Cancer therapy related cardiac dysfunction as a result of Panitumumab.

Panitumumab is a human immunoglobulin monoclonal antibody designed to target the epidermal growth factor receptor (EGFR) which is used in the treatment of metastatic colorectal cancer alone or in combination with chemotherapy. In this report, we present a case of new onset heart failure with reduced ejection fraction in a patient following panitumumab therapy. A 73-year-old gentleman with metastatic rectal adenocarcinoma presented to his local hospital with increased shortness of breath, two months after his first and only dose of panitumumab. A transthoracic echocardiogram demonstrated dilated left ventricle with global hypokinesis and an estimated left ventricular ejection fraction of 25%. Our patient underwent a comprehensive diagnostic assessment at his presentation, including ECG, transthoracic echocardiogram, cardiac magnetic resonance, computed tomography coronary angiography (CTCA), invasive coronary angiogram and 18F-FDG PET-CT. These investigations revealed no evidence of ischemic events or inflammatory processes that could account for the severe left ventricular dysfunction. To our knowledge, this is the first reported case of heart failure with reduced ejection fraction linked to panitumumab with subsequent deep phenotyping. The current guidelines do not recommend specific cardiovascular monitoring protocols for patients receiving anti-EGFR monoclonal antibodies. Until more data are available, it would be prudent to implement the same cardiovascular surveillance measures outlined for individuals receiving osimertinib, which is an EGFR tyrosine kinase inhibitor.

Late cardiotoxicity related to HER2-targeted cancer therapy.

Long-term anti-HER2 therapy in metastatic HER2 + cancers is increasing, but data about the incidence and risk factors for developing late Cancer therapy-related cardiac dysfunction (CTRCD) are missing. We conducted a single-centre, retrospective analysis of a cohort of late anti-HER2 related cardiac dysfunction referred to our Cardio-Oncology service. We include seventeen patients with metastatic disease who developed CTRCD after at least five years of continuous anti-HER2 therapy. Events occurred after a median time of 6.5 years (IQR 5.3-9.0) on anti-HER2 therapy. The lowest (median) LVEF and GLS were 49% (IQR 45-55) and - 15.4% (IQR - 14.9 - -16.3) respectively. All our patients continued or restarted, after a brief interruption, their anti-HER2 therapy. Most (16/17) were started on heart failure medical therapy and normalized their left ventricular ejection fraction at a follow-up. Our study has demonstrated that CTRCD can occur after many years of stability on anti-HER2 therapy and reinforces the importance of continuing cardiovascular surveillance in this population.

Advancing Cardio-Oncology in Asia.

Cardio-oncology is an emerging multi-disciplinary field, which aims to reduce morbidity and mortality of cancer patients by preventing and managing cancer treatment-related cardiovascular toxicities. With the exponential growth in cancer and cardiovascular diseases in Asia, there is an emerging need for cardio-oncology awareness among physicians and country-specific cardio-oncology initiatives. In this state-of-the-art review, we sought to describe the burden of cancer and cardiovascular disease in Asia, a region with rich cultural and socio-economic diversity. From describing the uniqueness and challenges (such as socio-economic disparity, ethnical and racial diversity, and limited training opportunities) in establishing cardio-oncology in Asia, and outlining ways to overcome any barriers, this article aims to help advance the field of cardio-oncology in Asia.

Delayed presentation of acute coronary syndrome with mechanical complication during COVID-19 pandemic: a case report.

BACKGROUND: The World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020. We report a patient with acute myocardial infarction (AMI) who presented late due to fears of contracting COVID-19. CASE SUMMARY: A 65-year-old man with a history of hypertension presented late to the emergency department (ED) with AMI. He gave a 2-month history of exertional angina but avoided seeking medical consult due to fears of contracting COVID-19. On the day of admission, he had 4 h of severe chest pain before presenting to the ED. He was hypotensive and tachycardic on arrival. Electrocardiogram showed inferolateral ST-elevation myocardial infarction. Chest radiograph revealed widened superior mediastinum and bedside echocardiogram revealed inferoseptal and inferolateral hypokinesia with features of cardiac tamponade. An urgent computed tomography aortogram showed possible left ventricular (LV) wall perforation with resulting haemopericardium and cardiac tamponade. Subsequent coronary angiogram showed 100% occlusion of mid left circumflex artery and a contained LV wall rupture was confirmed with LV ventriculogram. He was transferred to a tertiary centre and underwent successful emergency surgical repair. DISCUSSION: Our index case demonstrates the impact of the COVID-19 pandemic on health seeking behaviour due to fears of contracting COVID-19 and the ensuing impact of delayed medical intervention. Cardiologists worldwide are seeing an alarming rate of rare complications of AMI in patients who present late. Physicians need to be aware of this phenomenon and have an active role to play in public education.

