A case study of myopericarditis due to immune checkpoint inhibitor therapy: Proposed surveillance and management.

ABSTRACT: Immune checkpoint inhibitor (ICI) therapy is a treatment modality used in many types of cancer. Immune-related adverse events are relatively common. Cardiovascular adverse events are uncommon, but carry a high mortality rate of 25-50%. They require cessation of therapy. There is currently no universal screening before initiation of ICI therapy to identify patients with cardiovascular risk. There is also no ongoing screening to identify myocarditis and treatment is driven by symptoms. This article provides a case study of a patient who developed myopericarditis and the patient's clinical course. Furthermore, it proposes surveillance for patients before and during ICI therapy to swiftly identify potential cases of myocarditis. There is currently no universal baseline screening for cardiovascular risk in patients planned for ICI therapy. A proposed baseline cardiac evaluation, as well as scheduled surveillance therapy, is outlined in this article. With further education and training, immune-related cardiac adverse events may be more promptly detected, leading to better patient outcomes.

Cardio-Oncology: The Intersection Between Cardiovascular Disease and Cancer.

Cardio-oncology is a rapidly emerging field, and advanced practitioners (APs) play key roles in the prevention, early detection, and optimal treatment of cardiotoxicities associated with cancer therapies. At JADPRO Live Virtual 2020, Jessica Shank Coviello, DNP, APRN, ANP-BC, and Kejal Amin, PharmD, MBA, BCOP, reviewed patient risk factors and cardiovascular therapeutic agents that APs should be aware of.

Left ventricular myocardial strain and tissue characterization by cardiac magnetic resonance imaging in immune checkpoint inhibitor associated cardiotoxicity.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are highly effective in treating cancer; however, cardiotoxicity can occur, including myocarditis. Cardiac magnetic resonance (CMR) imaging is useful for evaluation of myocarditis, although it has not been well studied in ICI cardiotoxicity. METHODS: We identified patients referred for CMR evaluation of ICI cardiotoxicity from September 2015 through September 2019. We assessed structural and functional parameters, feature tracking (FT) left ventricular and atrial strain, T2- weighted ratios and quantitative late gadolinium enhancement (LGE). We also applied the Updated Lake Louise Criteria for diagnosis of myocarditis. RESULTS: Of the 20 patients referred, the median left ventricular ejection fraction (LVEF) was 52.5% ± 19.1 and 50% had a normal LVEF (≥53%). FT strain analysis revealed an average abnormal global longitudinal strain (GLS) of -9.8%± 4.2%. In patients with a normal LVEF, the average GLS remained depressed at -12.3%± 2.4%. In all patients, GLS demonstrated a significant negative correlation with LVEF (rs = -0.64, p 0.002). Sixteen patients (80%) had presence of LGE (14 non-ischemic pattern and 2 ischemic). Percent LGE did not correlate with any CMR parameters and notably did not correlate with LVEF (rs = -0.29, p = 0.22) or GLS (rs = 0.10, p = 0.67), highlighting the value of tissue characterization beyond functional assessment. Nine patients (45%) met full Updated Lake Louise Criteria and 85% met at least one criterion, suggestive of myocarditis in the correct clinical context. Thirteen patients (65%) were treated for ICI-associated myocarditis and, of these, 54% (n = 7) had recovery of LVEF to normal. There was no correlation between LVEF (p = 0.47), GLS (0.89), or % LGE (0.15) and recovery of LVEF with treatment. CONCLUSION: In patients with suspected ICI cardiotoxicity, CMR is an important diagnostic tool, even in the absence of overt left ventricular dysfunction, as abnormalities in left ventricular strain, T2 signal and LGE can identifying disease.

Improving Provider Compliance With Adult Inflammatory Bowel Disease Patient Care Guidelines in the Ambulatory Setting Through the Use of Electronic Health Records.

Electronic health record (EHR) systems have the ability to improve the quality of patient care, patient safety, and provide benefits to providers and clinic practices. These systems can transform quality measurement and quality improvement methods, facilitate workflow, and track patients over time to ensure that they receive guideline-recommended, evidence-based care. Simply having an EHR system, however, may not be enough to improve the quality and safety of healthcare, especially if the system is not designed to include features specific to the treatment population. A comprehensive literature review of the evidence on EHRs and the implementation of clinical guidelines was conducted. The positive outcomes in this review supports the notion that using well-designed, evidence-based clinical decision tools or checklists within the workflow of the EHR system can improve provider compliance with inflammatory bowel disease (IBD) clinical practice guidelines. Critical content to include in the IBD checklist for the adult patient in the ambulatory setting is also recommended.

Cardiovascular and Cancer Risk: The Role of Cardio-oncology.

Cardio-oncology is a subspecialty of cardiology. It was created to address oncology data indicating that newly developed drugs for cancer treatment were having unanticipated cardiac side effects. Cardio-oncology designs primary and secondary risk strategies through surveillance as well as interventions to reduce cardiovascular risk (CVR), prevent cardiotoxicities, and manage the side effects that may occur. Rather than discuss in detail the cardiotoxicities of specific therapies or radiation, this review article will explore the interplay of cancer, cancer treatment, and CVR. It will examine the link between CVR and cancer risk, define mechanisms associated with cardiotoxicity, and describe screening and surveillance for patients undergoing cancer treatment. Finally, effective preventative and management strategies used to reduce the incidence of cardiotoxicities in those receiving chemotherapeutics or radiation will be presented.

Assessing and managing metabolic syndrome and cardiovascular risk in midlife women.

BACKGROUND: The components of metabolic syndrome (MetS), a major cardiovascular risk in women that includes diabetes, hypertension, and dyslipidemia, can evolve during the perimenopause transition. Lifestyle interventions have been shown to ameliorate or prevent individual components of MetS. PURPOSE: This article will describe the hormonal and vascular changes occurring during perimenopause and discuss how they set the stage for MetS in women. The available screening tools (Framingham Assessment for Coronary Heart Disease vs Framingham General Cardiovascular Risk Profile vs Reynolds Risk Assessment) will be compared and contrasted within the context of the 2011 Updated Guidelines for the Prevention of Cardiovascular Disease in Women via case study. CONCLUSIONS AND CLINICAL IMPLICATIONS: Target goals and interventions to reduce or ameliorate the components of MetS will be presented, with a focus on achieving ideal cardiovascular health.

Accomplishing quality of life in end-stage heart failure: a hospice multidisciplinary approach.

The literature addresses using multidisciplinary teams to manage outpatient heart failure patients to reduce hospital readmission rates, increase functional capacity, and improve quality of life. This article shows how a multidisciplinary team can be used for these same patients in a hospice home care program.