In this episode, we discuss the spectrum of cardiovascular diseases encountered by the interventional onco-cardiologist, with a focus on nuances in endovascular therapies tailored to cancer patients and their unique comorbidities and complications. We also discuss certain special scenarios seen in the critically ill cancer patient, such as chronic thrombocytopenia, and how they alter standard of care compared to non-cancer patients.
Show notes were drafted by Dr. Bala Pushparaji and episode audio editing was performed by Dr. Akiva Rosenzveig.
This episode is supported by a grant from Pfizer Inc.
Cancer should be treated as a chronic illness akin to hypertension or diabetes and should not deprive patients from receiving appropriate cardiovascular treatment if otherwise indicated (e.g., PCI for acute coronary syndromes, etc.).
In cancer patients with stable angina, along with maximizing medical therapy, multimodality imaging (CTA/PET), intravascular imaging (IVUS/OCT), and physiologic testing (iFR/FFR) should be used routinely to prevent unnecessary stenting.
Caution is required in the cath lab for the cancer patient with thrombocytopenia. Techniques include utilizing micropuncture access, transfusing appropriate blood products based on thromboelastogram (TEG), and adjusting antiplatelet therapy regimens and duration.
Transcatheter aortic valve replacement (TAVR) is now the recommended treatment for most cancer patients with symptomatic/severe aortic stenosis and, if otherwise indicated, should preferably be pursued prior to cancer treatment to optimize the patient’s cardiovascular fitness and tolerance of anti-cancer therapy.
Pericardiocentesis in the cancer patient should be performed preferably under fluoroscopy with echocardiography and vascular ultrasound guidance (“triple guidance”).
Show notes – Interventional CardioOncology
What is the general approach to cardiovascular illness in the cancer patient?
Cancer and cardiovascular diseases share numerous risk factors. In addition, cancer and cancer therapies can be atherogenic, by means of inducing pro-inflammatory and hyprecoagulable states, increasing the risk of ischemic heart disease, stroke, and peripheral arterial disease.1
In the outpatient setting, emphasis should be placed on optimizing cardiovascular risk factors and improving overall cardiovascular fitness by exercising, having a healthy diet, and having regular sleep hours as these favor survivorship after cancer treatment. Questions to be answered in the clinic are – Is the patient cardiovascularly fit? Will the patient’s heart withstand cancer treatment? Is there concern for coronary artery disease, valvular disease, pericardial disease, or pulmonary hypertension?
Risk assessment and treatment for cancer patients with suspected or known cardiovascular disease should generally follow established ACC/AHA guidelines, with special considerations as outlined by the Society of Cardiovacular Angiography and Interventions (SCAI).2
Pre-chemotherapy cardioprotection for patients without coronary artery disease (CAD) with prophylactic beta-blockers, ACEi/ARB, and statins should be considered when appropriate. For high-risk patients with CAD, blood pressure control, frequent screening via echocardiography, and measurement of serum cardiac biomarkers is encouraged.
What is the approach to stable angina in cancer patients?
Start the evaluation by identifying cardiovascular risk factors and cardiovascular co-morbidities such as hypertension and diabetes. Review prior or active cancer treatments that might increase the risk for CAD (e.g., chest radiotherapy).
Utilize prior imaging that the patient may have had for cancer staging, to look for coronary artery calcification.
Depending on the patient’s risk profile for ischemic heart disease, stress testing/multi-modality imaging techniques ranging from coronary CTA to cardiac PET can be pursued to delineate coronary anatomy and identify the myocardium at risk.
The final step is invasive coronary imaging – with the intent of fixing main vessel, proximal, and ostial lesions. A wait and watch approach with optimized medical management is preferred for stable lesions in small branches subtending smaller portions of the myocardium.
Intravascular imaging (optical coherence tomography – OCT, intravascular ultrasound – IVUS) and physiologic techniques (iFR and FFR) add value to guide decision-making about revascularization.
Maximally optimize medical therapy before resorting to an invasive strategy.
Sometimes, in anticipation of progressing CAD following cancer treatment/cancer evolution, it may be pertinent to have an aggressive approach during the initial presentation of the patient in the clinic. Patients with advanced cancer may have anemia, thrombocytopenia, or pancytopenia which could make downstream coronary interventions more complicated.
What is the approach to acute coronary syndromes (ACS) in cancer patients?
