Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
What is your approach to left sided PMRT in patients with on-going cardiac issues (ie. cardiomyopathy, heart failure, coronary heart disease)?
In this circumstance, like for any medical intervention, we need to carefully weigh the risks and benefits of treatment. The likelihood of radiotherapy-induced cardiac injury appears to dependent on two variables: 1) Cardiac dose. This is variably defined - I think mean heart dose may be the best su...
For a young patient with stage 4 endometrial cancer with an excellent response to anthracyclines, would you continue to give anthracyclines beyond the standard dosage cap if cardiac function remains normal by echocardiogram?
A few things to consider in this case: What is the status of her stage IV disease/what response has she had to chemotherapy? How is she tolerating chemotherapy? If she has symptomatic disease and is contuning to respond to therapy, then it becomes a discussion of risk versus benefits (risk of cardio...
When would you consider using radiation for cardiac metastases?
I would consider it if it's likely to be effective based on histology. If it it a relatively radioresistant tumor, I would consider if there's no other viable option.
How are you using the data on cardiac morbidity in regards to the LV-V5 in breast cancer patients?
At present we use MHD as our hard constraints and limit to less than 2Gy for patients with breast only RT. Besides make sure that no part of beam passes through any portion of heart (thus limiting heart dose from scatter and transmission only) Darby data was also validated by similar study from UK w...
How do you minimize the risk of cardiotoxicity in metastatic Her2 + breast cancer patients who are receiving trastuzumab and have a history of pre-existing cardiac disease?
Currently there are no proven strategies that are widely used to minimize the risk of cardiac toxicity in patients receiving Her2 therapy. Development of inexpensive, protective regimens with minimal side effects for patients at risk for cardiac dysfunction and the devlopment of models identifying w...
What is the rate of a cardiac events that you quote to a patient with preexisting heart disease going on trastuzumab for metastatic Her2+ breast cancer?
I tell patients that it depends on their baseline risk factors and that some have reported rates as high as 25-28%. I discuss that if they have had prior anthracycline therapy, borderline baseline LVEF (50-54%), age > 65, and other cardiac risk factors like hypertension, that they could fall into th...
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...