinded placebo-controlled trial aimed to assess the effectiveness of carvedilol in the prevention of anthracycline-induced cardiomyopathy in patients with breast cancer treated with doxorubicin, cyclophosphamide, and paclitaxel. The cumulative doxorubicin dose was 240 mg/m2. Patients were treated with carvedilol/placebo for 6 months during treatment. The primary study endpoint at 2 years of LVEF decrease ≥10% showed no difference between the 2 groups (10% carvedilol vs. 11% placebo). There was a trend toward less diastolic dysfunction in the carvedilol group at the 2-year follow-up.

V. Other Outcomes

Cardiovascular Disease in Adult Survivors of Pediatric Cancers: Role of a Multidisciplinary Survivorship Clinic in Identification and Care
By Nisha Raiker

  • The authors evaluated the prevalence of cardiovascular disease, cardiovascular medication use, and major adverse cardiac event (MACE) free survival in a retrospective cohort study of 124 adult survivors of pediatric cancer treated with anthracycline, chest radiation, or both. Prevalence of cardiovascular disease was high (total 48%:  cardiomyopathy 17%, hypertension (HTN) 19%, dyslipidemia 27%, coronary artery disease 6%, carotid atherosclerosis 17%) and the majority of patients received cardiovascular medications (57%), which included statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors. MACE occurred in 12% of the cohort, and patients who received both anthracycline and radiation had lower MACE-free survival compared to patients treated with either anthracycline or radiation.

Lifetime Burden of Traditional Cardiovascular Disease Risk Factors and Incidence of Cancer: The Bogalusa Heart Study
By Camilo Fernandez-Alonso

  • The authors assessed the relationship between traditional atherosclerotic cardiovascular disease risk factors (including BP, BMI, fasting blood glucose, fasting serum triglycerides, high-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol) throughout life and adult onset cancer. Total cholesterol had the most robust association with incident cancer, with a hazard ratio of 9.09 (95% confidence interval [CI], 2.99, 27.48; p < 0.0001). There was a strong association between annualized change in BP per mmHg and hazard of all cancers.

Malignancy Diagnosis and Cause of Death Among Patients With Submassive Pulmonary Embolism
By Apoorva Gupta

  • In a prospective study of 106 patients presenting to a single academic center with a submassive pulmonary embolism (PE), the authors found that the prevalence of malignancy in this population is 14%. Patients with submassive PE and malignancy had significantly higher 6-month mortality compared to patients with submassive PE without malignancy (39% vs. 2%; p < 0.001). The most common cause of death in patients with submassive PE was progressive malignancy followed by sepsis/infection and intracranial hemorrhage/cerebrovascular accident. No patients died from acute decompensation related to the PE. No mortality events occurred at 6 months among the population of patients selected for catheter-directed lysis, although patients with malignancy were less likely to be offered catheter-directed lysis.

Assessment for Dynamic Effects Of Cisplatin-Based Cancer Chemotherapy on Coagulation and Fibrinolytic System
By Wataru Shioyama

  • In a prospective study of 36 patients with cancer undergoing cisplatin-based chemotherapy, the authors investigated the impact of cisplatin on arterial thrombogenesis and endogenous fibrinolytic activity as assessed by occlusion time and lysis time, respectively. At baseline, patients with cancer had enhanced platelet reactivity and suppressed spontaneous thrombolytic activity. After cisplatin treatment, occlusion time was significantly shortened, and lysis time was unchanged.

Comparison of Patients' Phenotypes, Guideline-Directed Recommendations Compliance and Rates of Cardiotoxicity Between Caribbean and United States Cardio-Oncology Programs
By Pamela Piña Santana

  • The authors compared the rate of cardiotoxicity in patients with cancer treated at tertiary centers in the Dominican Republic versus the US Midwest. They included 597 consecutive patients with cancer (predominantly breast cancer) who were being considered for or treated with potentially cardiotoxic drugs. Patients treated in the Dominican Republic had a significantly higher likelihood of cardiotoxicity (odds ratio 2.24; 95% CI, 1.28-3.91; p < 0.004). Age >60, HTN, diabetes mellitus, BMI, tobacco, or chemotherapy were not associated with development of cardiotoxicity.

Beta-Blocker Use Is Associated With Increased All-Cause Mortality in Lung Cancer Patients Receiving Immune Checkpoint Inhibitors
By Ohad Oren

  • The authors investigated beta-blocker use and outcomes in 3,326 patients treated at the Mayo Clinic with an immune checkpoint inhibitor by 7/1/2019. The majority of patients (53.9%) had pre-immunotherapy treatment with beta-blockers. Beta-blocker use was associated with higher all-cause mortality for patients with lung cancer receiving immune checkpoint inhibitors. For patients with absolute indications for beta-blocker use (HF, AF, acute coronary syndrome), there was no association with excess mortality risk. Beta-blocker users had a higher incidence of sepsis after immune checkpoint inhibitor initiation.

