Gender aspects in cardiooncology.

BACKGROUND: Cardiooncology is a relatively new subspeciality, investigating the side effects of cytoreductive therapies on the cardiovascular (CV) system. Gender differences are well known in oncological and CV diseases, but are less elucidated in cardiooncological collectives. METHODS: Five hundred and fifty-one patients (278 male, 273 female) with diagnosed cancer who underwent regular cardiological surveillance were enrolled in the 'MAnnheim Registry for CardioOncology' and followed over a median of 41 (95% confidence interval: 40-43) months. RESULTS: Female patients were younger at the time of first cancer diagnosis [median 60 (range 50-70) vs. 66 (55-75), P = 0.0004], while the most common tumour was breast cancer (49.8%). Hyperlipidaemia was more often present in female patients (37% vs. 25%, P = 0.001). Male patients had a higher cancer susceptibility than female patients. They suffered more often from hypertension (51% vs. 67%, P = 0.0002) or diabetes (14% vs. 21%, P = 0.02) and revealed more often vitamin D deficiency [(U/l) median 26.0 (range 17-38) vs. 16 (9-25), P = 0.002] and anaemia [(g/dl) median 11.8 (range 10.4-12.9) vs. 11.7 (9.6-13.6), P = 0.51]. During follow-up, 140 patients died (male 77, female 63; P = 0.21). An increased mortality rate was observed in male patients (11.4% vs. 14%, P = 0.89), with even higher mortality rates of up to 18.9% vs. 7.7% (P = 0.02) considering tumours that can affect both sexes compared. CONCLUSIONS: Although female patients were younger at the time of first cancer diagnosis, male patients had both higher cancer susceptibility and an increased mortality risk. Concomitant CV diseases were more common in male patients.

Blood Cholesterol and Outcome of Patients with Cancer under Regular Cardiological Surveillance.

Cardiovascular (CV) diseases and cancer share several similarities, including common risk factors. In the present investigation we assessed the relationship between cholesterol levels and mortality in a cardiooncological collective. In total, 551 patients receiving anticancer treatment were followed over a median of 41 (95% CI 40, 43) months and underwent regular cardiological surveillance. A total of 140 patients (25.4%) died during this period. Concomitant cardiac diseases were more common in patients who deceased (53 (37.9%) vs. 67 (16.3%), p < 0.0001), as well as prior stroke. There were no differences in the distribution of classical CV risk factors, such as hypertension, diabetes or nicotine consumption. While total cholesterol (mg/dL) was significantly lower in patients who deceased (157 ± 59 vs. 188 ± 53, p < 0.0001), both HDL and LDL cholesterol were not differing. In addition, cholesterol levels varied between different tumour entities; lowest levels were found in patients with tumours of the hepatopancreaticobiliary system (median 121 mg/dL), while patients with melanoma, cerebral tumours and breast cancer had rather high cholesterol levels (median > 190 mg/dL). Cholesterol levels were significantly lower in patients who died of cancer; lowest cholesterol levels were observed in patients who died of tumours with higher mitotic rate (mesenchymal tumours, cerebral tumours, breast cancer). Cox regression analysis revealed a significant mortality risk for patients with stem cell transplantation (HR 4.31) and metastasised tumour stages (HR 3.31), while cardiac risk factors were also associated with a worse outcome (known cardiac disease HR 1.58, prior stroke/TIA HR 1.73, total cholesterol HR 1.70), with the best discriminative performance found for total cholesterol (p = 0.002).

Prognostic Impact of Pretherapeutic Hemoglobin Levels on All-cause Mortality in Cardiooncology.

BACKGROUND/AIM: We investigated the prognostic impact of hemoglobin (Hb) levels in tumour patients receiving routine cardiological surveillance during anticancer treatment. The aim of the study was to identify independent predictors of all-cause mortality in a cardio-oncological collective. PATIENTS AND METHODS: A total of 551 patients (273 males, 278 females) were enrolled in the Mannheim Registry for Cardiooncology and were included in the present analysis. Median follow-up was 41 months (95% CI=40-43). RESULTS: Patients were grouped according to a pretherapeutic Hb-threshold (determined by ROC analysis) into cohorts with Hb<11.4 g/dl (n=232, 42.1%) and Hb >11.4 g/dl (n=319, 57.9%). Patients with lower Hb levels were older at the time of first diagnosis (63.8±14.4 vs. 59.9±15.4 years, p=0.003) and were more likely to have advanced tumour stages (92 (39.7%) vs. 83 (26.0%), p=0.0007). There were no differences regarding cardiovascular comorbidities such as hypertension or diabetes, while chronic kidney disease was more common in patients with lower Hb. Anticoagulants were used more often in patients with lower Hb (88 (37.9%) vs. 84 (26.3%), p=0.01). Left ventricular ejection fraction (LVEF) was lower in patients with Hb <11.4 g/dl (51.9±11.0% vs. 55.1±9.7%, p=0.003). Correlation analysis revealed a significant correlation of Hb levels and LVEF (R2=0.07, p<0.0001). During follow-up, a total of 140 patients (25.4%) were deceased, with significantly more deaths occurring in the group of patients with low Hb values [108 (46.6%) vs. 32 (10.0%), p<0.0001]. In multivariable analysis, Hb was identified as independent predictor for mortality (OR=5.3, CI=0.41-0.89, p<0.0001). CONCLUSION: Low Hb levels were identified as an independent predictor of mortality in patients with cancer. There was a significant correlation of Hb and LVEF, suggesting that low Hb values are not solely due to anaemia, but rather reflect the severity of cancer.

