CLINICAL RESEARCH: CARDIAC EFFECTS OF RADIOTHERAPY
Asymptomatic cardiac disease following mediastinal irradiation
Paul A. Heidenreich, MD, FACC* ,*,
Steven L. Hancock, MD ,
Byron K. Lee, MD, FACC,
Carol S. Mariscal, RN and
Ingela Schnittger, MD, FACC
* Palo Alto Veterans Affairs Health Care System, Stanford, California, USA
Department of Medicine, Stanford University, Stanford, California, USA
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.
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Abbreviations and Acronyms
| | HF | | heart failure | | LV | | left ventricular | | MI | | myocardial infarction |
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