Comparison of Yearly Trends in Location of Death Due To Heart Failure Versus Cancer
By Muhammad S. Khan

  • The authors evaluated the trends in location of deaths for patients dying of cancer or HF based on data obtained from the Centers for Disease Control and Prevention from 2003 to 2017. The proportion of in-hospital deaths has declined while the proportion of deaths occurring in hospice facilities has modestly increased in both patient populations. However, the overall inpatient hospice utilization remains low.

Cardiovascular Events Are Very Frequent in Lung Cancer and Multiple Myeloma When Compared To Breast Cancer Survivors
By Joshua Mitchell

  • The authors investigated the prevalence of cardiovascular risk factors and disease in patients with different cancer types, and the incidence of major cardiovascular events following a diagnosis of cancer. HTN was most prevalent across all cancer types. Patients with breast cancer or melanoma had the lowest rates of comorbidities. The incidence of cardiovascular events 12-months post cancer diagnosis was high in patients with lung cancer and multiple myeloma compared to breast cancer.

Clonal Hematopoiesis Associated Mutations, Cardiovascular Events, and All-Cause Death Among Patients With Acute Myeloid Leukemia
By Oscar Calvillo Argüelles

  • In a retrospective study of 198 patients with acute myeloid leukemia, the authors evaluated whether clonal hematopoiesis-related mutations are associated with cardiovascular events or mortality. Presence of a clonal hematopoiesis-related mutation and baseline LVEF were both independently associated with cardiovascular events. Clonal hematopoiesis-related mutations and cardiovascular events were both independent predictors of all-cause death.

Cardiovascular Mortality Risk in Patients With Prostate Cancer Treated With Androgen Deprivation Therapy: A Systematic Review and Meta-Analysis
By Neville Tan

  • The authors performed a meta-analysis including 460,151 patients with prostate cancer to investigate the association between androgen-deprivation therapy and cardiovascular events. In patients with prostate cancer on androgen-deprivation therapy compared to patients not on androgen-deprivation therapy, there was a nonsignificant trend toward increased myocardial infarction and no significant difference in risk of cardiovascular mortality.

The Association Between Heart Failure and Incident Cancer in Women: An Analysis of the Women's Health Initiative
By Douglas Leedy

  • In a prospective observational study of 3,272 and 17,474 post-menopausal women with HF and cancer, respectively, from the Women's Health Initiative, HF was associated with incident cancer (hazard ratio 1.46; 95% CI, 1.29-1.66). HF was associated with obesity- and tobacco-related cancers, as well as lung cancer and colorectal cancer. In a subgroup analysis, HF with preserved ejection fraction was associated with total cancer; however, there was no significant association between HF with reduced ejection fraction and total cancer.

Impact Of Hypertension On Left Ventricular Function In Patients With Malignant Lymphoma After Anthracycline Chemotherapy
By Yusuke Tanaka

  • The authors evaluated the correlation between presence of HTN and occurrence of cancer therapeutics-related cardiac dysfunction in 92 patients with malignant lymphoma who received anthracycline chemotherapy at the Kobe University Hospital and had echocardiograms before and 2 months after termination of therapy. HTN was associated with development of cancer therapy-related cardiac dysfunction especially in patients with evidence of LV hypertrophy.

Renin-Angiotensin System and Beta Blockers in Prevention of Anthracycline Cardiotoxicity: A Systematic Review and Meta-Analysis
By Monica Avila

  • This was a meta-analysis of 17 randomized trials of 1,525 adults treated with anthracycline chemotherapy who received renin-angiotensin system therapies or beta-blockers versus placebo as primary prevention. Results showed that neurohormonal therapy was associated with fewer changes in LVEF, higher final LVEF, and lower incidence of HF but no change in mortality.

Healthcare Disparities in Cardio Oncology: Patients Receive Same Level of Surveillance Regardless of Race and Socioeconomic Status at a Safety Net Hospital
By Crystal Chen

  • This retrospective analysis based on echocardiogram database query aimed to evaluate racial disparities in cardiology clinic referral for cardiotoxicity based on LVEF drop among patients receiving anthracycline and/or trastuzumab in a safety net hospital, defined by high proportion of patients with Medicaid or no insurance. Among 115 patients identified, the study showed similar levels of surveillance, treatment, and outcome in cardiotoxicity regardless of race.