Comparison of the Outcome of Patients Protected by the Wearable Cardioverter Defibrillator (WCD) for <90 Wear Days versus ≥90 Wear Days.

BACKGROUND/AIM: The wearable cardioverter/defibrillator (WCD) is recommended to prevent sudden cardiac death (SCD). Guidelines suggest a 90 days' period, but prolongation of WCD wear time until increasing the ejection fraction (≥35%) might be suggested. PATIENTS AND METHODS: A cohort of 153 patients with prescribed WCD were divided into two groups: A <90 wear days' group (n=112) vs. ≥90 wear days' group (n=41) and followed. RESULTS: In the first group, WCD shock occurred in 3.6% of patients, 47.3% improved in left ventricular ejection fraction (LVEF) after 3 months, and 37.5% had a cardiac implantable electronic device (CIED) implantation with appropriate implantable cardioverter defibrillator (ICD) shock events occurring in 6 patients. Two of these patients already received WCD shock therapy due to ventricular fibrillation. A 20.5% improved in LVEF after 6-12 months, but 73% were already implanted with ICD. In the second group, 4.9% received WCD shock, 34.1% improved in LVEF after 3 months, 48.8% were implanted with ICD, and 2 had ICD shocks during follow up time. LVEF improvement after 6-12 months occurred in 26.8%. ICD implantation was prevented in 7.3% of patients due to LVEF recovery. CONCLUSION: Prolonging wearing days of WCD may reduce the number of inappropriate ICD implantation.

The Wearable Cardioverter-Defibrillator: Experience in 153 Patients and a Long-Term Follow-Up.

Background: The wearable cardioverter-defibrillator (WCD) is available for patients at high risk for sudden cardiac death (SCD) when immediate implantable cardioverter-defibrillator (ICD) implantation is not possible or indicated. Patient selection remains challenging especially in primary prevention. Long-term data on these patients is still lacking. METHODS: 153 patients were included in this study. They were prescribed the WCD between April 2012 and March 2019 at the University Medical Center, Mannheim, Germany. The mean follow-up period was 36.2 ± 15.6 months. Outcome data, including all-cause mortality, were analyzed by disease etiology and ICD implantation following WCD use. RESULTS: We analyzed 56 patients with ischemic cardiomyopathy, 70 patients with non-ischemic cardiomyopathy, 16 patients with prior need for ICD/CRT-D (device for cardiac resynchronization therapy with defibrillator) explanation, 8 patients with acute myocarditis and 3 patients with congenital diseases. 58% of the patients did not need ICD/CRT-D implantation after WCD use. 4% of all patients suffered from appropriate WCD shocks. 2 of these patients (33%) experienced appropriate ICD shocks after implantation due to ventricular tachyarrhythmias. Long-term follow-up shows a good overall survival. All-cause mortality was 10%. There was no significant difference between patients with or without subsequent ICD implantation (p = 0.48). Patients with ischemic cardiomyopathy numerically showed a higher long-term mortality than patients with non-ischemic cardiomyopathy (14% vs. 6%, p = 0.13) and received significantly more ICD shocks after implantation (10% of ischemic cardiomyopathy (ICM) patients versus 3% of non-ischemic cardiomyopathy (NICM) patients, p = 0.04). All patients with ventricular tachyarrhythmias during WCD use or after ICD implantation survived the follow-up period. CONCLUSION: Following WCD use, ICD implantation could be avoided in 58% of patients. Long-term follow-up shows good overall survival. The majority of all patients did not suffer from WCD shocks nor did receive ICD shocks after subsequent implantation. Patient selection regarding predictive conditions on long-term risk of ventricular tachyarrhythmias needs further risk stratification.