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J Am Coll Cardiol, 2003; 42:743-749, doi:10.1016/S0735-1097(03)00759-9
© 2003 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: CARDIAC EFFECTS OF RADIOTHERAPY

Asymptomatic cardiac disease following mediastinal irradiation

Paul A. Heidenreich, MD, FACC*{dagger},*, Steven L. Hancock, MD{ddagger}, Byron K. Lee, MD, FACC{dagger}, Carol S. Mariscal, RN{ddagger} and Ingela Schnittger, MD, FACC{dagger}

* Palo Alto Veterans Affairs Health Care System, Stanford, California, USA
{dagger} Department of Medicine, Stanford University, Stanford, California, USA
{ddagger} Department of Radiation Oncology, Stanford University, Stanford, California, USA.

Manuscript received November 22, 2002; revised manuscript received January 31, 2003, accepted February 25, 2003.

* Reprint requests and correspondence: Dr. Paul A. Heidenreich, 111C Cardiology, Palo Alto VA Health Care System, 3801 Miranda Avenue, Palo Alto, California 94034, USA.
pah{at}smi.stanford.edu

OBJECTIVES: This study was designed to evaluate the potential benefit of screening previously irradiated patients with echocardiography.

BACKGROUND: Mediastinal irradiation is known to cause cardiac disease. However, the prevalence of asymptomatic cardiac disease and the potential for intervention before symptom development are unknown.

METHODS: We recruited 294 asymptomatic patients (mean age 42 ± 9 years, 49% men, mean mantle irradiation dose 43 ± 0.3 Gy) treated with at least 35 Gy to the mediastinum for Hodgkin's disease. After providing written consent, each patient underwent electrocardiography and transthoracic echocardiography.

RESULTS: Valvular disease was common and increased with time following irradiation. Patients who had received irradiation more than 20 years before evaluation had significantly more mild or greater aortic regurgitation (60% vs. 4%, p < 0.0001), moderate or greater tricuspid regurgitation (4% vs. 0%, p = 0.06), and aortic stenosis (16% vs. 0%, p = 0.0008) than those who had received irradiation within 10 years. The number needed to screen to detect one candidate for endocarditis prophylaxis was 13 (95% confidence interval [CI] 7 to 44) for patients treated within 10 years and 1.6 (95% CI 1.3 to 1.9) for those treated at least 20 years ago. Compared with the Framingham Heart Study population, mildly reduced left ventricular fractional shortening (<30%) was more common (36% vs. 3%), and age- and gender-adjusted left ventricular mass was lower (90 ± 27 g/m vs. 117 g/m) in irradiated patients.

CONCLUSIONS: There is a high prevalence of asymptomatic heart disease in general, and aortic valvular disease in particular, following mediastinal irradiation. Screening echocardiography should be considered for patients with a history of mediastinal irradiation.

Abbreviations and Acronyms
  HF
  heart failure
  LV
  left ventricular
  MI
  myocardial infarction




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