SCAI Issues Guide for Treating Cancer Patients in the Cardiac Cath Lab

Marlene Busko

January 21, 2016

HOUSTON, TN — The Society for Cardiovascular Angiography and Interventions (SCAI) has released an expert consensus statement for managing patients with cancer who are seen in the cardiac catheterization laboratory, which was published online January 12, 2016 in Catheterization and Cardiovascular Interventions[1].

The statement describes "special considerations to be addressed by interventional cardiologists when managing this frail patient subgroup," lead author Dr Cezar A Iliescu (MD Anderson Cancer Center, University of Texas, Houston) and colleagues write.

The document covers a broad swath of issues that interventional cardiologists face when they are treating cancer patients—from chemotherapy-induced vascular toxicities and radiation-induced coronary and peripheral arterial disease to procedures such as right heart catheterization and transcatheter aortic-valve replacement (TAVR).

Researchers estimate that by 2020 there will be almost 20 million cancer survivors in the US, the group writes. Meanwhile, when the DAPT trial was presented at the American Heart Association meeting in 2014 it suggested that, already, "one in 10 patients going to the cath lab will have a history of cancer," coauthor Dr Joerg Herrmann (Mayo Clinic, Rochester, Minnesota) told heartwire from Medscape.

Anticancer therapies can harm the vasculature, leading to angina, acute coronary syndrome (ACS), stroke, arrhythmias, and heart failure (HF), and cancer is generally associated with a hypercoagulable state, which increases the risk of acute thrombotic events, the report notes. Although patients with cancer will need to be evaluated in the cardiac cath lab, they have unfortunately been excluded from national PCI registries and most randomized PCI clinical trials.

Thus, the SCAI commissioned a writing committee to provide recommendations based on published articles and opinions of interventionalists with broad experience in cardiac catheterization of patients with cancer.

One of the important sections in the consensus statement deals with chemotherapy-induced vascular toxicities, Herrmann noted. For example, the tyrosine kinase inhibitor ponatinib (Iclusig, Ariad Pharmaceuticals), which is used to treat chronic myeloid leukemia and Philadelphia chromosome–positive acute lymphoblastic leukemia, was temporarily pulled from the market by the US Food and Drug Administration (FDA) in 2013 because of cardiovascular toxicities, "which was really a warning sign for the whole community," he added.

The report also discusses radiation-induced toxicities.

Importantly, the consensus statement provides two algorithms for screening patients receiving these two types of cancer treatments—chemotherapy and radiation therapy—for cardiovascular risk factors. The emphasis is on keeping "a close eye on [modifiable] cardiovascular risks . . . and on [earlier], more aggressive screening," Herrmann said.

The report also provides practical recommendations for managing cancer patients who have thrombocytopenia or anemia and, for example, determining when PCI is appropriate. "Sometimes, if patients come in with a history of cancer, we take a step back and don't want to be overly aggressive," Herrmann observed. However, it's important to strike the right balance. The consensus statement presents a recommended revascularization approach used at the MD Anderson Cancer Center.

The statement also gives guidance for performing other interventional procedures in patients with cancer. For example, right heart catheterization is "something that we do not necessarily routinely do," Herrmann noted, but it can accurately assess heart failure, cardiomyopathy, and valvular dysfunction. The report also discusses endomyocardial biopsies, which might be useful in some cases, he added.

TAVR is another procedure that has been largely unexplored in this patient population, according to Herrmann. "I'm sure every institution has cases where patients are between a rock and a hard place—they have severe aortic stenosis and cancer." Clinicians may feel the cancer patient is too sick to benefit from TAVR, but on the other hand, without TAVR, the patient may be too sick to have chemotherapy. "We've done cases though where TAVR was successful, and the patients really improved and went on to have chemotherapy," he noted.

Treating patients with concomitant cancer and heart disease requires a multidisciplinary, collaborative approach with cardiologists and hematologists/oncologists, Iliescu and colleagues summarize. They say that this report provides some guidance for managing cancer patients seen in the cath lab, but more research is needed to better determine optimal care for this patient population.

The authors have no relevant financial relationships.

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