A case series of ventricular cystic masses.

BACKGROUND: Ventricular cystic masses are uncommon. Elucidating the cause is essential for early directed therapy and prevention of complications. We present two cases of ventricular cystic masses, one in each ventricle, after myocardial infarction (MI) and ventricular septal rupture (VSR), respectively. CASE SUMMARY: Patient 1 is a 58-year-old male with left brachio-facial stroke and evolved anterior MI. A left ventricular (LV) cystic thrombus was seen on transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) imaging. He was started on anticoagulation with reduction in thrombus size 11 days later. Patient 2 is a 67-year-old male with evolved anterior MI, severe LV systolic dysfunction, and normal right ventricular (RV) function. He was readmitted two weeks later with fever, heart failure, Streptococcus agalactiae bacteraemia, and septic pulmonary emboli. Transthoracic echocardiogram showed biventricular systolic dysfunction and a RV cystic mass associated with a partial VSR. He was treated with anticoagulation and antibiotics. Repeat TTE 5 weeks later revealed near resolution of the cystic mass and complete VSR. Cardiac magnetic resonance confirmed these findings and also showed a localized mid-septal transmural infarction at the VSR site. He underwent percutaneous coronary intervention to the left anterior descending and circumflex arteries, and percutaneous VSR closure with a muscular ventricular septal defect device later. DISCUSSION: Our two cases demonstrate that ventricular thrombi can present as cystic masses after MI and VSRs. Infectious, vascular, or oncogenic causes should be considered in the appropriate clinical context. Early diagnosis and treatment is essential to prevent embolic complications, and secondary infection.

Clinical outcomes of elderly South-East Asian patients in primary percutaneous coronary intervention for ST-elevation myocardial infarction.

OBJECTIVE: To evaluate the clinical characteristics and in-hospital outcomes of elderly South-East Asian patients undergoing primary percutaneous coronary intervention (PPCI). METHODS: From January 2009 to December 2012, 1268 patients (86.4% male, mean age of 58.4 ± 12.2 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: elderly group defined as age ≥ 70 years and non-elderly group defined as age < 70 years. Data were collected retrospectively on baseline clinical characteristics, door-to-balloon (D2B) time, angiographic findings, therapeutic modality and hospital course. RESULTS: The elderly group constituted 19% of the study population with mean age 76.6 ± 5.0 years. There was a higher proportion of female gender and ethnic Chinese patients in the elderly group when compared with the non-elderly group. The former was less likely to be smokers and have a significantly higher prevalence of hypertension. The mean D2B time was significantly longer in the elderly group. They also had a significantly higher incidence of triple vessel disease and obstructive left main disease. The use of radial artery access, glycoprotein 2b/3a inhibitors and drug-eluting stents during PPCI were also significantly lower. In-hospital mortality was significantly higher in the elderly group. The rate of cardiogenic shock and inhospital complications were also significantly higher. CONCLUSIONS: Our registry showed that in-hospital mortality rate in elderly South-East Asian patients undergoing PPCI for STEMI was high. Further studies into the optimal STEMI management strategy for these elderly patients are warranted.

Healthcare Needs of Patients with Amyotrophic Lateral Sclerosis (ALS) in Singapore: A patient-centred qualitative study from multiple perspectives.

BACKGROUND: One challenge for those who manage amyotrophic lateral sclerosis (ALS) is to understand patients' needs. AIM: The aim of this study was to examine the needs of Singapore ALS patients from their perspective as well as that of their caregivers and healthcare professionals in order to develop a template for better services. METHODS: A cross-sectional qualitative study was conducted, with one-to-one interviews and focus group discussions. RESULTS: All 30 participants, key stakeholders in the field of caring for ALS patients, identified these needs categories: psychological--diagnosis must be staged and comfortably paced, and efforts must be made to encourage patients' resilience; social--positive relationships, open communication, and spiritual support must be developed; physical--attention should be paid to alleviating discomfort and disability; and environmental--appropriate services should be made available. CONCLUSION: The identified needs categories do overlap, but there are significant differences. Our findings provide a template for developing individualized patient services, which should be done within the framework of a comprehensive palliative care program.