Cancer patients with ACS typically present with dyspnea, followed inconsistently by chest pain thereby creating a layer of challenge in the diagnosis. A high index of suspicion is necessary in order to not miss this diagnosis. A subset of patients with ACS-type presentation could have stress induced cardiomyopathy or chemotherapy induced vasospasm/endothelial dysfunction (5-fluorouracil is the most common cause).
After risk assessment, invasive approach with left heart catheterization/coronary angiogram with or without intervention can be the next best step in selected patients.
Choosing the appropriate stent (bare metal stent, BMS, vs. drug eluting stent, DES) and antiplatelet regimen is key, especially in the setting of chronic thrombocytopenia.3 Although BMS were once commonly used in cancer patients due to their brief antiplatelet drug requirement, they are associated with increased risks for in-stent restenosis and are not preferred in the current era. Modern DES have safer profiles and evidence shows that abbreviated dual antiplatelet thearpy (DAPT) regimens can be implemented with DES as well, if needed.
In cancer patients, due to various factors such as thrombocytopenia or need for cancer treatment resumption, DAPT duration may be abbreviated to <6 months, and recent studies have shown the risk of stent thrombosis to be minimal.5,6 As in non-cancer patients, stent optimization with intravascular imaging (IVUS or OCT) is good practice.4
Hematologic malignancies have the highest risk of thrombocytopenia (less than 10,000) and may necessitate even more abbreviated courses of DAPT, after a discussion of the risks with the patients. A multi-disciplinary team comprising the cardiologist, interventional cardiologist, and the hematologist (the cardio-oncology team) should be involved in decision making.
Balloon angioplasty without stenting should be considered for cancer patients who are not candidates for DAPT (i.e., platelets <30.000/mL) or when a non-cardiac procedure or surgery is necessary as soon as possible. The risk of a complication (i.e., iatrogenic coronary dissection) requiring stenting should be discussed and contingencies should be in place.
Cancer treatment resumption following percutaneous intervention (PCI) depends on the malignancy being treated. In acute hematological malignancies treatment can be started/resumed within days after PCI, however in slow growing tumors treatment can be started/resumed in 2-4 weeks. Radiation therapy can be resumed as soon as needed. Surgery could be performed after at least 1 month of DAPT therapy.
What are special considerations prior to invasive testing and therapies in cancer patients with thrombocytopenia?
Approximately 10% of cancer patients have concurrent thrombocytopenia and thrombosis.
In a thrombocytopenic patient with ACS requiring PCI, a thorough risk/benefit discussion needs to occur, given the increased risk of bleeding.
Thromboelastograms (TEG) may be utilized to help choose the right product for transfusion among platelets, plasma, or cryoprecipitate. In the event of a catastrophic bleed, achieving hemostasis is paramount, and transfusion all three products may be considered rather than waiting for TEG scan.
Prophylactic platelet transfusion is recommended if the platelet count is <20,000/mL and one of the following: (a) high fever, (b) leukocytosis, (c) rapid fall in platelet count, (d) other coagulation abnormality, platelet count <20,000/mL in solid tumor patients receiving therapy for bladder, gynecologic, or colorectal tumors, melanoma, or necrotic tumors. Repeat platelet counts must be obtained after transfusion.
30–50 U/kg unfractionated heparin is the initial recommended dose for thrombocytopenic patients undergoing PCI who have platelets <50,000/mL. Activated clotting time should be maintained over 250 sec.
For platelet counts <30,000/mL, revascularization and DAPT should be decided after a preliminary multidisciplinary evaluation (interventional cardiology/oncology/hematology)
Aspirin administration may be used when platelet counts are >10,000/mL. DAPT with clopidogrel may be used when platelet counts 30,000–50,000/mL. Prasugrel, ticagrelor, and IIB-IIIA inhibitors should not be used in patients with platelet counts <50,000.
If platelet counts are <50,000, the duration of DAPT may be restricted to 2 weeks following PTCA alone, four weeks after bare-metal stent (BMS), and six months after second or third-generation drug-eluting stents (DES) if optimal stent expansion was confirmed by IVUS or OCT. There is data for shorter DAPT durations following newer DES platforms.
There is no minimum platelet count to perform a diagnostic coronary angiogram.
Radial access is preferred to femoral due to lower bleeding risk and increased patient satisfaction. Femoral access is the preferred approach for cancer patients on hemodialysis, those with abnormal Allen’s tests in both arms, multiple radial procedures or a-lines, bilateral mastectomy, or when a complex intervention is anticipated. Notably, radial access requires intravenous heparin administration to maintain vessel patency, for which thrombocytopenia may be a barrier.
