Optimizing screening and management of cardiovascular health in prostate cancer: A review.

In clinical practice, cancer management does not consistently encompass screening and identification of cardiovascular (CV) risk. The use of androgen deprivation therapy (ADT) in prostate cancer has been associated with increased CV risk and development of metabolic syndrome, necessitating identification of patients at risk in this population (e.g., those with pre-existing CV disease). A multidisciplinary team of Canadian physicians was assembled to develop a series of recommendations intended to identify patients who may benefit from optimal management of their CV disease and/or modification of cardiac risk factors. A key goal was the development of a simple screening tool for identification of patients with pre-existing CV disease. This simple and inclusive set of recommendations are intended for use within urology clinics to facilitate holistic approaches and simplify the management of patients.

Normal ventricular diameter ratio on CT provides adequate assessment for critical right ventricular strain among patients with acute pulmonary embolism.

There is variability in guideline recommendations for assessment of the right ventricle (RV) with imaging as prognostic information after acute pulmonary embolism (PE). The objective of this study is to identify a clinical scenario for which normal CT-derived right-to-left ventricular (RV/LV) ratio is sufficient to exclude RV strain or PE-related short-term death. This retrospective cohort study included 579 consecutive subjects (08/2003-03/2010) diagnosed with acute PE with normal CT-RV/LV ratio (<0.9), 236 of whom received subsequent echocardiography. To identify a clinical scenario for which CT-RV/LV ratio was considered sufficient to exclude RV strain or PE-related short-term death, a multivariable logistic model was created to detect factors related to subjects for whom subsequent echocardiography detected RV strain or those who did not receive echocardiography and died of PE within 14 days (n = 55). The final model included five variables (c-statistic = 0.758, over-fitting bias = 2.52 %): congestive heart failure (adjusted odds ratio, OR 4.32, 95 % confidence interval, CI 1.88-9.92), RV diameter on CT >45 mm (OR 3.07, 95 % CI 1.56-6.03), age >60 years (OR 2.59, 95 % CI 1.41-4.77), central embolus (OR 1.96, 95 % CI 1.01-3.79), and stage-IV cancer (OR 1.94, 95 % CI 0.99-3.78). If these five factors were all absent (37.1 % of the population), the probability that "CT-RV/LV ratio is sufficient to exclude RV strain/PE-related short-term death" was 0.97 (95 % CI = 0.95-0.99). Normal CT-RV/LV ratio plus readily obtained five clinical predictors were adequate to exclude RV strain or PE-related short-term mortality.

Orthotopic Heart Transplantation and Mechanical Circulatory Support in Cancer Survivors: Challenges and Outcomes.

Chemotherapy-induced cardiomyopathy (CCMP) is a significant cause of morbidity and mortality. Compared to cardiomyopathy due to other causes, anthracycline-induced cardiomyopathy is associated with a worse survival. As cancer survival improves, patients with CCMP can be expected to comprise a significant proportion of patients who may require advanced therapies such as inotropic support, cardiac transplantation, or left ventricular assist device (LVAD). Distinct outcomes related to advanced therapies for end-stage heart failure in this patient population may arise due to unique demographic characteristics and comorbidities. We review recent literature regarding the characteristics of patients who have survived cancer undergoing orthotopic heart transplantation and mechanical circulatory support for end-stage heart failure. The challenges and outcomes of advanced therapies for heart failure related specifically to anthracycline-induced cardiomyopathy are emphasized.

Computed tomography and echocardiography in patients with acute pulmonary embolism: part 2: prognostic value.

PURPOSE: The aim of the study was to compare the prognostic value of right ventricular (RV) dysfunction detected on computed tomography pulmonary angiography (CTPA) and transthoracic echocardiography (TTE) in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS: From all consecutive CTPAs performed between August 2003 and May 2010 that were positive for acute PE (n=1744), those with TTE performed within 48 hours of CTPA (n=785) were selected as the study cohort. Multivariate logistic regression analysis was performed to assess the association of CTPA RV/left ventricular (LV) diameter ratio and TTE RV strain with PE-related 30-day mortality, including other associated factors as covariates. The predictive ability (area under the curve) was compared between the model including the CT RV/LV diameter ratio and that including TTE RV strain. Test characteristics of the 2 modalities were calculated. RESULTS: Both CT RV/LV diameter ratio and TTE RV strain were independently associated with PE-related 30-day mortality (adjusted odds ratio=1.14, P=0.023 for 0.1 increment of the CT RV/LV diameter ratio; and odds ratio=2.13, P=0.041 for TTE RV strain). History of congestive heart failure and malignancy were independent predictors of PE-related mortality, while there was significantly lower mortality associated with anticoagulation use. The model including TTE RV strain and that including CT RV/LV had similar predictive ability (area under the curve=0.80 vs. 0.81, P=0.50). The sensitivity, specificity, and positive and negative predictive values of TTE RV strain and CT RV/LV diameter ratio at a cutoff of ≥1.0 were similar for PE-related 30-day mortality. CONCLUSIONS: Both RV strain on TTE and an increased CT RV/LV diameter ratio are predictors of PE-related 30-day mortality with similar prognostic significance.

