Cardiovascular Oncology: The Need for a Multidisciplinary Approach.

Improved cancer survivorship has led to an increase in cardiovascular (CV) complications in the oncologic population, mainly associated with therapeutic regimens. Hence, cardio-oncology has grown toward unifying the cancer care process in which the best prevention, early detection, treatment, and CV surveillance are offered to patients. This multidisciplinary approach allows us to optimize and agree upon clinical decisions to enhance clinical outcomes. Atrial fibrillation is one of the hot topics in the field because it is still challenging in cancer patients. The optimal antithrombotic therapy remains unclear. Nevertheless, evidence supports that specific recommendations are needed due to a hemorrhagic/thrombotic disbalance present within this subgroup of patients and a low rate of anticoagulation treatments compared with the general population. Further, cardiotoxicity management is currently transforming. Increasingly, early detection of subclinical alterations is raising awareness. When medical therapy is initiated early, fewer patients progress to ventricular dysfunction and the rate of patients completing cancer therapy gradually increases. New approaches are demonstrating better outcomes and these strategies will expectedly be established in clinical practice. Cardio-oncology enables us to find the best balance between cancer treatment and CV health protection. Nowadays, more and more physicians are being instructed in this discipline, which gradually exhibits a greater presence in conferences and scientific journals. However, given the need for physicians thoroughly trained in cardio-oncology, this subspecialty must be promoted further.

Malignant Left Atrial Appendage Morphology: Current Classification vs H-L System.

INTRODUCTION: In previous studies the risk of stroke recurrence has been associated with the left atrial appendage (LAA) morphology (non-chicken wing (NCW)), knowing those with a greater risk as malignant LAA. Recently, a simpler morphological classification has been suggested with two categories: Low-risk (LAA-L) and High-risk (LAA-H); which could be easier to apply and may correlate better with the risk of embolic stroke. METHODS: Retrospective analysis from a registry of patients with recurrent cardioembolic strokes despite appropriate anticoagulant therapy, in which LAA morphology was studied with cardiac CT scan. LAA morphology was classified according to the four current categories and H-L morphology by the same cardiologist. Other variables associated with a high risk of stroke were also assessed, such as CHA2DS2-VASc score and left atrial (LA) size. RESULTS: Twenty-six cases were included in the analysis. We identified 22 (84.6%) chicken wing (CW), 1 (3.8%) windsock and 3 (11.5%) cactus by the current classification system, while 15 (57.7%) were classified as LAA-H and 11 (42.3%) as LAA-L by the new system. Half of the 22 cases with CW morphology were considered LAA-H, whereas all NCW were also classified as LAA-H. LA diameter and area were significantly higher in cases with LAA-H morphology (p=0.03 and 0.014), and also in those CW and LAA-H, compared to those CW with LAA-L (p=0.035). CONCLUSIONS: With this new classification system more than half of the cases of our malignant LAAs were classified as high-risk morphology. This morphology was also associated with an increased LA size.

Current status of anticoagulation in patients with breast cancer and atrial fibrillation.

OBJECTIVE: Balance between embolic and bleeding risk is challenging among patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. We further evaluated the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with cancer. METHODS AND RESULTS: The AMBER-AF registry is an observational multicentre study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain. 1,237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. Mean follow-up was 3.1 years. Both groups were similar in age, embolic risk and bleeding risk. Lack of guidelines-recommended therapies was more frequent among patients with cancer. Compared with patients without cancer, adjusted rates of stroke (hazard ratio [95% confidence interval]) in cancer patients were higher (1.56 [1.04-2.35]), whereas bleeding rates remained similar (1.25 [0.95-1.64]). Within the group of patients with cancer, the use of DOACs vs VKAs did not entail differences in the adjusted rates of stroke (0.91 [0.42-1.99]) or severe bleedings (1.53 [0.93-2.53]). CONCLUSIONS: Antithrombotic management of AF frequently differs in patients with breast cancer. While breast cancer is associated with a higher risk of incident stroke, bleeding events remained similar. Patients with cancer treated with DOACs experienced similar rates of stroke and bleeding as those with VKAs.

Frailty predicts major bleeding within 30days in elderly patients with Acute Coronary Syndrome.

OBJECTIVE: Bleeding in ACS patients is an independent marker of adverse outcomes. Its prognostic impact is even worse in elderly population. Current bleeding risk scores include chronological age but do not consider biologic vulnerability. No studies have assessed the effect of frailty on major bleeding. The aim of this study is to determine whether frailty status increases bleeding risk in patients with ACS. METHODS: This prospective and observational study included patients aged ≥75years admitted due to type 1 myocardial infarction. Exclusion criteria were severe cognitive impairment, impossibility to measure handgrip strength, cardiogenic shock and limited life expectancy due to oncologic diseases. The primary endpoint was 30-day major bleeding defined as a decrease of ≥3g/dl of haemoglobin or need of transfusion. RESULTS: A total of 190 patients were included. Frail patients (72, 37.9%) were older, with higher comorbidity features and with a higher CRUSADE score at admission. On univariate analysis, frailty predicted major bleeding during 30-day follow-up despite less frequent use of a P2Y12 inhibitor (66.2% vs 83.6%, p=0.007) and decreased catheterisation rate (69.4% vs 94.1%, p<0.001). Major bleeding was associated with increased all-cause mortality at day 30 (18.2% vs 2.5%, p<0.001). On multivariate analysis, frailty was an independent predictor for major bleeding. CONCLUSION: Frailty phenotype, as a marker of biological vulnerability, is an independent predictor of major bleeding in elderly patients with ACS. Frailty can play an important role in bleeding risk stratification and objective indices should be integrated into routine initial evaluation of these patients.