Incidence and Clinical Evolution of Long-Term Anthracycline Cardiotoxicity
By Jose Maria Serrano Antolin

  • Eight-five patients receiving anthracycline (mean dose 243.5 mg/m2) were prospectively monitored for long-term cardiotoxicity with clinical data and echocardiographic parameters collected at baseline, at the end of chemotherapy, 3 months after the end of chemotherapy, and 1-4 years after starting chemotherapy. The results showed that the incidence of long-term cardiotoxicity in patients receiving a low-cumulative dose of anthracycline was 16.5% at the end of the follow-up (14 of 85 patients) with asymptomatic LV dysfunction in 12 patients, HF in 1 patient, and sudden death in 1 patient.

Beta-Blockers and Angiotensin Conversion Enzyme Inhibitors for the Prevention of Anthracycline-Induced Cardiomyopathy: Systematic Review and Network Meta-Analysis
By Raul Montanez

  • A network meta-analysis was performed on 14 randomized control trials to assess if ejection fraction after chemotherapy was significantly higher among patients treated with beta-blockers, ACE inhibitors, and placebo for primary prevention. The results showed that treatment with beta-blockers and ACE inhibitors was not significantly associated with higher LVEF after chemotherapy compared to placebo.

Systemic Hypertension in Patients Exposed to Anthracycline Chemotherapy is Associated With Long Term Mortality
By Jason Cole

  • This retrospective study of 225 survivors of childhood cancer with prior anthracycline exposure found that survivors treated with anti-HTN medications such as beta-blockers, ACE inhibitors, or calcium channel blockers had significantly higher mortality than patients not treated with anti-HTN medications (20% vs. 9%). The study concluded that systemic HTN is associated with increased mortality independent of cumulative anthracycline dose.

Oxygen Uptake Efficiency Slope Identifies Preclinical Cardiotoxicity in Pediatric Cancer Survivors
By Takeshi Tsuda

  • This study compared the findings of cardiopulmonary exercise testing in 39 asymptomatic survivors of pediatric cancer with 39 age- and gender-matched controls. Despite normal LV shortening fraction, survivors of pediatric cancer showed significantly lower peak exercise parameters and submaximal parameters, which may be indicative of subclinical anthracycline-induced cardiotoxicity.

The Combination Therapy of Anti-PD1 Antibody Pembrolizumab and Anti-HER2 Antibody Trastuzumab Exerts Cardiotoxic, Pro-Inflammatory and Pro-Fibrotic Properties in Preclinical Models
By Nicola Maurea

  • The cardiotoxic effects of combined therapy with trastuzumab and pembrolizumab were studied in a mice model. The results showed that the combination therapy led to a reduction of the cardiomyocyte viability. Moreover, the combination therapy increased the inflammation of cardiomyocytes by enhancing the expression NF-kB and interleukins 40-50% compared to single treatment.

The Sodium-Glucose Cotransporter-2 Inhibitor Dapagliflozin Exerts Cardioprotective Effects Against Doxorubicin and Trastuzumab Toxicity Through TLR4/MyD88/Nf-kB Signaling and NLRP3 Inflammasome Pathway
By Nicola Maurea

  • This study assessed the cardioprotective effects of dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, in HL-1 cardiomyocytes exposed to subclinical concentration of doxorubicin and trastuzumab alone or in combination with dapagliflozin. The results showed that dapagliflozin significantly increased the cardiomyocytes' viability during exposure to doxorubicin and trastuzumab, explainable by the reduction of intracellular Ca overload. Moreover, cardiomyocytes exposed to dapagliflozin have reduced expression of pro-inflammatory cytokines involved.

Checkpoint Inhibitors and Their Association With Valvular Dysfunction Among Cancer Patients
By Ali Agha

  • This retrospective study included 285 patients with cancer treated with one or more immune checkpoint inhibitors who had a baseline echocardiogram prior to initiation and at least 1 serial echocardiogram after initiation of immune checkpoint inhibitor therapy. The study showed that immune checkpoint inhibitor administration was associated with new onset or an increase in mitral regurgitation on initial post-therapy echocardiogram. No decline in LVEF with immune checkpoint inhibitor therapy was observed.

Exposure to Low-Dose Ionizing Radiation From Cardiac Procedures and Risk of Malignancy in Children With Congenital Heart Disease
By Elie Ganni

  • This nested case-control study including 272 cancer cases matched by age, sex, and time of cancer with 8,160 controls sought to determine the association between low-dose ionizing radiation exposure from cardiac procedure and cancer incidence in pediatric patients with congenital heart disease. Measurement of association between binary exposure to cardiac low-dose ionizing radiation and cancer risk revealed a threefold increase in those exposed compared to those not exposed. Cancer surveillance guidelines should be considered for patients with congenital heart disease who are exposed to low-dose ionizing radiation.