Characterization of mitral valve prolapse with cardiac computed tomography: comparison to echocardiographic and intraoperative findings.

A single imaging modality that can accurately assess both coronary anatomy and mitral valve (MV) anatomy prior to surgery may be desirable. We sought to determine the diagnostic accuracy of cardiac computed tomography (CT) to detect and characterize mitral valve prolapse (MVP) compared to echocardiography. Consecutive patients referred for 'single-source' cardiac CT for investigation prior to non-coronary cardiac sugery were identified. MV anatomy was assessed for MVP and results were compared to echocardiography and to intra-operative visual assessment of the MV. Comparison between the three modalities was performed at the per-patient, per-leaflet and per-scallop levels. A total of 67 consecutive patients that were referred for Cardiac CT prior to non-coronary cardiac surgery and were prospectively recruited into a Cardiac CT registry. Of these, 65 patients underwent cardiac surgery. 63 patients had echocardiography and 32 patients had intra-operative visual assessment of the mitral valve. Compared to echocardiography, cardiac CT had excellent sensitivity (92.6%) and specificity (97.1%) for the detection of any MVP, but had poor sensitivity (68.5%) for the detection of individual prolapsing scallop. Compared to intra-operative visual assessment of the prolapsing scallop, both cardiac CT and echocardiography had low sensitivity (58.1 and 78.1%, respectively). Cardiac CT was able to identify patients with MVP but had difficulty identifying the prolapsed scallops compared to echocardiography. Single-source CT may not be ready for characterization of individual mitral valve scallops.

Recent progress in the genetics of cardiomyopathy and its role in the clinical evaluation of patients with cardiomyopathy.

PURPOSE OF REVIEW: This review will provide an overview of the genetic basis of cardiomyopathy with an emphasis on the clinically relevant breakthroughs that have occurred recently and their role in the evaluation of patients with cardiomyopathy. RECENT FINDINGS: Recent developments that have occurred in genetic cardiomyopathy include the finding of a shared genetic basis of familial dilated cardiomyopathy in at least a subset of cases of peripartum cardiomyopathy; the increased yield for the diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) when genetic testing is incorporated into Task Force Criteria; and the value of testing a spectrum of implicated genes in hypertrophic cardiomyopathy and ARVC because of the severe phenotype associated with compound mutations. SUMMARY: Recent progress in genetic cardiomyopathy points to the potential value of genetic testing in shaping the clinician's ability to diagnose and understand the pathogenetic basis of the inherited cardiomyopathies. The rapid rate at which the field is progressing emphasizes the importance of referral of such patients to multidisciplinary teams equipped to address the complex biological, social and psychological issues that accompany the genetic diagnosis of inherited cardiomyopathy.

The acute treatment of maternal supraventricular tachycardias during pregnancy: a review of the literature.

OBJECTIVE: Since evidence-based guidelines for the treatment of acute supraventricular tachyarrhythmia (SVT) in pregnancy are not available, our objective was to document published reports and immediate outcomes in this patient population. DATA SOURCES: A search of the literature was performed using Medline, Embase, CINAHL, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, and Cochrance Central Register of Controlled Trials, using key word searching and citations in the English language literature from January 1950 to March 2010, on the subject of SVT. STUDY SELECTION/DATA EXTRACTION: We reviewed 38 studies (case-controlled cohort studies, case series, and case reports) using the key words "supraventricular tachycardia," "paroxysmal tachycardia," and "atrial tachycardia," combined with "pregnancy" or "pregnancy complications." CONCLUSION: No randomized controlled trials have addressed the acute treatment of SVT in pregnancy. If non-invasive manoeuvres fail, adenosine should be the first-line agent for treatment if needed during the second and third trimester. There is a paucity of data on management of SVT in the first trimester.

