CVD in Patients and Survivors of Breast Cancer

Mehta LS, Watson KE, Barac A, et al.
Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. Circulation 2018;Feb 1:[Epub ahead of print].

The following are summary points to remember about this American Heart Association (AHA) Scientific Statement on Cardiovascular Disease (CVD) and Breast Cancer:

  1. In older, postmenopausal women, the risk of mortality attributable to CVD is higher in breast cancer survivors than in women without a history of breast cancer. This greater risk manifests itself approximately 7 years after the diagnosis of breast cancer.
  2. Age-adjusted mortality rates of coronary heart disease (CHD) and stroke are higher than that of breast cancer. Mortality rates are higher in non-Hispanic black women than in non-Hispanic white and Hispanic women for CHD, stroke, and breast cancer.
  3. CVD and breast cancer have shared risk factors including age, diet, family history, alcohol intake, hormone replacement, obesity/overweight, physical activity, and tobacco use. Adherence to a larger number of ideal CV health behaviors or factors from the AHA’s Life’s Simple 7 health campaign is associated with a trend toward a lower incidence of breast cancer (p for trend = 0.11).
  4. Cancer treatment can result in early or delayed cardiotoxicity that can vary from left ventricular (LV) dysfunction to overt HF, hypertension, arrhythmias, myocardial ischemia, valvular disease, thromboembolic disease, pulmonary hypertension, and pericarditis. The most commonly reported and monitored side effect of chemotherapy is LV systolic dysfunction. Patients at risk for CV dysfunction with cardiotoxic therapies include any of the following: a) High-dose anthracycline therapy: doxorubicin ≥250 mg/m2 or epirubicin ≥600 mg/m2; b) High-dose radiation therapy when the heart is in the field of treatment: radiotherapy ≥30 Gy; c) Sequential treatment: lower-dose anthracycline therapy (doxorubicin <250 mg/m2 or epirubicin <600 mg/m2) and then subsequent therapy with trastuzumab; or d) Combination therapy: lower-dose anthracycline (doxorubicin <250 mg/m2 or epirubicin <600 mg/m2) combined with lower-dose radiation therapy when the heart is in the field of treatment (<30 Gy).
  5. Patients more likely to develop cardiotoxicity include those with any of the following risk factors: a) Older age at time of cancer treatment (≥60 years), ≥2 CVD risk factors during or after cancer treatment: diabetes mellitus, dyslipidemia, hypertension, obesity, smoking; and b) History of myocardial infarction, moderate valvular disease, or low normal LV function (50–55%) before or during potentially cardiotoxic chemotherapy.
  6. Radiotherapy can result in coronary atherosclerosis and accelerated endothelial injury as early as 5 years after exposure among breast cancer survivors who receive left-sided thoracic therapy, and persistence of risk remains for up to 30 years. In addition to macrovascular disease, patients can also develop microvascular dysfunction that results clinically in impaired coronary flow reserve, myocardial ischemia, and myocardial fibrosis.
  7. Monitoring strategies for cardiotoxicity include echocardiography and/or strain imaging, MUGA scans (but this is exposing a cancer patient to radiation), cardiac magnetic resonance imaging (MRI) and/or feature tracking (FT-MRI), and biomarkers (troponins, B-type natriuretic peptide).
  8. Since data from large randomized controlled trials of beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker, and spironolactone use in breast cancer patients are not yet available, the authors opine that it is reasonable to treat anthracycline or trastuzumab-induced cardiomyopathy in accordance with the American College of Cardiology/AHA HF guidelines.
  9. There are no definitive guidelines specific to CVD prevention in breast cancer patients, because most of these studies were small and had variable endpoint definitions.
  10. The authors concluded that comprehensive care is an essential element in the management of cancer patients to maximize gains in cancer therapy while minimizing the potential deleterious impact on CV health. This includes surveillance in survivorship programs.

Perspective: This article shines a light on a burgeoning field, but with a paucity of randomized clinical data. There are not enough evidence-based data to make specific recommendations on management of such patients.

Keywords: Arrhythmias, Cardiac, Anthracyclines, Biomarkers, Breast Neoplasms, Cardiomyopathies, Cardiotoxicity, Coronary Artery Disease, Diabetes Mellitus, Diet, Doxorubicin, Dyslipidemias, Echocardiography, Epirubicin, Exercise, Heart Failure, Hypertension, Hypertension, Pulmonary, Magnetic Resonance Imaging, Myocardial Infarction, Natriuretic Peptide, Brain, Neoplasms, Obesity, Overweight, Postmenopause, Primary Prevention, Risk Factors, Smoking, Spironolactone, Stroke, Troponin

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