THE NEED OF SCREENING OF ASYMPTOMATIC PATIENTS RESULTS CHEST RADIOTHERAPY AS CARDIOVASCULAR RISK FACTOR: THE NEED OF SCREENING OF ASYMPTOMATIC PATIENTS *C. Lestuzzi, *M. Berretta, *L. Tartuferi, #E. Cervesato, *E.Viel, #M. Cassin, °M. De Biasio, #F. Vendrametto, #F. Macor, #R. Piazza, ^I. Bisceglia, *N. Meneguzzo. *Cardiology and Oncology, CRO, National Cancer Institute, Aviano (PN); #Cardiology, ARC, Pordenone Hospital; °Cardiology, UdineUniversity Hospital; ^Cardiology, S. Camillo Forlanini Hospital, Rome METHODS OF SCREENING IN ASYMPTOMATIC RT PATIENTS INTRODUCTION AIM OF THE STUDY AND POPULATION Mediastinal (MED) and left chest wall (LCW) radiation therapy (RT) may cause late damages to the heart: Constrictive pericarditis (CP), Valvular disease (VHD), mostly aortic and mitral, coronary artery disease (CAD), and left ventricular dysfunction (LVD). In most cases radiation-induced heart disease (RIHD)are detected only when the patients become symptomatic RIHD is usually a late side-effect, occurring even decades after RT and few prospective studies on its incidence have been carried out so far to assess the incidence of RIHD detected through a prospective screening in 161 asymptomatic patients (group A) who received MED or LCW RT to compare the clinical data of the patients with RIHD with those of 23 patients (group B) first seen because of symptoms as dyspnoea (n=7), congestive heart failure (n=13), angina/myocardial infarction (n=4) Those of 135 patients (group C) without history of RT or CAD, undergoing stress test because of multiple CVRF (n=129) or chest pain (n=6) M-mode, 2D, Doppler echocardiogram Treadmill stress test Myocardial scintigraphy and/or coronary angiography if positive or equivocal stress test Further echocardiograms and stress test every 1-3 years RESULTS DATA OBTAINED FROM ECHO SCREENING OVERALL 52 PATIENTS WITH RIHD 20 m 32 f, age 27-76 (mean 54, median 53) DATA OBTAINED FROM STRESS TEST SCREENING ECHO + STRESS TEST Total 673 echocardiograms on 161 patients (mean 4/patient) First echo screening 0 to 37 years (mean 7) after RT Last echo screening 3 to 38 years (mean 15) after RT 17 pts (10.6%) with RIHD: 12 left ventricular dysfunction 4 with later detected associated CAD 5 valvular heart disease 1 with also pericardial constriction Total 252 tests on 149 patients First screening 1 to 37 years (mean 14) after RT Last screening 2 to 37 years (mean 16) after RT 21 (14%) positive stress test 14 (66.7%) with silent ischemia Age at detection of CAD was 33 to 69 years (mean 55 + 10) Time from RT to detection of CAD was 2 to 29 years (mean 16 + 7) 12 LV Dysfunction 1 VHD + constriction 20 CAD 1 LVD + VHD 5 VHD 1 VHD + CAD 12 LVD + CAD Asymptomatic LVD and CAD Male, 53 years, former smoker, high BP and cholesterol 2006: EF 61%. Chemo- and radiotherapy 2009: drop of EF to 49%. Silent ischemia 100% stenosis LAD 2 years after successful PTCA: EF 55% LV dysfunction Ischemic Heart Disease LVD + CAD Valvular Heart Disease Age at treatment: min-max (mean) 25-52 (39) 14-64 (41) 14-61 (40) 21-60 (32) % with anthra 75 63 90 67 % mediastinal RT 70 100 Time from RT to diagnosis of RIHD: min-max (mean) 0-20 (8) 3-32 (17) 2-27 (16) 10-35 (23) Age at diagnosis of RIHD: min-max (mean) 27-62 (47) 40-70 (56) 41-75 (55) 45-76 (59) Asymptomatic 61-year-old woman 35 years after RT Silent ischemia (48 y-o man) 22 years after RT (main LCA stenosis) CONCLUSIONS RT PATIENTS WITH CAD vs CONTROL PATIENTS WITH MULTIPLE RISK FACTORS ASYMPTOMATIC POST RT (A) SYMPTOMATIC POST RT (B) CONTROL (C) A vs C A+B vs C M/F (tot) 43/106 (149) 3/9 (12) 86/49 (135) <0.001 Mean age 53 + 13.5 57 + 8 60 + 10 <0.01 <0.05 With CVRF 86 (58%) 10 (83%) 126(93%) Diabetes 10 (6.7%) 2 (16.7%) 35 (25.9%) Dyslipidemia 43 (28.9%) 7 (58.3%) 85 (63%) Hypertension 26 (17.4%) 4 (33.3%) 89 (65.9%) Smoking 13 (8.7%) 6 (50%) 24 (17.8%) NS Others 32 (21.5%) 3 (25%) 49 (36.3%) <0.005 With > 3 CVRF 8 (5.9%) 5 (41.7%) 45 (33.3%) With ischemia 21 (14.1%) 12 (100%) 12 (8.8%) Silent ischemia 14 (66.7%) 8 (66.7%) 5 (41.6%) 20% of the pts had asymptomatic but clinically relevant heart disease about 15 years after MED or LCW RT The most frequent and threatening pathologies were CAD and LVD (alone or in association) Among the pts with CAD, 66.7% had silent ischemia the first symptoms may be myocardial infarction or heart failure Mediastinal or left chest wall RT is a strong risk factor for CAD An aggressive treatment of other CVRF is needed An echocardiographic screening should be started immediatly after RT, mostly in patients who received also anthracyclines treatments In case of LVD, associated CAD should be ruled out Regular stress tests should be planned after 5 and 10 years after RT they should be more frequent after 10 years A lifelong periodic screening is necessary In spite of a significantly younger age and lower cardiovascular risk, the pts treated with MED or LCW RT had similar (slightly higher) rate of CAD detected at screening, compared to the control group.