Chemotherapy Induced Cardiotoxicity: A State of the Art Review on General Mechanisms, Prevention, Treatment and Recent Advances in Novel Therapeutics.

As medicine advances to employ sophisticated anticancer agents to treat a vast array of oncological conditions, it is worth considering side effects associated with several chemotherapeutics. One adverse effect observed with several classes of chemotherapy agents is cardiotoxicity which leads to reduced ejection fraction (EF), cardiac arrhythmias, hypertension and Ischemia/myocardial infarction that can significantly impact the quality of life and patient outcomes. Research into possible mechanisms has elucidated several mechanisms, such as ROS generation, calcium overload and apoptosis. However, there is a relative scarcity of literature detailing the relationship between the exact mechanism of cardiotoxicity for each anticancer agent and observed clinical effects. This review comprehensively describes cardiotoxicity associated with various classes of anticancer agents and possible mechanisms. Further research exploring possible mechanisms for cardiotoxicity observed with anticancer agents could provide valuable insight into susceptibility for developing symptoms and management guidelines. Chemotherapeutics are associated with several side effects. Several classes of chemotherapy agents cause cardiotoxicity leading to a reduced ejection fraction (EF), cardiac arrhythmias, hypertension, and Ischemia/myocardial infarction. Research into possible mechanisms has elucidated several mechanisms, such as ROS generation, calcium overload, and apoptosis. However, there is a relative scarcity of literature detailing the relationship between the exact mechanism of cardiotoxicity for each anticancer agent and observed clinical effects. This review describes cardiotoxicity associated with various classes of anticancer agents and possible mechanisms. Further research exploring mechanisms for cardiotoxicity observed with anticancer agents could provide insight that will guide management.

Utilization of sacubitril-valsartan for right ventricular failure in a patient with arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular (RV) cardiomyopathy is an autosomal dominant inherited cardiomyopathy that is characterized by an increased risk of ventricular arrhythmias, sudden cardiac death and, less commonly, heart failure. The authors present the case of a 36-year-old woman with familial lamin cardiomyopathy with positive LMNA mutation and genetic testing revealing LMNA and TMEM43 mutations consistent with arrhythmogenic RV cardiomyopathy. The patient presented with clinical signs of RV failure. Transthoracic echocardiogram showed newly reduced RV function in the absence of left ventricular involvement. Cardiac MRI demonstrated diffuse late gadolinium enhancement of the mid-level and apical RV anterior free wall. Diuretics were started, and sacubitril-valsartan was added when the patient's symptoms persisted. Diuretics were then discontinued, and sacubitril-valsartan was the primary therapy. This is the first reported case of symptomatic and imaging-proven RV recovery in a patient with symptomatic RV failure in the setting of arrhythmogenic RV cardiomyopathy treated with sacubitril-valsartan.

The authors present the case of a 36-year-old woman who was found to have arrhythmogenic right ventricular cardiomyopathy, a rare inherited cardiomyopathy. This condition is caused by various mutations that lead to cardiac muscle cells being replaced with fibrofatty tissue and manifests as heart arrhythmias, sudden cardiac death or heart failure. The patient presented with symptoms of right heart failure. Imaging found a new reduction in right ventricular function, confirming the diagnosis of right heart failure. The patient was treated initially with diuretics. However, her symptoms persisted despite treatment and sacubitril­valsartan was started, after which she symptomatically improved. Repeat imaging showed improvement in right ventricular function with sacubitril­valsartan therapy.

Proton beam therapy causing pericarditis - a rare case of radiation induced cardiotoxicity.

Acute pericarditis is caused by the inflammation of the pericardium which can result in an effusion around the heart. Proton beam therapy causing radiation-induced pericarditis is not a well-known cause of pericarditis. We present a case of a patient with Li-Fraumeni Syndrome who developed acute onset pericarditis, presumed to be secondary to proton beam therapy.

"House Calls" by Mobile Integrated Health Paramedics for Patients with Heart Failure: A Feasibility Study.

Background: Early readmissions following hospital discharge for heart failure (HF) remain a major concern. Among the various strategies designed to reduce readmissions, home evaluations have been observed to have a favorable impact. We assessed the feasibility of integrating community paramedics into the outpatient management of HF patients. Methods: Selected paramedics completed an educational HF curriculum. These Mobile Integrated Health Paramedics (MIHP) performed scheduled home visits 2- and 15-days post-discharge for patients with Stage C HF (Phase I) and patients with Stage D HF (Phase II). Facilitated by a Call Center, a process was created for performing urgent MIHP house calls within 60 minutes of a medical provider's request. A HF specialist, with an on-call emergency department command physician, could order an intravenous diuretic during home visits. During each phase of the study the incidence of 30-day HF readmissions, 30-day all-cause readmissions, emergency room evaluations, unplanned office encounters, as well as any adverse events were prospectively documented. Results: Collaborative relationships between our hospital network and local EMS organizations were created. There were 82 MIHP home visits. Eight patients received urgent home evaluations within 60-minutes post-request, one requiring transport to an ED. The incidence of all-cause 30-day readmissions in 20 Stage C and 20 Stage D patients was 15% and 40%, respectively. There were no adverse events attributable to the MIHP house calls. Conclusions: It is feasible to integrate MIHPs into the outpatient management of HF. Signals of effectiveness for reducing early readmissions were observed. Obstacles to creating an effective paramedic "House Calls" program were identified. A randomized trial is required to assess the value of this care process and its impact on early readmissions in patients with Stage C and Stage D HF.

A case report: rapid progression of coronary atherosclerosis in a patient taking Targretin (Bexarotene).

Anti-neoplastic drugs have made major advancements in oncology, however they are not without cardiovascular consequences. We present a patient with cutaneous T-cell lymphoma receiving Targretin therapy who presented with accelerated atherosclerosis. His triglyceride level (TG) was greater than 1000 mg/dL, which rapidly improved with discontinuation of Targretin.

Stress Cardiomyopathy Caused by Diving: Case Report and Review of the Literature.

BACKGROUND: Stress cardiomyopathy is characterized by transient myocardial dysfunction that mimics a myocardial infarction in the absence of obstructive coronary artery disease. The onset is frequently triggered by an acute illness or intense physical or emotional stress. CASE REPORT: We describe the case of a 47-year-old woman who was brought to the emergency department with acute onset shortness of breath while scuba diving. She was found to have acute pulmonary edema radiographically. Her troponins were noted to be positive. Initial echocardiogram showed basal hypokinesis with hyperkinesis of apex. She was treated with noninvasive ventilation and intravenous diuretic therapy and her symptoms significantly improved. She subsequently underwent cardiac catheterization which revealed nonobstructive coronary artery disease. An exercise stress echocardiogram was performed 2 days later that revealed resolution of the wall motion abnormality and no ischemia at high levels of exercise. A diagnosis of reverse stress (Takotsubo) cardiomyopathy was made based on Mayo Clinic Diagnostic criteria. ​WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case brings to light the risk of stress cardiomyopathy in divers. The diagnosis should be considered in patients presenting with acute pulmonary edema during diving.