Pericardial Decompression Syndrome: A Case Series and Literature Review.

Cardiac tamponade is a medical emergency requiring prompt recognition and intervention to avoid potentially fatal consequences. We present a case series of ventricular dysfunction and cardiogenic shock following pericardiocentesis in 3 patients with pericardial effusions at The Ottawa Hospital between 2014 and 2020. This report highlights the need for monitoring post-pericardiocentesis and raises awareness of this phenomenon, particularly in patients with malignancy. We propose a novel pressure-monitoring protocol to guide drainage and prevent development of pericardial decompression syndrome. The novel teaching points include limiting drainage to prevent development of pericardial decompression syndrome and a protocol for intra-pericardial pressure monitoring.

La tamponnade cardiaque est une urgence médicale qui, à défaut d'une reconnaissance et d'une intervention rapides, peut avoir des conséquences potentiellement fatales. Nous présentons une série de cas sur des dysfonctions ventriculaires et des chocs cardiogéniques survenus après une péricardiocentèse chez trois patients présentant des épanchements péricardiques traités à l'Hôpital d'Ottawa entre 2014 et 2020. Notre article souligne la nécessité de surveiller les patients au cours de la période suivant la péricardiocentèse et met en lumière le phénomène de la tamponnade cardiaque, en particulier chez les patients atteints de cancer. Nous proposons un nouveau protocole de surveillance des pressions conçu pour guider le drainage et prévenir le syndrome de décompression péricardique. Les nouveautés à enseigner comprennent la limitation du drainage afin de prévenir le syndrome de décompression péricardique et un protocole de surveillance des pressions intrapéricardiques.

Comparison of Framingham risk score and chest-CT identified coronary artery calcification in breast cancer patients to predict cardiovascular events.

BACKGROUND: In breast cancer patients, coincidental detection of CAC at chest CT may be important in determining cardiovascular (CV) outcomes and facilitate CV disease primary prevention strategies. METHODS: 408 consecutive breast cancer patients referred to cardiac oncology clinic were included in the study. 256 patients without a prior history of coronary artery disease had undergone a chest CT. CT images were reviewed to detect CAC. Framingham risk score (FRS) was calculated and patient electronic medical records were interrogated to document the incidence of a composite clinical end point of all-cause mortality and cardiac events (coronary revascularization, heart failure hospitalization and de novo atrial fibrillation). Prevalence of statin prescribing was also collected. RESULTS: Patients were followed for a median of 6.5 years. 112 clinical events occurred. Clinical follow up was 98%. CAC was found in 26% of patients. On multivariable analysis, CAC and advance cancer stage, but not FRS predicted the composite clinical end point (OR for CAC 2.59, p < 0.01). CAC but not FRS also predicted the incidence of cardiac events (OR for CAC 4.90, p < 0.01). CAC was present in 7.3% of patients with low FRS; none had been prescribed a statin. In patients with CAC and FRS ≥ 10%, 45% were not on a statin. CONCLUSION: CAC is a common coincidental finding at CT chest in breast cancer patients referred to cardiac oncology. CAC but not FRS was predictive of composite clinical events and cardiac events. Detection of CAC at chest CT could alter the prescribing of primary prevention strategies to help prevent future cardiac events in breast cancer patients.

Reporting of coronary artery calcification on chest CT studies in breast cancer patients at high risk of cancer therapy related cardiac events.

BACKGROUND: The identification of coronary artery calcification (CAC) detected coincidentally on chest CT exams could assist in cardiovascular risk assessment but may not be reported consistently on clinical studies. Cardiovascular risk factor stratification is important to predict short term cardiac events during cancer therapy and long term cardiac event free survival in cancer patients. We sought to determine the prevalence of CAC and clinical reporting rates in a cohort of cancer patients at high risk of cancer therapy related cardiac events. METHODS: 408 Breast cancer patients who were referred to a cardiac oncology clinic were screened. Inclusion criteria included having had a CT chest and the absence of known coronary disease. Among those screened 263 patients were included in the study. RESULTS: CAC was identified in 70 patients (26%). CAC was reported in 18% of studies. The reporting rates of CAC increased with the extent of coronary calcification (p < 0.01) and increased during the period of the study (p < 0.05). CONCLUSIONS: CAC was commonly detected on chest CT studies in this observational study of breast cancer patients at high risk of cardiac oncology events. The presence of CAC was often not reported clinically but reporting rates have increased over time. Recent SCCT/STR guidelines recommend reporting the presence of CAC on routine chest CT scans in recognition of the importance of CAC as a predictor of cardiovascular events. Reporting of CAC on chest CTs may help to further risk stratify breast cancer patients and improve cardiovascular outcomes in this vulnerable population.

Shared Risk Factors for Cardiovascular Disease and Cancer: Implications for Preventive Health and Clinical Care in Oncology Patients.

The cardiovascular toxicity of cancer therapy has raised awareness of the importance of heart disease in cancer care among oncologists and cardiologists, leading to the new interdisciplinary field of cardio-oncology. Evidence is accumulating to suggest that risk factors associated with cardiovascular disease are also related to an increased incidence of cancer and excess cancer mortality. We review the epidemiologic evidence that smoking, obesity, poor diet, and inactivity can cause both heart disease and cancer. The importance of cardiovascular disease and cardiovascular risk factors in adversely affecting oncological outcomes and leading to increased cancer mortality is discussed. Cardiotoxicity prediction tools that incorporate cardiac disease and risk factors are described. Raising awareness about shared risk factors for cancer and heart disease may result in more effective advocacy to promote healthy lifestyle changes through the combined efforts of the historically separate specialties of cardiology and oncology.

