Cardioprotective Meds Underutilized in Patients With Cancer History

Patrice Wendling

June 16, 2020

Although cancer is associated with increased cardiovascular disease (CVD) risk, cancer survivors are less likely to receive cardioprotective therapies to mitigate this risk, according to a cross-sectional study.

"It confirms that even years after cancer treatment, cancer survivors are undertreated for their CVD/CV risk factors, and it is not limited to a particular cancer subgroup or CV disease state," study author Doan Ngo, BPharm, PhD, University of Newcastle, Callaghan, New South Wales, Australia, told | Medscape Cardiology in an email.

Optimizing CV management in patients with a cancer history has not been widely addressed and data are inconsistent, the authors note. Some studies suggest greater use of guideline-directed therapy but less use of bypass surgery in cancer patients, whereas others report less frequent use of stains and P2Y12 blockers after a myocardial infarction in this growing population.

For the present study, Ngo and colleagues analyzed 320 patients admitted to a cardiology unit at a single center between July 2018 and January 2019, of which 69 had a history of cancer and 251 did not.

The most common cancer types were colorectal (20.3%), breast (13%), and melanoma (11.6%). Only 11 patients were receiving active cancer treatment. Two-thirds developed CVD after their cancer diagnosis, which on average predated the index admission by 11 years.

There were no significant differences between the two groups in age, body mass index, sex, hypertension, diabetes, dyslipidemia, or atrial fibrillation.

Still, patients with a history of cancer were significantly less likely than those without previous cancer to receive statins (63.8% vs 79.7%; P = .010) or antiplatelet therapies (58.0% vs 75.3%; P = .007).

Rates were also numerically lower for use of angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers (55.1% vs 61.4%) and beta-blockers (62.3% vs 70.1%).

During active cancer treatment, concerns about increased thrombotic and bleeding risk do sometimes affect use of CV medications, Ngo noted. "However, that should have little impact on cancer survivors post active cancer treatment. Furthermore, if anything, increased thrombotic risk in cancer patients should lead to greater use of antiplatelet therapies, not lower rates of use."

On multivariate analysis, patients with a history of cancer were less likely to be on a statin (odds ratio [OR], 0.41; 95% CI, 0.22 - 0.77) or antiplatelets (OR, 0.53; 95% CI, 0.29 - 1.00), the authors reported today in a research letter in JACC: CardioOncology.

"We believe there should be greater emphasis on CV risk factor management specifically for cancer patients in CV and cancer guidelines and position statements," Ngo said. "Development of cardio-oncology models of care specifically targeting CV risk factor management, especially in early survivorship, would be a key strategy."

These could include incorporating dedicated CV risk factor management clinics into survivorship programs with long-term patient follow-up and primary care liaison to ensure uptake and compliance, she said.

The results add to a large body of retrospective research that shows this is a consistent problem, said Mohammad Shahsahebi, MD, MBA, a family physician and member of Duke Cancer Institute's Center for Onco-Primary Care, Durham, North Carolina, who was not involved in the study.

"This once again highlights that the ugly truth of it is we're getting better and better at cancer care and yet we're losing patients to the bread-and-butter things that we know how to do very well," he told | Medscape Cardiology. "It's the fragmentation of our healthcare system that's causing a lot of this harm."

To address this will require a team approach, but also the help of asynchronous technologies, like smartphones and wireless devices, to message patients directly and to connect providers throughout the system so they're all aware of what's going on, Shahsahebi said.

"It's going to take some trial and error but the technology is there to help us," he said. "We're seeing right now that we are able to do things very well from a distance, we just weren't getting paid for it."

More research needs to be done but more definitive statements on CVD risk management in patients with cancer would be helpful as well, Shahsahebi agreed.

"Expert recommendations are great when the knowledge is lacking, so having our organizations put out statements of how to manage blood pressure during chemotherapy or cancer therapy is essential," he said.

Future research needs to focus on developing, validating, and implementing strategies to improve CV management of cancer patients and survivors at all stages of their journey, Ngo said. "The research also needs to focus on developing dedicated CV risk calculators for cancer patients or incorporating cancer history/cancer treatment into existing CV risk calculators and management algorithms."

The authors and Shahsahebi reported no relevant financial relationships.

JACC CardioOncol. 2020;2:312-315. Full text

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