This January, Efstathia Andrikopoulou, MD, a cardiologist in the UAB Cardiovascular Institute, sat down with the Birmingham Medical News to talk about Cardio Oncology.
What is Cardio Oncology?
Cardio Oncology is a new field that sits at the intersection of cardiology and oncology. It involves cardiologists who specialize in caring for people who are either currently diagnosed with cancer and undergoing treatment ,whether it be chemotherapy or radiation treatment, or people who have survived cancer and had these treatments in the past.
This field, which is about 10 to 15 years old, is growing at a dramatic pace because, as our diagnosis of cancer gets more accurate and we develop novel treatments, more and more cancer patients survive. This, of course, is great. The problem, however, is that we are recognizing that chemotherapy and radiation therapy can damage the heart muscle both in the near term and in the long run.
There could be heart-related complications like heart attacks, high blood pressure, or inflammation of the heart muscle, known as myocarditis. The most common condition is heart failure, which is weakness of the heart muscle. These could manifest while patients get chemotherapy or months or years later.
Who do you see?
In our clinics we see patients who have been diagnosed with any type of cancer. It could be breast cancer, colon cancer, kidney cancer, head and neck cancers, bone cancers, or blood cancers like Leukemia or Lymphoma.
If a patient has already had heart issues, like high blood pressure, elevated cholesterol, or a past heart attack or stroke, they are at higher than average risk for developing or worsening heart disease as a result of chemotherapy or radiation treatment.
We definitely want to see these people in our clinic, even before they start chemotherapy, and our oncology colleagues are good at identifying them. We want to see the state of their heart muscle. Is there good blood flow to the walls of their heart? Is the heart muscle pumping strongly on both the left and the right side? Are the valves opening and closing nicely?
For example, yesterday I saw a man who was diagnosed with sarcoma a few weeks ago. The UAB oncologist did an echocardiogram of his heart to make sure his heart was in good shape, and even though he was young and active, the oncologist found that his heart muscle was weak.
We want to help him get the strongest chemo that has been shown to work best for him, while at the same time, ensuring that we keep his heart healthy. Before starting chemo, we got him on medications that are proven to help the heart muscle stay strong, but also recover its strength when its weakened.
Are there some types of chemotherapy that are more risky for the heart than others?
Yes. One chemo medication that is one of the highest risk in causing heart failure is anthracycline. These are drugs like Doxorubicin, Daunorubicin, and Epirubicin, to name a few. With these drugs, the heart problems can manifest years later.
Another class of agents is Tyrosine Kinase inhibitors, which can be used for various types of blood cancers or organ cancers. Others include new types of agents that are coming out now – immunotherapies – things like immune check point inhibitors (ICI). The other new kid on the block is car-t cell therapies. We are starting to recognize that they may also cause heart disease.
The most fearful complication from ICI is myocarditis, in which the heart inflammation can range from mild to life-threatening and manifests soon after they get the medication. We have started to recognize that a small percentage of people can get this medication and then go into acute heart failure where the heart muscle can’t pump and they were at risk of dying. We’ve had to give them strong treatment like high doses of steroids to reverse the inflammation.
The potential for cardiac harm is worsened if a patient has to take a combination of these drugs, which is not uncommon in the case of breast cancer. So we are more aggressive in keeping a close eye on these patients, doing frequent tests with ultrasounds of the heart, electrocardiogram, echocardiograms, as well as blood tests that can show early signs of abnormal function of the heart muscle.
What about patients who don’t have heart problems in advance?
There is some standardization of who needs to be seen. But at the same time, we also want to personalize our approach. Let me add that not all heart disease causes symptoms. A diabetes sufferer might get a heart attack without any pain, which we call silent heart attacks.
There are things we have to look out for to try to uncover heart disease when there are no symptoms. For example: let’s say a doctor sends us a patient who is going to have chemo, but who doesn’t show any signs of heart trouble. She is a 50 year old woman with breast cancer. We will start by checking her blood pressure and her heart to make sure there is no undiagnosed high blood pressure. If there is, we want to control the high blood pressure with a heart healthy diet and more exercise. We also get an EKG to make sure the electrical activity in her heart is good. Then we ask about her family’s heart history.
Is your clinic involved in any innovations in the field?
Yes, actually. At the beginning of February, we’ve started the first of its kind artificial intelligence driven cardiology program. We’ll use AI to screen through all our ECG reports to identify certain features that will put people at risk of getting or worsening heart disease when they receive chemo. This will help us ensure that no patients fall through the cracks and that everyone gets high-quality cardiac care.