PracticeUpdate Cardiology Best of 2018

ACC 2018 19

An Overview of Chemotherapy- Induced Heart Failure

Interview with Joerg Herrmann MD by Jennifer N. Caudle DO Dr. Herrmann is an Associate Professor of Medicine at Mayo Graduate School of Medicine in Rochester, Minnesota. Dr. Caudle: Could you briefly summarize the current importance in recognition of chemotherapy-induced cardiotoxicity and heart failure?

Dr. Herrmann: It has, for a long time, not really made the press. The anthracyclines, they’ve been around since the 1960s…they were discovered in the 1970s, but we all know anthracycline-induced cardiotoxicity based on our education. But what really changed was in 2001 when the results of the pivotal trastuzumab trial were pub- lished. And then, for the first time, there was an incidence of almost 30% of heart failure, at times life-threatening, which became the major game-changer. And one unique difference, from all that we had before, is that it actually affected the deliv- ery of the chemotherapy. And so, it got really close to home for the oncologists. Anthracycline cardiotoxicity is often late, it can be decades later, when they’re all cured and often forgotten. So for the cardio-oncologist it’s not really much of an impact for the therapy. But trastuzumab and then all these newer agents, collectively called targeted therapies, that became an issue. If you have cardiotoxicity, drop in the ejection frac- tion, which is more common, or clinical heart failure – less common – and you cannot proceed with what you feel is the best therapy for the cancer patient that is an issue. So that, I think, is really the relevance that we’ve recognized now for over a decade. Dr. Caudle: Two trials were presented regarding using heart failure treatment medications to prevent chemotherapy-induced cardiotoxicity. Can you explain why this data is so important? Dr. Herrmann: It comes with a first question, the dark implication is well if it’s impairing delivery of best cancer care and cure rates, and then possibly survival, that is an issue. And trastuzumab has been shown, in those patients who do develop cardio- toxicity or have interruption of therapy, they don’t do as well as those who can just go on with their 1 year of adjuvant therapy for instance. So looking for ways to pre- vent them to have a drop in the actual infection is really critical. As far as cardiology we would say, “It’s a no-brainer,” you’ve got to protect the heart. But for the oncologists it’s really also this aspect, “Can we then continue with the therapy as much as we want to?” So I think that’s why these trials are important and why I’m sure we’re going to see more and more of these in the years to come. There have already been a number done. I have to mention these two mainly related to anthracycline cardiotoxicity, but now we will see more and more related to trastu- zumab cardiotoxicity. The trials before there were two major trials and they were negative, so now we’re looking is there something positive? Dr. Caudle: How do you feel that the future of management of chemotherapy-induced cardiotoxicity will change? What do you think about that? Dr. Herrmann: There are really active efforts of all the major cardiology societies, but also the oncology societies, who have come to the realization that this is an issue particularly as it pertains to those aspects I’ve mentioned. If it doesn’t allow the oncol- ogist to complete chemotherapy, that’s really an issue. And so, we will see more formulated and, hopefully with the trials being presented, more and more guideline, type style of recommendations. I have to say that, for the most part, what we have are consensus papers where a group of experts got together and just summarized the evidence. But what we really need, and what is hopefully to come in the next few years, are more evidence-based guidelines. So, I think that’s where this is going.

© ACC/Scott Morgan 2018

but also very safe, very low thrombosis rates, and therefore, it has been raised whether we do need to continue DAPT as long with our current generation drug-eluting stents. I think a big determinant is whether the patient has an underlying ACS or not. If they do, based on trials most recently such as SMART DAPT, but a number of older trials as well, at least 12 months of dual antiplate- let therapy would be indicated as long as the patient is at low bleeding risk. So the basic calculus hasn’t changed if there’s an ACS. Now, if there isn’t an ACS, that’s a bit different. There, if a patient has a simple lesion, gets a single second generation drug-eluting stent, there the guidelines in both the United States and Europe would say 6 months of dual anti- platelet therapy is adequate. But if there are other high-risk features, multivessel disease, multivessel stenting, diabetes, a combina- tion, then a longer duration of DAPT may be warranted there as well. Again, assuming the patient is a low bleeding risk.

Dr. Caudle is a Board-Certified Family Medicine Physician and Assistant Professor in the Department of Family Medicine at Rowan University- School of Osteopathic Medicine in Stratford, New Jersey.

Go to www.practiceupdate.com/c/65257 to watch this interview with Dr. Herrmann.

Go to www.practiceupdate.com/c/65299 to watch this interview with Dr. Bhatt.

VOL. 3 • NO. 4 • 2018