Expert Consensus Highlights Needs of Cancer Patients in the Cath Lab and Beyond

Noting the growing number of cancer survivors, an expert panel has put together a consensus statement to help cardiologists, oncologists, and internal medicine physicians who treat patients with concomitant cancer and cardiovascular disease or those with risk factors for vascular conditions based on cancer history and treatment.

The Society for Cardiovascular Angiography and Interventions (SCAI) document was published January 12, 2016, in Catheterization and Cardiovascular Interventions and is endorsed by the Cardiological Society of India (CSI) and Sociedad Latino Americana de Cardiologia Intervencionista (SOLACI). 

“[I] think it’s the beginning of an exciting journey for all interventionalists that take care of cancer patients,” said lead author Cezar A. Iliescu, MD, of MD Anderson Cancer Center (Houston, TX), in an interview with TCTMD. “Patients are living long enough that they are having both cancer and heart disease, and we have the knowledge to treat both.”

Cancer is known to be associated with a hypercoagulable state, which has long raised concern about the risk of acute thrombotic events, he noted. The skill sets of general cardiologists and interventional cardiologists, Iliescu added, make them a good fit for understanding special needs of cancer patients.

Among the topics covered in the document are pre-chemotherapy and pre-radiation cardioprotection based on cardiovascular risk scores, as well as screening and prevention of cardiovascular risk factors. The latter, when combined with the injury inflicted by chemotherapeutic agents and radiotherapy, can directly affect coronary and peripheral arteries and the myocardium.

“This multifactorial insult can lead to an increased risk of developing cardiomyopathy, myocardial ischemia, vascular disease, or conduction abnormalities as well arrhythmias and QT prolongation,” they write.

Another issue critical to care of patients who have undergone radiation or chemotherapy is treatment-related injuries to the vascular system, including coronary and peripheral circulation. To assist in the recognition of these, the document contains a list of chemotherapeutic agents and radiation types and correlates them with known potential vascular injuries. It also reminds clinicians that cancer survivors, including those who had childhood cancers, may be at higher risk for vascular diseases and require specialized follow up.

Iliescu and colleagues cite data from a retrospective cohort of the Childhood Cancer Survivor Study, which found that adult survivors of childhood malignancies who underwent chemoradiation had a 7-fold higher mortality rate, a 15-fold increased rate of heart failure, a 10-fold higher rate of cardiovascular disease, and a 9-fold higher rate of stroke compared with their siblings. The document contains a table of specific screening recommendations for such patients.

PCI Considerations

Importantly, for clinicians in the cath lab, the document discusses PCI in patients with thrombocytopenia and anemia, with a recommendation to consult with hematology/oncology specialists in patients with severe anemia prior to any catheterization. However, it notes that there is no minimum platelet level that poses an absolute contraindication to angiogram and specifies that “a platelet count of 40,000 to 50,000/mL may be sufficient to perform most interventional procedures with safety, in the absence of associated coagulation abnormalities.”

Iliescu and colleagues also suggest that in cancer patients who are excellent candidates for either femoral or radial access, the radial artery is preferred.

As for patients needing CABG, the authors say tumor stage and general health are the primary considerations. In some cases, CABG and cancer surgery can be performed simultaneously as a 1- or 2-stage procedure, they add.

The paper also touches on TAVR, explaining that while cancer patients are excluded from most TAVR programs, it can be a viable option in those with acceptable prognoses and severely symptomatic aortic stenosis.

Iliescu noted that cancer patients have been excluded from national PCI registries and from most randomized trials involving PCI. Despite this, the experiences of what he called “the first generation of onco-cardiologists” made important contributions to the literature, particularly with regard to recognizing and documenting cardiac care needs in cancer survivors, which assisted in the creation of the consensus document.

Examples of recommendations for revascularization in cancer patients include:

• In those with an expected survival less than 1 year, PCI may be considered for acute STEMI and high-risk NSTEMI
• In those with stable angina, every effort must be made to maximally optimize medical therapy before resorting to an invasive strategy
• FFR is recommended before non-urgent PCI to justify the need for revascularization

“This is a landmark document, and it’s a great day for cancer patients throughout the world,” Iliescu said, adding that he hopes the information will be useful to interventionalists and make dealing with “the double jeopardy” of cancer and heart disease a little less daunting than it may have been in the past. 

“What we want to encourage our colleagues to do is to be more aggressive and more present in cancer care. Our goal in doing this was for them to have a document that they can grab and get some guidance on medications, thresholds for platelets, transfusions, TAVR, etc,” he said. Iliescu added that the writing group has 2 additional papers delving deeper into cancer and cardiovascular disease issues that will be published in the near future.

Source:
Iliescu CA, Grines CL, Herrmann J, et al. SCAI expert consensus statement: evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory. Cath Cardiovasc Intv.2016;Epub ahead of print.

Disclosures:

• Iliescu reports no relevant conflicts of interest.

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