Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
How do you assess the risk of cardiotoxicity from HER2+ agents?
The standard risk factors for cardiac dysfunction from Her2+ therapy are age, prior chest radiation, prior cardiotoxic therapy, baseline LVEF, and co-morbidities such as diabetes, dyslipidemia, obesity, hypertension, atrial fibrillation/flutter, and coronary artery disease. In addition to these, som...
What is your approach to adjuvant HER-2 directed therapy in a patient who developed cardiotoxicity following neoadjuvant TC-HP?
Depending on the risk of the cancer and how bad the cardiotoxicity was, it may be worth trying to reinstitute HER2-directed therapy. Typically I hold HER2-directed therapy for a month at a time (until the EF gets to 50% or higher at which point I reinstitute) and involve a cardiologist familiar with...
Are the cardiac risks of LHRH agonists also seen in patients undergoing bilateral orchiectomy for ADT in hormone-sensitive prostate cancer?
Although the true implications of testosterone suppression on cardiac risk/disease remains somewhat undefined, it is the low testosterone levels, not the mechanism of how these levels were obtained i.e. either surgical or medical castration that is the issue.
How would you modify therapy for a metastatic HER2+ breast CA who develops persistent cardiomyopathy after dual HER2 blockade with trastuzumab + pertuzumab?
The clinical data suggests that dual blockade is not associated with significantly increased cardiomyopathy over trastuzumab based therapy alone. In significant cases holding anti-HER2 therapy for 4-8 weeks can allow the dysfunction to reverse while medical therapy for CHF is optimized. After recove...
Do you refer patients to cardiology if they have no history of cardiac disease but will be receiving XRT with high mean doses to the heart?
Great question! Yes, we are starting to refer patients to cardiology who have Stage III NSCLC or LS-SCLC and are receiving high-dose radiation therapy. Trying to tease out whether its heart dose or central tumor location, or some combination of the two, that confers a poorer prognosis is challenging...
How would you approach the management of newly diagnosed metastatic colon cancer in a patient who experienced infusional 5FU-related cardiotoxicity with initial chemotherapy?
I have a patient who developed documented coronary spasm with EKG changes and troponin elevation on 5 FU infusion, given as part of FOLFOX cycle 1, 3 weeks ago. She is now on the FLOX regimen with Isosorbide mononitrate and amlodipine prescribed by cardiology with specific dosing and timing recommen...
Is there any role for palliative radiation in the treatment of pericardial metastases?
I love these “have you ever” questions. Somehow, as you get gray in the hair and long in the tooth, you’ve done about every weird thing and I have done a few very crazy cardiac mets over the course of my career. I was on a publication for one of the wildest ones: Kazemi et al., PMID 31993571. I’ve a...
What therapy would you recommend for metastatic myxoid liposarcoma in a young patient with anthracycline cardiomyopathy with EF 25% who failed eribulin?
I am going to guess that:1. Patient has doxorubicin cardiomyopathy because she got adjuvant doxorubicin and ifosfamide with initial tumor.2. It was long enough ago that there has been time to develop cardiomyopathy.3. If she was without progression long enough to develop cardiomyopathy you could mak...
How do you approach the re-challenge with trastuzumab in metastatic HER2+ patients who develop cardiomyopathy on trastuzumab/pertuzumab with subsequent improvement with discontinuation?
First, I send all my patients in this situation to the cardiologist. Second, I will re-start the treatment with close cardiology follow-up. Whether to re-load or not is an open question. I personally do not re-load, but I don’t think is wrong to re-load.
Would you discontinue dabrafenib/trametinib in a patient with BRAF mutant metastatic lung cancer if you see mild cardiomyopathy which could be related to the drugs?
This is a good question and a clinical scenario that I just recently ran into. The main question relates to the degree of LVEF change and whether the patient is symptomatic or not. It is not that uncommon overall. In the phase 2 trial of dabrafenib and trametinib that led to approval of this regimen...