cardio-oncology & advanced heart failure therapies
TRANSCRIPT
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Minneapolis Heart Institute® at Abbott Northwestern Hospital
Cardio-Oncology at MHI
Innovation SummitKasia Hryniewicz, MD
September 26th, 2015
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• No disclosure
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Why cardio-oncology?
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Background• The advent of modern cancer therapy has
considerably improved the outcome of patients with cancer and, for the first time, has introduced "survivorship" as a theme in the management of cancer patients.
• These therapies may have cardiovascular consequences that may affect continued therapy of the cancer and cause short- and long-term morbidity or mortality.
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Potential offenders
Trastuzumab (herecptin)
Cyclophosphamide
Busulfan
Melphalan
Carfilzomib
Adriamycin
Imatinib (Gleevec)Avastin (bevacizumab)
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Cardiotoxicity• Cardiomyopathy• HTN• Acute coronary
syndrome/myocardial infarction• Thrombosis, • Electrocardiographic changes• Arrhythmias, • Myocarditis, pericarditis
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Risk factors- age (> 50, > 65)- female gender- history of or pre-existing cardiovascular
disorders- mediastinal/chest radiation - cumulative dose - total dose administered during a day or a course- rate of administration - concurrent administration of cardiotoxic agents- prior anthracycline chemotherapy- electrolyte imbalances
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Chemo-induced CM - prognosis
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Diagnosis• Echo EF, diastolic function,
global longitudinal strain• Troponin• BNP• Cardiac MRI• Standard cardiac evaluation
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Therapies• Prevention
- carvedilol- spironolactone- allopurinol- statin
• Treatment- standard HF therapy- dextrazoxane
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Evolution of Cardio-Onc Clinic at MHI
1 MD,1 RN
Risk factor list
Reach out to
Minnesota Oncology
Prevention/
therapy and f/u
protocols
Imaging protocols (strain)
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Cardio-Oncology Clinic at MHI
Kasia Hryniewicz, M.D.
Elizabeth Grey, M.D.
Mosi Bennett, M.D.
Michelle Vanhove, NP
Rebecca Giraldo, RN
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Our philosophy• Physicians and NPs available to
see new referrals within 24 hours. • Education provided by nurse
coordinator at initial visit.• Close follow up including visits
and phone calls. • Efficient uptitration of
medications to allow the shortest time off chemotherapy“ We like to be bothered and we like to bother”
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Standardized 2D echocardiogram
- Designated machine- All techs trained- All patients have longitudinal
strain measurements- All patients have 3D LV systolic
function assessment- Report generator updated to
include strain and 3D measurements
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Our Stats• 117 patients• 90 (77%) women• Mean age 68 years (31-88)• Most common diagnosis breast
cancer (39%)
lymphoma (12%)
8/117 (7%) presented with low EF, able to restart chemotherapy after 4-6 weeks of HF treatment
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When to refer? • Early!• Ideally before chemotherapy
started if any of the risk factors present
• If any decrement in LVEF during therapy
• Symptoms of heart failure and side effects of chemotherapy are very similar – refer when in doubt!
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Future directions• Clinical trials
- stem cells in chemo induced CM (SENECA trial), starting this fall- Prevention and screening- Provider manual- Patient information booklet- Expanding to outreach clinics- NP involvement
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Thank you!