INTRODUCING
A NEW
SUBSPECIALTY OF
CARDIOLOGY…
New subspecialty
• Cardio-Oncology
Cardio-Oncology
• curtain
Introduction
International Cardio-Oncology Society
• Consortium of cardiac images supporting oncologists:
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Vanderbilt University- Nashville, TN
MD Anderson Cancer Center- Houston, TX
University of Texas Medical Branch- Galveston, TX
Centro Cardiologico Fondazione Monzino- Milan, Italy
University of Insubria- Como and Varese, Italy
The University Hospital of Bern- Berne, Switzerland
University of Tasmania- Tasmania, Australia
University of Manchester- Manchester, UK
St. Boniface Hospital- Winnipeg, Manitoba
Cardiac Care Critique- Tampa, FL
Moffitt Cancer Center- Tampa, FL
Florida Cancer Specialist- Tampa, FL
University of South Florida- Tampa, FL
University of Pennsylvania- Pittsburg, PA
Thomas Jefferson University- Philadelphia, PA
Stanford University- Stanford, CA
University of Michigan- Ann Arbor, MI
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University of Chicago- Chicago, IL
Huntsman Cancer Center- Salt Lake City, UT
University of Utah- Salt Lake City, UT
St. Louis University Cancer Center- St. Louis, MO
Washington University- St. Louis MO
Emory University- Atlanta, GA
Duke University- Durham, NC
Columbia University- New York, NY
Memorial Sloan-Kettering Cancer Center- New York, NY
University of Rochester Medical Center- Rochester, NY
West Virginia University- Morgantown, WV
Ottawa Hospital
Dartmouth College- Hanover, NH
University of Kansas Medical Center- Kansas City, KS
Cleveland Clinic- Cleveland, OH
Ochsner Medical Center- Jefferson, LA
Cardiac Arrhythmia Institute of Arizona- AZ
Monthly conference/webinar of consortium originates from Tampa monthly.
Case Study 1
• 41 yo Caucasian female
• Diagnosed with left breast cancer in Feb 2012
after surveillance mammo, breast US, and
core biopsy.
• Breast Cancer (G2) Type= Ductal, ER=pos,
PR=neg, HER2 IHC= 3+, HER2 Flsh= N/A,
Sentinal Lymph Node= N/A, OncoType Dx=
Not available, Menopausal status= Premenopausal, BRCA=neg
Case Study 1
• PMHx: Hashimoto’s hypothyroidism
treated in 2004, iron deficiency anemia2009, hysterectomy- 2011, palpitations
in past
• FHx: Breast cancer in mother and sister,
although BRCA1/2 negative.
• Allergies: Keflex
• SHx: Cigs-socially x 5 yrs, but not since
2003. Alcohol: weekly
• Current Meds: Zofran 8 mg prn,
Lorazepam 1 mg prn, Vit D qd,
Levothyroxine 75 mcg qd, Iron qd.
Case Study 1
Treatment
• Chemotherapy started March 8, 2012
– Carboplatin + Taxotere x 6 rounds
– Herceptin x 1 year, q3weeks
• Double mastectomy August 1, 2012
• Radiation therapy to left breast x 25
treatments (August-September 2012)
• Reconstruction planned for May 2013
Case Study 1
Surveillance
• Echocardiograms q3months
– March 2, 2012: EF 63%
– June 5, 2012: EF 64%
– September 12, 2012: EF 63%
– January 7, 2012 @ new site: 48% (BP 103/71- EF
not decreased secondary to increase in afterload)
• At this point, patient was referred to our office for
further investigation.
Case Study 1
Assessment
• Symptoms: Patient c/o fatigue and shortness of breath on
occasion, but not consistent. Has peripheral paresthesias
secondary to chemotherapy. Denies chest pain, edema, cough,
nausea, SOB at rest.
• EKG
– NSR, HR 65, non-specific ST and T wave changes
• Lab work ordered:
– Highly sensitive Troponin I: <0.006, negative
– Troponin T: negative
– BNP: 9.70
Case Study 1
Imaging Workup
• Echocardiogram:
– GE vivid 9E and portable GE vivid-Q- 2D in 2 image
planes as well as speckle tracking.
• EF: 65%
• Global strain: -19%
• Regional strain: normal
• Cardiac MRI:
• Normal EF: ~60’s range
• Main left, proximal LAD, proximal RCA: all normal
Case Study 1
Plan and Follow-up
• Ejection fraction normal
• Continue Herceptin treatment
• Regular follow-ups with special attention to:
– BP monitoring
– HS Trop I & BNP q3mo
– Echo with strain upon completion of Herceptin
• Post treatment:
– Yearly echos and Coronary MRI if chest pain,
especially LAD for any changes secondary to left
breast radiation.