What is the approach to valvular heart disease (aortic stenosis) in cancer patients?
In patients with cancer, there is a reduction in mortality when aortic stenosis is treated prior to cancer treatment.
Options include the percutaneous vs. surgical valve, although TAVR is now preferred for patients in all risk categories.7
Cancer treatment can generally be resumed two weeks after a percutaneous valve and two months after surgical valve replacement, although shorter waits may be necessary if cancer treatment is more urgent.
What is the approach to pericardiocentesis in cancer patients?
Malignant pericardial effusions are commonly encountered in cancer patients.
Percutaneous pericardiocentesis is preferred when indicated, as mortality/morbidity is high with a surgical approach.8
The procedure is preferably performed under fluoroscopy with echocardiography and vascular ultrasound guidance (“triple guidance”).
Obtain a chest x-ray to rule out colonic distension/gastric bubble. CT chest/abdomen is helpful for delineating landmarks.
A thorough physical exam of the patient, focusing on the scars (surgical/radiation), and cancers on the chest wall, should be performed.
For patients on blood thinners and chronic thrombocytopenia, an apical approach (lateral) is preferred to avoid puncturing the liver.
Micropuncture needle and small 5F sheath are utilized for access, inserted above the specific rib margin, to avoid the vascular bundles.
The pericardial drain should be maintained for a minimum of 3 days (optimally 5 days).
References – Interventional CardioOncology
Giza DE, Boccalandro F, Lopez-Mattei J, et al. Ischemic Heart Disease: Special Considerations in Cardio-Oncology. Curr Treat Options Cardiovasc Med. 2017;19(5):37. doi:10.1007/s11936-017-0535-5 https://doi.org/10.1007/s11936-017-0535-5
Iliescu CA, Grines CL, Herrmann J, et al. SCAI Expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologıa intervencionista). Catheter Cardiovasc Interv. 2016;87(5):E202-E223. doi:10.1002/ccd.26379 https://doi.org/10.1002/ccd.26379
Ahmed T, Pacha HM, Addoumieh A, et al. Percutaneous coronary intervention in patients with cancer using bare metal stents compared to drug-eluting stents. Front Cardiovasc Med. 2022;9:901431. Published 2022 Oct 19. doi:10.3389/fcvm.2022.901431 https://doi.org/10.3389/fcvm.2022.901431
Kim JW, Dayah TJ, Javaid A, et al. Reclassification of Treatment Strategy with Fractional Flow Reserve in Cancer Patients with Coronary Artery Disease. Medicina (Kaunas). 2022;58(7):884. Published 2022 Jul 1. doi:10.3390/medicina58070884 https://doi.org/10.3390/medicina58070884
Iliescu CA, Cilingiroglu M, Giza DE, et al. “Bringing on the light” in a complex clinical scenario: Optical coherence tomography-guided discontinuation of antiplatelet therapy in cancer patients with coronary artery disease (PROTECT-OCT registry). Am Heart J. 2017;194:83-91. doi:10.1016/j.ahj.2017.08.015 https://doi.org/10.1016/j.ahj.2017.08.015
Balanescu DV, Aziz MK, Donisan T, et al. Cancer treatment resumption in patients with new-generation drug-eluting stents. Coron Artery Dis. 2021;32(4):295-301. doi:10.1097/MCA.0000000000000986 https://pubmed.ncbi.nlm.nih.gov/33196581/
Schechter M, Balanescu DV, Donisan T, et al. An update on the management and outcomes of cancer patients with severe aortic stenosis. Catheter Cardiovasc Interv. 2019;94(3):438-445. doi:10.1002/ccd.28052 https://doi.org/10.1002/ccd.28052
Jacob R, Palaskas NL, Lopez-Mattei J, et al. How to Perform Pericardiocentesis in Cancer Patients With Thrombocytopenia: A Single-Center Experience. JACC CardioOncol. 2021;3(3):452-456. Published 2021 Jul 27. doi:10.1016/j.jaccao.2021.05.005 https://doi.org/10.1016%2Fj.jaccao.2021.05.005
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International Cardio-Oncology Society ( IC-OS). IC-OS exits to advance cardiovascular care of cancer patients and survivors by promoting collaboration among researchers, educators and clinicians around the world. Learn more at https://ic-os.org/.