The Impact of Anthracycline-Based and Non-Anthracycline-Based Chemotherapy on Left Ventricular Function in Cancer Patients: A Prospective Single Center Study
By Hua Zhong

  • This is a prospective study of 34 patients with cancer, with 18 patients receiving anthracycline-based chemotherapy and 16 patients receiving non-anthracycline-based chemotherapy. The anthracycline group, treated with a mean low cumulative dose of 237 mg/m2, had significantly lower LVEF and GLS as early as 6 months after initiation of therapy than the non-anthracycline-treated group, suggesting that patients receiving anthracycline-based chemotherapy should be more closely monitored than is currently recommended.

VI. ACS, PCI, TAVR, and Other Procedures

TAVR Versus SAVR in Patients With Cancer and Aortic Stenosis: A Nationwide Readmission Database Registry Study
By Amer N. Kadri

  • Based on data from the Nationwide Readmission Database, 2,566 patients with malignancy and severe aortic stenosis who underwent isolated surgical versus transcatheter aortic valve replacement (TAVR) were compared. Patients who underwent TAVR were older and had more metastasis, higher prevalence of comorbidities, and shorter hospital stay. There was no significant difference in in-patient mortality or 30-day readmission between the 2 groups; however, patients who underwent TAVR did have significantly lower rates of complications, including vascular complications, acute deep venous thrombosis, acute kidney injury, blood transfusions, cardiogenic shock, and respiratory complications.

Transcatheter Aortic Valve Replacement Outcomes in Radiation-Associated Aortic Stenosis: A Systematic Review and Meta-Analysis
By Abdul Haseeb

  • The authors conducted a meta-analysis including 3 prospective cohort studies to investigate the outcomes of TAVR in patients with radiation-associated aortic stenosis compared to patients with non-radiation-associated aortic stenosis. There was no significant difference between the groups in 30-day mortality, 6-month mortality, all-cause mortality, or the rate of complications that included stroke, major bleeding, pericardial effusion, and new pacemaker implant.

PCI Provides Costly Mortality Reductions For Breast Cancer Patients: Propensity Score And Machine Learning Augmented Nationally Representative Case-Control Study Of 30 Million+ Hospitalizations
By Rahul Gaiba

  • The authors examined the mortality benefit and cost-effectiveness of percutaneous coronary intervention (PCI) in patients with breast cancer based on data from the 2016 National Inpatient Sample. When patients with breast cancer who underwent PCI (cases) were compared with those who did not get PCI (controls), cases had a reduction in mortality that extended to patients with metastatic disease; however, outcomes varied based on geographic location. Cases also had an increase in length of stay and total cost. The net national cost to save the lives of 38 extra patients with breast cancer with PCI was $9.40 billion, with a cost-effectiveness ratio of $247.30 million per averted death.

Long-Term Outcomes Among Patients With Mediastinal Radiation-Induced Coronary Artery Disease Undergoing Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting
By Aaron Dunn

  • In a retrospective cohort study of 333 patients with prior mediastinal radiation who underwent either PCI or coronary artery bypass grafting (CABG) for coronary artery disease, there was no significant difference in death at a mean follow-up of 106 ± 79 months (PCI 40% vs. CABG 53%; p = 0.72). Patients undergoing CABG with valve surgery had a significantly higher mortality rate compared to those patients undergoing CABG alone.

Accelerated Vulnerable Plaque Formation at the Target Lesion in Stable Angina Pectoris Patients With Cancer
By Kazuya Tateishi

  • In a retrospective study, 81 patients with stable angina who underwent PCI with near-infrared spectroscopy intravascular ultrasound were stratified by history of cancer versus no history of cancer. Patients with cancer had a significantly higher coronary lipid core plaque in the target vessel compared to those without cancer.

Contemporary Trends in Left Ventricular Assist Device Implantations and Associated Outcomes in Cancer Patients From 2008 Through 2016: Insights From National Inpatient Sample
By Abhishek Chaturvedi

  • The study examined the national trends in the use of LV assist devices and associated outcomes in patients with cancer from 2008 to 2016 using the National Inpatient Sample. The rates of LV assist device implantation have increased in patients with cancer over the 9-year study period, with a concomitant increase in mean charges, but inpatient mortality (13.6% in 2008 vs. 12.5% in 2016; p = NS) and length of stay (40 days in 2009 vs. 32 days in 2016; p = NS) have not significant changed.

