ABSTRACT
Modern treatment strategies have led to improvements in cancer survival, however, these gains might be offset by the potential negative effect of cancer therapy on cardiovascular health. Cardiotoxicity is now recognized as a leading cause of long-term morbidity and mortality among cancer survivors. This guideline, authored by a pan-Canadian expert group of health care providers and commissioned by the Canadian Cardiovascular Society, is intended to guide the care of cancer patients with established cardiovascular disease or those at risk of experiencing toxicities related to cancer treatment. It includes recommendations and important management considerations with a focus on 4 main areas: identification of the high-risk population for cardiotoxicity, detection and prevention of cardiotoxicity, treatment of cardiotoxicity, and a multidisciplinary approach to cardio-oncology. All recommendations align with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Key recommendations for which the panel provides a strong level of evidence include: (1) that routine evaluation of traditional cardiovascular risk factors and optimal treatment of preexisting cardiovascular disease be performed in all patients before, during, and after receiving cancer therapy; (2) that initiation, maintenance, and/or augmentation of antihypertensive therapy be instituted per the Canadian Hypertension Educational Program guidelines for patients with preexisting hypertension or for those who experience hypertension related to cancer therapy; and (3) that investigation and management follow current Canadian Cardiovascular Society heart failure guidelines for cancer patients who develop clinical heart failure or an asymptomatic decline in left ventricular ejection fraction during or after cancer treatment. This guideline provides guidance to clinicians on contemporary best practices for the cardiovascular care of cancer patients.
Subject(s)
Antineoplastic Agents/adverse effects , Cardiotoxicity/diagnosis , Cardiotoxicity/prevention & control , Radiotherapy/adverse effects , Arrhythmias, Cardiac/etiology , Arrhythmias, Cardiac/therapy , Biomarkers/blood , C-Reactive Protein/analysis , Cardiotonic Agents/therapeutic use , Cardiotoxicity/etiology , Cardiotoxins/adverse effects , Coronary Thrombosis/etiology , Coronary Thrombosis/therapy , Early Diagnosis , Echocardiography, Three-Dimensional , Humans , Hypertension/etiology , Hypertension/therapy , Magnetic Resonance Imaging, Cine , Myocardial Ischemia/etiology , Myocardial Ischemia/therapy , Natriuretic Peptide, Brain/blood , Neoplasms/therapy , Primary Prevention , Risk Factors , Troponin T/blood , Ventricular Dysfunction, Left/etiology , Ventricular Dysfunction, Left/therapyABSTRACT
PURPOSE OF REVIEW: Nearly half of patients presenting with heart failure have a preserved left ventricular ejection fraction (LVEF), previously known as diastolic heart failure. The diagnosis requires fulfillment of three criteria: signs or symptoms of heart failure, presence of a normal LVEF, and evidence of diastolic dysfunction. Two of the criteria can be evaluated by echocardiography. This article reviews the echocardiographic approach to the patient with suspected heart failure with a normal left ventricular ejection fraction (HFNEF). RECENT FINDINGS: Echocardiography is the primary modality for evaluating left ventricular (LV) systolic and diastolic function in heart failure patients. Measurements of LVEF from two-dimensional echocardiography can have significant variability despite the use of quantitative methods. The use of contrast agents and three-dimensional echocardiography can improve the accuracy. Newer modalities of tissue Doppler imaging and deformation imaging are challenging the concept that systolic function is preserved in HFNEF. Evaluation of diastolic function with echocardiography requires a comprehensive approach using multiple modalities to quantitate transmitral flow, pulmonary venous flow, mitral annular motion, myocardial deformation, and cardiac structure. The clinical applicability of parameters used for evaluating diastolic function and filling pressures is dependent on the LVEF, necessitating a unique approach in patients with suspected HFNEF. SUMMARY: A comprehensive examination with knowledge of the potential limitations of echocardiography is required to accurately interpret LV systolic and diastolic function in patients with suspected HFNEF.