Case Study 2
First Encounter, June 2002:
• 55 yo African American female
• HPI: Abnormal EKG showing abnormal T vector. Patient c/o
discomfort and fullness in chest, tingling of left arm x 3
weeks.
• PMHx: Left breast carcinoma, lymph node negative in 1996
s/p left radical modified mastectomy with 6 cycles of 5FU
870 mg/ Cytoxan 870 mg/ Adriamycin 87 mg. Followed by
Tamoxifen 10 mg BID x 5 yrs
• HTN x 30 yrs, hyperlipidemia, GERD
• Meds: Atenolol 50 mg qd, pravachol, ASA.
• FHx: Father: CABG x 2 in 50’s
Case Study 2
• Echo: 2+ MR, Trace TR, RVSP 37 mmHg, bulging intraatrial
septum, No ASD
• Stress echocardiogram: exercised 9 min 47 sec
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Normal SE
Maximal exercise test
No ischemic changes
Maximum HR achieved
Normal rate recovery
No wall motion abnormalities
1-2 PVC’s
EKG changes secondary to long-standing HTN. No LVH
Case Study 2
August 2004
• HPI: Murmur evaluation
• PE: BP 120/82, HR 86, short grade 2/6 systolic
murmur at the apex, upper left sternal border.
No S3.
• Echo: Dilated LA, mild MR, mild TR, RVSP 37
mmHg, small pericardial effusion adjacent IL
wall, negative for LVH
• Plan: CorCTA negative
Case Study 2
2006:
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3/28/06: awakened with burning in chest, radiation to left arm, elevated HR
x 30 mins. Meds: Atenolol, Vytorin. Plan: Nexium 20 mg qd and SE
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12/18/06: Orthopnea, uses 1-3 pillows, chest fullness, SOB walking ½ block,
palpitations, loss of stamina, exhausted after vacuuming. Symptoms more
frequent and severe last 6 weeks. No pedal edema.
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SE 4/6/06: reveals 3+ MR, LAE, no LVH, EF 50%, RVSP 32 mmHg, normal wall motion.
BNP 5/11/06: 80
Plan: SBE prophylaxis, tx with PPI, continue HTN tx
BNP 234.7
Echo changes: mild global LV dysfunction, EF 50%  48%, LVEDD 50  59.5, LA 60, RVSP 32  48
Class II  III
Start Diovan 80 mg qd, sodium restriction
12/27/06 TEE: 3-4+ MR, no evidence of prolapse or flail leaflet.
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Review with Dr. W. Randolph Chitwood, consider whether she is a candidate for MVR.
Case Study 2
2007:
• 1/18/07: BNP: 274.0
• 2/26/07: c/o SOB when walking.
– Echo: Severe MR, moderate TR, RVSP 43 mmHg, LAE- 44, Mild
global LV dysfunction, EF 48%
– 6/1/07: Cardiac Cath: moderate to severe MR, RVSP 43 mmHg,
no obstructive CAD, normal LV function.
– Clearance for Dr. Chitwood in Greenville, NC 
• 6/22/07: Pt admitted to Pitt County Memorial
Hospital. Minimally invasive mitral valve repair with
placement of #29 ATS ring. Postop uncomplicated.
Discharged on postop day #4.
Case Study 2
2007 s/p MVRepair:
• 7/2/07: Echo- NSR, LAE, Trace PI, Trace TR, Mild diffusely
diminished LV function, EF 49%.
• CXR reveals small to moderate right pleural effusion
– 7/13/07: f/u CXR no change
• Pt begins cardiac rehab
• Possible post cardiotomy syndrome
– Increase ASA 325 mg to TID x 3 weeks
• 12/10/07: Pt c/o decreased ROM right arm
– PT ordered
– Continue Atenolol 50 mg qd. Pt desires generic BP drug Diovan
switched to Cozaar 100 mg qd (Office visit BP 140/72)
Case Study 2
2008:
• 4/7/08: Memorial Hospital- Patient not taking any BP
med due to miscommunication with PCP. Now pt c/o
SOB walking a few steps. EKG: no change. No edema.
Chest clear.
• Echo: NSR, LAE 46, s/p MVRepair, Global LV
dysfunction, EF 26%, Trace MR, Trace TR, Trace AR,
RVSP 45 mmHg.
• DC Atenolol 25 mg qd, Restart Diovan 80 mg qd,
Start Coreg 12.5 mg BID and Digoxin 0.125 mg qd
Case Study 2
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4/24/08: Pt states SOB with walking improved. Can walk into lunch room without panting.
C/O of blurry vision when driving.
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5/28/08: Blurry vision continues when driving. Office BP 138/90
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Add Aldactone 25 mg qd.
8/25/08: Echo- NSR, Diffuse significant LV dysfunction, EF 20%, LAE 43, s/p MVR, 2+ MR, 2+
TR, RVSP 33 mmHg.
