CORRESPONDENCE: LETTER TO THE EDITOR
Imaging Surveillance for Cardiovascular Complications of Cancer Therapy
William O. Ntim, MB, ChB* and
W. Gregory Hundley, MD
* Section on Cardiology, Department of Internal Medicine, Wake Forest University School of Medicine, Bowman Gray Campus, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1045 (Email: wntim{at}wfubmc.edu).
We read with great interest the state-of-the-art paper by Yeh and Bickford (1) on the cardiovascular complications of cancer therapy. Although the review on monitoring for chemotherapy associated left ventricular (LV) dysfunction discussed the role of established noninvasive tools, such as radionuclide ventriculography and echocardiography, evidence on emerging tools such as cardiac magnetic resonance (CMR) was not provided. The potential influence of cancer therapy on the vascular system was also not addressed.
CMR, with its heightened spatial resolution compared with these established modalities, has become a valuable tool in the assessment of myocardial function, perfusion, and tissue characterization (2). In addition, CMR has low intra- and interobserver variability and high test-retest reproducibility for measurement of LV function (3,4), characteristics that are crucial in clinical situations requiring accurate serial monitoring of LV function that occurs in cancer patients receiving potentially cardiotoxic therapy for cancer. Also, CMR is considered by the American College of Cardiology Foundation and multiple professional societies as an appropriate tool for evaluation of LV function in patients with technically suboptimal echocardiograms and evaluation of specific cardiotoxic therapy associated with cardiomyopathy (5).
Tissue characterization by CMR is a robust technique of prognostic importance (6). In a pilot study, Wassmuth et al. (7) demonstrated the strength of CMR to detect subclinical cardiotoxic effects of anthracyclines. Increase of relative myocardial contrast enhancement of >5 on day 3 compared with baseline predicted a significant decline in LV ejection fraction at 28 days (p < 0.05).
An emerging concern for cancer survivors is the increasing prevalence of cardiovascular events (8). For survivors of breast cancer and hematologic malignancies, cardiovascular events are the second most common cause of mortality after cancer recurrence (8). At present, there are few studies that have been performed to identify subclinical markers of increased cardiovascular events in cancer survivors. Increased aortic stiffness is an independent predictor of cardiovascular events beyond the Framingham score (9,10). In a soon-to-be published prospective case-control study, Chaosuwannakit et al. (11), observed a significant increase in CMR measures of aortic stiffness among cancer patients within 4 months of exposure to anthracycline chemotherapy. As cancer survivors experience higher incidence of cardiovascular events, further studies will be necessary to identify subclinical markers of cardiovascular disease.
CMR holds great potential in the comprehensive cardiovascular evaluation of cancer patients on therapy and should therefore be included in discussions on contemporary cardiovascular imaging of this growing patient population.
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References
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1. Yeh ETH, Bickford CL. Cardiovascular complications of cancer therapy J Am Coll Cardiol 2009;53:2231-2247.[Abstract/Free Full Text]2. Pennell DJ. Cardiovascular magnetic resonance: twenty-first century solutions in cardiology Clin Med 2003;3:273-278.[Web of Science][Medline] 3. Cranney GB, Lotan CS, Dean L, et al. Left ventricular volume measurement using cardiac axis nuclear magnetic resonance imaging. Validation by calibrated ventricular angiography. Circulation 1990;82:154-163.[Abstract/Free Full Text] 4. Chuang ML, Hibberd MG, Salton CJ, et al. Importance of imaging method over imaging modality in noninvasive determination of left ventricular volumes and ejection fraction: assessment by two- and three-dimensional echocardiography and magnetic resonance imaging J Am Coll Cardiol 2000;35:477-484.[Abstract/Free Full Text] 5. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology J Am Coll Cardiol 2006;48:1475-1497.[Free Full Text] 6. Assomull RG, Prasad SK, Smith G, et al. Cardiovascular magnetic resonance, fibrosis and prognosis in dilated cardiomyopathy J Am Coll Cardiol 2006;48:1977-1985.[Abstract/Free Full Text] 7. Wassmuth R, Lentzsch S, Erdbruegger U, et al. Subclinical cardiotoxic effects of anthracyclines as assessed by magnetic resonance imaging—a pilot study Am Heart J 2001;141:1007-1013.[CrossRef][Web of Science][Medline] 8. Carver JR, Shapiro CL, Andre NG, et al. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects J Clin Oncol 2007;25:3991-4008.[Abstract/Free Full Text] 9. Sutton-Tyrrell K, Najar SS, Boudreau RM, et al. Elevated aortic pulse wave velocity, a marker of arterial stiffness, predicts cardiovascular events in well-functioning older adults Circulation 2005;111:3384-3390.[Abstract/Free Full Text] 10. Hundley WG, Kitzman DW, Morgan TM, et al. Cardiac cycle-dependent changes in aortic area and distensibility are reduced in older patients with isolated diastolic heart failure and correlate with exercise intolerance J Am Coll Cardiol 2001;38:796-802.[Abstract/Free Full Text] 11. Chaosuwannakit N, D'Agostino R, Hamilton CA, et al. Aortic stiffness increases upon receipt of anthracycline chemotherapy J Clin Oncol 2009 Nov 9[E-pub ahead of print].
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