An International Survey of Health Care Providers Involved in the Management of Cancer Patients Exposed to Cardiotoxic Therapy.

Cardiotoxicity is the second leading cause of morbidity and mortality in cancer survivors. The objective of this international cardiac oncology survey was to gain a better understanding of current knowledge and practice patterns among HCPs involved in the management of cancer patients exposed to potentially cardiotoxic drugs. Between 2012 and 2013, we conducted an email-based survey of HCPs involved in the management of cardiac disease in cancer patients. 393 survey responses were received, of which 77 were from Canadian respondents. The majority of respondents were cardiologists (47%), followed closely by medical oncologists. The majority of respondents agreed that cardiac issues are important to cancer patients (97%). However, only 36% of total respondents agreed with an accepted definition of cardiotoxicity. While 78% of respondents felt that cardiac medications are protective during active cancer treatment, only 51% would consider prescribing these medications up-front in cancer patients. Although results confirm a high level of concern for cardiac safety, there continues to be a lack of consensus on the definition of cardiotoxicity and a discrepancy in clinical practice between cardiologists and oncologists. These differences in opinion require resolution through more effective research collaboration and formulation of evidence-based guidelines.

Clinical Experience of Patients Referred to a Multidisciplinary Cardiac Oncology Clinic: An Observational Study.

Cardiotoxicity is the second leading cause of long-term morbidity and mortality among cancer survivors. The purpose of this retrospective observational study is to report on the clinical and cardiac outcomes in patients with early stage and advanced cancer who were referred to our multidisciplinary cardiac oncology clinic (COC). A total of 428 patients were referred to the COC between October 2008 and January 2013. The median age of patients at time of cancer diagnosis was 60. Almost half of patients who received cancer therapy received first-line chemotherapy alone (169, 41.7%), of which 84 (49.7%) were exposed to anthracyclines. The most common reasons for referral to the cardiac oncology clinic were decreased LVEF (34.6%), prechemotherapy assessment (11.9%), and arrhythmia (8.4%). A total of 175 (40.9%) patients referred to the COC were treated with cardiac medications. The majority (331, 77.3%) of patients were alive as of January 2013, and 93 (21.7%) patients were deceased. Through regular review of cardiac oncology clinic referral patterns, management plans, and patient outcomes, we aim to continuously improve delivery of cardiac care to our patient population and optimize cardiac health.

The experience of a multidisciplinary clinic in the management of early-stage breast cancer patients receiving trastuzumab therapy: an observational study.

Background. We established a dedicated cardiac oncology clinic in 2008 for the rapid diagnosis and treatment of cardiotoxicity related to cancer therapy. In this retrospective observational study, we report on clinical outcomes in women with early-stage breast cancer (EBC) referred to this clinic. Methods. Patients with EBC treated with chemotherapy/trastuzumab and referred between October 2008 and December 2010. Data included patient demographics, staging, cancer treatment/completion, dose delays, left ventricular ejection fraction (LVEF) and cardiac treatment. Results. Forty eight patients: median age 55.5 years, stage I/II disease (77%) and HER-2 positive (98%). The majority of women (n = 32) were referred for decreases in LVEF (from baseline). Overall, 37 (77%) patients experienced at least one drop in LVEF while on treatment, of which 22 patients (59%) experienced a ≥10 percentage point drop. The majority of patients (30/37; 81%) experienced declines in LVEF while on trastuzumab. Interventions included trastuzumab delays (n = 16/48; 33%) and cardiac medication (12/48: 25%). A total of 81% of patients completed ≥90% of trastuzumab therapy and 15% of patients discontinued therapy due to cardiotoxicity. Conclusion. The majority of patients referred to our clinic completed therapy. Further studies are needed to determine the impact of this multidisciplinary approach on treatment completion and cardiac outcomes.

Negative predictive value of multiplane transesophageal echocardiography in the diagnosis of infective endocarditis.

BACKGROUND: The clinical implications of a negative multiplane transesophageal echocardiography (TEE) have not yet been reported. We aim to determine the negative predictive value (NPV) of a negative multiplane TEE in patients with suspected infective endocarditis (IE). METHODS AND RESULTS: We identified 83 consecutive patients with suspected IE and negative multiplane TEE from our echocardiographic database. Of 74 patients with a minimum of 1-month follow-up, only 1 patient developed "definite IE". Eight patients had "possible IE". The calculated NPV of multiplane TEE in IE was 98.6% if we only considered the case of "definite IE". If we assumed that all patients with "possible IE" had the disease, then the NPV of multiplane TEE was 87.8%. CONCLUSIONS: Multiplane TEE is a highly accurate diagnostic tool with excellent NPV in IE. However, in a highly suspicious clinical setting for IE, a repeat TEE is still recommended to assess evolving echocardiographic features.

Hyperthyroidism six years post-BMT for acute myeloblastic leukemia in a patient on long-term lithium therapy for bipolar affective disorder.

Lithium is commonly used to treat bipolar affective disorder. It is well known to adversely affect thyroid function, most commonly causing hypothyroidism. Hyperthyroidism is a rare complication. Similarly, total body irradiation (TBI) associated with BMT is well known to affect thyroid function frequently causing hypothyroidism. Hyperthyroidism secondary to TBI is unusual. To have both a history of chronic lithium therapy and TBI with a BMT in patient presenting with hyperthyroidism is an extremely atypical situation. We describe a 39-year-old male who presented with primary hyperthyroidism after 18 years of lithium use for bipolar affective disorder and 6 years post-BMT for AML-M4.