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Increase Diovan to 160 mg qd.
6/18/08: C/O palpitations 2-3x week at night, night sweats, resolves with raising head off
bed. Orthopnea. No improvement with increased Diovan.
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Change digoxin to 0.125 mg qod, Coreg 25 mg BID
Decrease Diovan to half- 40 mg qd. Contact Dr. Auerbach regarding chemotherapy treatments.
8/29/08: MRI- EF 39%, thinning of LV apex
9/05/08: TEE- No mitral valve vegetation, or other abnormalities. 2+ MR, LAE, LV
contractility appeared moderately reduced.
9/22/08: SOB and fatigue better. BNP 38
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Decrease aldactone 12.5 mg qd
Case Study 2
• 8/11/09: NSR, Normal LV Contractility, EF
56%, Normal chamber sizes, Trace PR, 1+
TR, s/p MVR
• Drop in BP’s changed meds:
– Hold Diovan, decrease Coreg to half, continue
Digoxin
• 4/13/10: NSR, Normal LV contractility, EF
60%, NO LAE, 1+ PR, 1+ TR, RVSP not
measured, difficult to assess MR- out of
plane.
• 4/26/11: NSR, Normal LV contractility, EF
73%, difficult to quantify MR- out of
plane, RVSP 30 mmHg, MAC, 1+ TR
• 2012: Hypotension. Stop Digoxin
Anthracyclines
and HF
CHF/Cardiac Toxicity
Cardiac Toxicity
Cardiac Toxicity
Hundley, 2012
Cardiac Toxicity
Cardiac Toxicity
• SEER-Medicare database in the USA showed a
cohort treated from 2002-2007 to have a 5
year incidence of heart failure of 18%
• For early stage breast cancer, a patient is
more likely to die of heart disease than
cancer.
Cardiac Toxicity
Strain Imaging
Cleveland Clinic
Markers and Images
Elevated values according
to MD Anderson:
Trop >0.05
BNP >125
Strain < 19%
Markers and Images
Markers and Images
Cardinale, 2012
Treatment
Cardinale, 2012
Treatment
Cardinale, 2012
Treatment
Treatment
Recovery of LV dysfunction with standard HF therapy
•
Jensen, et al. Annals of Oncology. 2002. 13:499-709.
Jensen, et al. Annals of Oncology. 2002. 13:499-709.
Treatment
It is unknown when you stop
these treatments- panel said
they stay conservative and
treat them on low dose ACEI
or BB forever. Unless females
become pregnant, switch ACE
to BB.
Durand, 2012
Algorithms
Early detection of Type II toxicity during F/U using
Algorithms
Starting ACE-I for Troponin I positive patients
Proposal
• Our protocol:
– Strain Surveillance During Chemotherapy for
Improving Cardiovascular Outcomes (SUCCOUR)
Study
• PI: Tom Marwick from Royal Hobart Hospital, Hobart
Australia
• US Study Center: Cardiac Care Critique with Florida
Cancer Specialists
Proposal
• International study centers:
– Australia: Royal Hobart Hospital, Royal Brisbane Hospital, Princess
Alexandra Hospital, Queen Elizabeth Hospital, Canberra Hospital
– Belgium: Cardiovascular Center Aalst, KUL, University of Liege, UCL
– Bulgaria: National Cardiovascular Hospital
– Canada: Universite de Montreal, University of Toronto
– Germany: Wuerzburg, Leipzig, Mainz
– Italy: Padua
– Japan: Sapporo
– Korea: Yonsei University, Seoul University, Ulsan University
– Norway: Oslo University Hospital
– Romania: Carol Davila University, Bucharest Hospital
– Spain: University Hospital
Proposal 1
20 patients with increased risk of cardiotoxicity from
medications
N=20
Control n=10
Strain n=10
EF alone
EF + GLS
A: EF drop >5% to <55%
With Symptoms
Start BB&ACE
Strain+
Start BB&ACE
B: Asx drop >10% to <55%
Start BB&ACE
Observing: 24 month follow-up
Proposal
Pilot Project:
• Control group: Standard of care, remote locations
• Case group
– Baseline:
• Complete 3D echo with strain
• hsTnI
• BNP
– Established intervals
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Limited 3D and 2D echo with strain for LVEF
hsTnI
BNP
Cardiac follow-up
Group B
Florida Cancer
Specialists
Locations
Group A
Cardiac Care
Critique
Radiation
Cardiac Toxicity
“
”
Radiation Algorithm
North America 501(3)(c)
Thank you!
ICOS holds case presentation webinars, 2nd Thursday of every
month, 9 am EST.
We have a Bike-a-Thon coming up in August from
Waynesville, NC to Grove Park Inn in Asheville, NC