Limitations in the current screening practice of assessing left ventricular ejection fraction for a primary prophylactic implantable defibrillator in southern Ontario.

BACKGROUND: Screening echocardiography (ECHO) is commonly performed to determine whether the patient's left ventricular ejection fraction (LVEF) is appropriate for primary prophylactic implantable cardiac defibrillator (ICD) referral. However, radionuclide ventriculography (RNA) is used by many implantation centres for decision making. OBJECTIVE: To determine whether current screening ECHO techniques are effective in identifying patients suitable for primary prophylactic ICD referral. METHODS: Correlation, sensitivity, specificity and likelihood ratios (LRs) of semiquantitative and numerical quantitative ECHO LVEFs were calculated for predicting RNA LVEFs that met implantation criteria (LVEF less than 30% and less than 35%). RESULTS AND DISCUSSION: Among 193 patients, the LRs for a semiquantitative ECHO predicting an RNA LVEF of less than 30% (negative LR was 0.21 to 0.69 and positive LR was 1.22 to 2.83) or RNA LVEF of less than 35% (negative LR was 0.24 to 0.73 and positive LR was 1.33 to 3.46) demonstrated that current screening ECHO techniques are ineffective. However, the positive predictive value of grade 4 ECHO was 93.0%, suggesting that these patients may not require further LVEF investigation before implantation. Among 102 patients, current quantitative ECHO techniques did not improve the screening characteristics. CONCLUSIONS: Current screening ECHO techniques may not be adequate for screening patients for consideration of a primary prophylactic ICD, but a grade 4 ECHO finding has a high positive predictive value in meeting implantation LVEF criteria. Improved screening standards should increase the number of patients referred with appropriate LVEF for primary prophylactic ICD implantation.

Arrhythmia device lead extraction: factors that necessitate laser assistance.

BACKGROUND: The removal of pacemaker and implantable cardioverter defibrillator (ICD) leads has become a common procedure. The need for laser use has considerable implications regarding cost and expertise. It is not an option at all centres and introduces an element of risk to the procedure. Anticipation of the need for laser assistance may be of benefit to procedure planning. METHODS: Data on all patients undergoing lead extraction at London Health Sciences Centre (London, Ontario) between July 2001 and October 2006 were reviewed. Variables were assessed for independent association with the need for laser assistance. A prediction rule for laser use was created based on the multivariate model. RESULTS: From July 2001 to October 2006, 154 patients underwent lead extraction, with laser assistance required in 106 patients (68.8%). One hundred seven patients (69.5%) had pacemakers and the remainder had ICDs. The mean (+/- SD) device age was 7.6+/-5.7 years, with 1.9+/-0.9 leads requiring extraction. Clinical success was achieved in 152 patients (98.7%). Multivariate analysis revealed that laser use was less likely among men (OR 0.24, 95% CI 0.069 to 0.84; P=0.026) and among septic patients (OR 0.25, 95% CI 0.072 to 0.84; P=0.025), and more likely with ICDs than pacemakers (OR 4.40, 95% CI 1.50 to 12.91; P=0.0069) and with each additional year of device age (OR 1.46 per year, 95% CI 1.26 to 1.70; P<0.0001). CONCLUSIONS: Laser assistance was required in 68.8% of cases, with clinical success in 98.7% of patients. Laser use was less likely among septic patients and men, and more likely with ICD leads and increasing time since lead implant. It was not possible to derive an accurate prediction rule for cases that would not need laser assistance. Therefore, it is prudent to ensure that a laser and appropriate infrastructure is available for lead extractions, and that the patient is aware of the possible need for laser assistance, along with the risks entailed.

An unusual case of chronic coronary artery dissection: did cisplatin play a role?

Spontaneous coronary artery dissection is an unusual cause of acute myocardial ischemia. The natural history of spontaneous coronary artery dissection that persists on angiography after the acute event has not been well characterized. A case of a 36-year-old man who presented with monomorphic ventricular tachycardia 12 years following a myocardial infarction that occurred during his last course of bleomycin-etoposide-cisplatin therapy for testicular cancer is reported. On further investigation, coronary angiography revealed a long chronic dissection of the right coronary artery. The patient was successfully treated with medical management and insertion of an implantable cardioverter defibrillator. The case also highlights the increased cardiovascular morbidity in testicular cancer survivors and evokes the possibility of mechanisms of myocardial ischemia other than atherosclerotic disease in these young patients.