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SCAI releases consensus statement on management of cardio-oncology patients in cath labs
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There are an estimated 14.5 million cancer survivors in the United States, a number that is expected to grow to 20 million by 2020. However, there is little guidance on the treatment of cancer survivors who have CVD.
The Society for Cardiovascular Angiography and Interventions released an expert consensus statement detailing treatment and management strategies for patients in the cath lab with CVD and cancer.
Understudied population
Cezar A. Iliescu
“Little data exist, as cancer patients have been excluded from national [PCI] registries and from most randomized trials involving PCI,” lead author Cezar A. Iliescu, MD, FSCAI, director of the cardiac catheterization laboratory at The University of Texas MD Anderson Cancer Center, said in a press release. “Therefore, SCAI commissioned a consensus group to define the landscape and provide recommendations based on the available published medical literature and the expertise of operators with accumulated experience in the cardiac catheterization of cancer patients.”
The document is aimed at cardiologists, oncologists and internal medicine physicians, according to the release.
The statement reviews the mechanisms of vascular toxicities in patients with cancer, including vascular toxicities induced by chemotherapy and coronary and peripheral artery disease induced by radiation. The authors identified 20 chemotherapeutic agents that have been associated with myocardial ischemia.
The statement offers recommendations for prevention of CVD in patients with cancer. Pre-chemotherapy cardioprotection with agents such as beta-blockers, ACE inhibitors and statins is recommended, “although data are limited and such approach remains controversial,” according to the statement. Pre-radiation therapy cardioprotection with aspirin and statins for patients with CAD or at high risk for atherosclerotic CVD is also recommended.
The statement lists a number of CV screening recommendations for patients with cancer, including performance of transthoracic echocardiography on patients with significant exposure to anthracycline or chest radiation starting within 2 years of completion of therapy, and screening within 2 years after radiation therapy in patients with known CAD, patients older than 60 years and patients with at least one CVD risk factor.
Revascularization algorithm
The authors recommend the revascularization approach used at MD Anderson Cancer Center, which calls for medical management of patients with ACS and a modified TIMI risk score of less than 3 (one point is added for patients who have received chest radiation, and one point is added for patients taking a prothrombotic chemotherapy drug), and invasive therapy or medical management for patients with ACS and a modified TIMI risk score of 3 or more, depending on severity of disease and platelet count.
The statement also includes recommendations on vascular access, favoring transradial access in cases in which the patient is a candidate for transradial or transfemoral access because of less risk for bleeding and higher patient satisfaction.
For patients with cancer with expected survival of less than 1 year being considered for non-urgent PCI, fractional flow reserve should be performed to justify revascularization; for patients with cancer with expected survival of less than 1 year and stable angina, medical management should be optimized before resorting to invasive therapy; and for patients with cancer with expected survival of less than 1 year and STEMI or high-risk non-STEMI, percutaneous revascularization may be considered, the authors wrote. For patients with cancer with a better prognosis, general revascularization criteria may be applied, but revascularization should be performed in only the most appropriate cases, they wrote.
When an invasive approach is required, angioplasty and stenting strategies should be based on platelet counts, bivalirudin should be considered to reduce bleeding risk, and IVUS or OCT should be performed after stenting, according to the statement.
Transcatheter aortic valve replacement “may be a viable option in cancer patients with acceptable prognoses and severely symptomatic [aortic stenosis],” Iliescu and colleagues wrote. – by Erik Swain
Disclosure: The authors report no relevant financial disclosures.
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