Aortic Valve Replacement in Patients With Malignancy: Surgical or Transcatheter Approach?
By Konstantinos Voudris

  • Data from the Healthcare Cost and Utilization Project National Inpatient Sample database showed that among 59,780 patients with history of malignancy undergoing aortic valve replacement, TAVR was performed in 11,654 (11%). Use of TAVR increased from 1.6% in 2011 to 34.7% in 2015. TAVR was associated with reduced in-hospital mortality, length of hospitalization, and rates of stroke, kidney injury, new onset hemodialysis, blood transfusion, and intra-aortic balloon pump use after adjusting for patient and procedural confounders.

Early Outcomes Following Transcatheter Aortic Valve Replacement (TAVR) in Patients With Prior Mediastinal Radiation: A Propensity Matched Analysis
By Riyad Y. Kherallah

  • The TAVR outcomes of 50 patients with prior mediastinal radiation were compared with 50 propensity-matched patients without history of mediastinal radiation. The 2 groups showed similar overall survival, 30-day mortality, and 30-day readmission rates with no difference in adverse events except for higher respiratory failure in patients with history of radiation, hypothesized to be related to radiation-induced lung injury.

Clinical Characteristics and Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement With and Without Underlying Malignancy
By Kamalpreet Dhaliwal

  • This study included 466 patients with malignancy who underwent TAVR from 2013 to 2018 at a single institution. Patients were divided into 2 groups: solid tumor (81%) and hematological malignancy (19%). The results showed no difference in all-cause mortality, post-TAVR stroke, or re-hospitalization between the 2 groups. Compared to TAVR patients without malignancy, patients with underlying malignancy had statistically significant lower cumulative survival probability.

Early Resumption of Cancer Treatment After Percutaneous Coronary Intervention: Impact on Cardiovascular Outcomes
By Teodora Donisan

  • This is a retrospective study of 76 patients with cancer who underwent PCI with drug-eluting stent. Patients with ST-segment elevation myocardial infarction were excluded. The study showed no significant cardiovascular mortality in patients who resumed cancer treatment (chemotherapy, radiotherapy, surgery, or immunotherapy) as early as 10-14 days after PCI.

Intracoronary Imaging-Guided Discontinuation of Dual Antiplatelet Therapy in Stented Patients Requiring Expedited Cancer Treatment
By Cezar Iliescu

  • This is a retrospective study of 89 patients with cancer stratified into those who underwent intravascular ultrasound or optical coherence tomography immediately after PCI and those who underwent optical coherence tomography in a second procedure before dual antiplatelet therapy discontinuation. The results showed similar clinical outcomes between these two treatment protocols, potentially obviating additional coronary imaging to identify patients at low thrombotic risk prior to planned dual antiplatelet therapy discontinuation.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardio-Oncology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), ACS and Cardiac Biomarkers, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Lipid Metabolism, Nonstatins, Heart Failure and Cardiac Biomarkers, Mechanical Circulatory Support, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Chronic Angina

Keywords: Cardio-oncology, Cardiotoxicity, Acute Coronary Syndrome, Androgen Antagonists, Angiogenesis Inhibitors, Angina, Stable, Angiotensin-Converting Enzyme Inhibitors, Aortic Valve, Aryldialkylphosphatase, Atrial Fibrillation, Calcium Channel Blockers, Breast Neoplasms, Cardiovascular Diseases, Anthracyclines, Blood Glucose, Body Mass Index, Cisplatin, Cholesterol, HDL, Case-Control Studies, Cohort Studies, Coronary Artery Disease, Diastole, Echocardiography, Drug-Eluting Stents, Heart, Enalapril, Healthcare Disparities, Heart Ventricles, Hospices, Hospital Mortality, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Heart-Assist Devices, Inflammasomes, Inpatients, Incidence, Ischemic Attack, Transient, Length of Stay, Medicaid, Multiple Myeloma, Myeloid Differentiation Factor 88, Myocytes, Cardiac, Odds Ratio, Paclitaxel, Patient Readmission, Peptidyl-Dipeptidase A, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Prospective Studies, Prevalence, Retrospective Studies, Renin-Angiotensin System, Spectroscopy, Near-Infrared, ST Elevation Myocardial Infarction, Stroke Volume, Tobacco, Systole, Transcatheter Aortic Valve Replacement, Tomography, Optical Coherence, Vascular Endothelial Growth Factor A, Ventricular Function, Left, acc20, ACC Annual Scientific Session


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