Radiation-associated cardiovascular disease: manifestations and management

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Abstract

Irradiation of the heart incidental to the treatment of malignancies can cause a spectrum of cardiovascular complications. These include pericarditis, myocardial fibrosis, muscular dysfunction, valvular abnormalities, and conduction disturbances. Survivors of Hodgkin’s disease and breast cancer survivors treated with radiotherapy after mastectomy appear to be the groups at highest risk for radiation-associated cardiovascular disease. Although modern techniques of chest radiotherapy have decreased its frequency by reducing the dose and volume of radiation exposure to the heart, survivors treated with radiation remain at increased risk of cardiovascular disease. The risk of fatal cardiovascular disease increases with younger age at treatment, longer follow-up, and higher dose volumes of exposure to the heart. Certain chemotherapeutic agents, such as anthracyclines, also increase the risk of damage to the heart. Cardiac damage associated with radiotherapy may be progressive. Screening of survivors may help identify those at highest risk for serious cardiovascular disease. The broad range of radiation-associated cardiovascular disease makes it necessary for survivors to be examined with multiple screening modalities, although data do not exist to support definitive recommendations on test frequency.

Section snippets

Spectrum of cardiovascular complications

The spectrum of radiation-associated CVD is broad and includes direct and indirect effects Table 1, Table 2.

Screening and diagnosis

Although screening regimens have been suggested for patients treated with doxorubicin,50 no screening regimen for those treated with mediastinal radiotherapy and/or an anthracycline has ever been tested for efficacy and cost-effectiveness. Yet, the wide range of possible cardiac abnormalities associated with therapeutic chest irradiation suggests the potential usefulness of multiple screening modalities (Table 3). This section will discuss potentially useful screening tests for

Management

Prevention is the best way to treat radiation-associated cardiotoxicity. Modern irradiation techniques have clearly decreased the frequency of cardiac disease, although it does not appear that they have significantly decreased the most serious risk, the incidence of fatal myocardial infarction. Modern techniques include using a linear accelerator as a radiation source, a daily fraction size <2 Gy, equally weighted anterior/posterior portals each treated daily, and minimizing the volume of heart

References (74)

  • G. Gyenes et al.

    Myocardial damage in breast cancer patients treated with adjuvant radiotherapyA prospective study

    Int J Radiat Oncol Biol Phys

    (1996)
  • J. Pihkala et al.

    Myocardial function in children and adolescents after therapy with anthracyclines and chest irradiation

    Eur J Cancer

    (1996)
  • R.G. Carlson et al.

    Radiation-associated valvular disease

    Chest

    (1991)
  • C. Glanzmann et al.

    Cardiac lesions after mediastinal radiation for Hodgkin’s disease

    Radiother Oncol

    (1994)
  • A. Gustavsson et al.

    Late cardiac effects after mantle radiation in patients with Hodgkin’s disease

    Ann Oncol

    (1990)
  • A. Gustavsson et al.

    No serious late cardiac effects after adjuvant radiotherapy following mastectomy in premenopausal women with early breast cancer

    Int J Radiat Oncol Biol Phys

    (1999)
  • R.L. Larsen et al.

    Electrocardiographic changes and arrhythmias after cancer therapy in children and young adults

    Am J Cardiol

    (1992)
  • F. Orzan et al.

    Associated cardiac lesions in patients with radiation-induced complete heart block

    Int J Cardiol

    (1993)
  • M. Warda et al.

    Radiation-induced valvular dysfuction

    J Am Coll Cardiol

    (1983)
  • D.L. Morton et al.

    Management of patients with radiation-induced pericarditis with effusionA note on the development of regurgitaion in two of them

    Chest

    (1973)
  • P.T. McEniery et al.

    Clinical and angiographic features of coronary artery disease after chest irradiation

    Am J Card

    (1987)
  • G.L. Hicks

    Coronary artery operation in radiation-associated atherosclerosisLong-term follow-up

    Ann Thorac Surg

    (1992)
  • F. Gharagozloo et al.

    Use of the internal mammary artery for myocardial revascularization in a patient with radiation-induced coronary artery disease

    Mayo Clin Proc

    (1992)
  • J.A. van Son et al.

    Use of internal mammary artery in myocardial revascularization after mediastinal irradiation

    J Thorac Cardiovasc Surg

    (1992)
  • S. Mittal et al.

    Radiation-induced cardiovascular dysfunction

    Am J Cardiol

    (1996)
  • J.R. Stewart et al.

    Radiation injury to the heart

    Int J Radiat Oncol Biol Phys

    (1995)
  • J.P. Veinot et al.

    Pathology of radiation-induced heart diseaseA surgical and autopsy study of 27 cases

    Hum Pathol

    (1996)
  • F.C. Brosius et al.

    Radiation heart disease. Analysis of 16 young (aged 15-33 years) necropsy patients who received over 3,500 rads to the heart

    Am J Med

    (1981)
  • C. Glanzmann et al.

    Cardiac risk after mediastinal irradiation for Hodgkin’s disease

    Radiother Oncol

    (1998)
  • P. Mauch et al.

    Long-term survival in Hodgkin’s diseaseRelative impact of mortality, second tumors, infection and cardiovascular disease

    Cancer J Sci Am

    (1995)
  • S.L. Hancock et al.

    Factors affecting late mortality from heart disease after treatment for Hodgkin’s disease

    JAMA

    (1993)
  • S.L. Hancock et al.

    Cardiac disease following treatment of Hodgkin’s disease in children and adolescents

    J Clin Oncol

    (1993)
  • J.-.F. Boivin et al.

    Coronary artery disease mortality in patients treated for Hodgkin’s disease

    Cancer

    (1992)
  • J. Cuzick et al.

    Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy

    J Clin Oncol

    (1994)
  • L.F. Paszat et al.

    Mortality from myocardial infarction after adjuvant radiotherapy for breast cancer in the surveillance, epidemiology, and end-results cancer registries

    J Clin Oncol

    (1998)
  • Favourable and unfavourable effects on long-term survival of radiotherapy for early breast cancerAn overview of randomised trials

    Lancet

    (2000)
  • L.E. Rutqvist et al.

    Mortality by laterality of the primary tumor among 55, 000 breast cancer patients from the Swedish center registry

    Br J Cancer

    (1990)
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      Many of these adverse effects are late and more commonly seen in long-term survivors irradiated to the mediastinum at a younger age.14 Factors associated with cardiac radiation damage include radiation dose (>30Gy), volume of irradiated heart, age at exposure (younger age) and patient and treatment specific factors including concurrent chemotherapy.15,16 Accelerated atherosclerosis is seen 10 to 30 years post exposure.17

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    Supported by the National Institute of Cancer (CA-79060); National Heart, Lung, and Blood Institute (HL-53392), (5K30HL04161), Preventive Cardiology Training Grant (1T32HL07937) and Wilmot Cancer Research Fellowship of the James P. Wilmot Foundation.

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