1. 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 (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 )
Time from RT to detection of CAD was 2 to 29 years (mean )
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
57 + 8
<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.