Advanced Heart Failure in Cardio-Oncology

Dr. Dharini Ramu, Associate Professor of Medicine at the Medical University of South Carolina, practicing advanced heart failure, leading the cardio-oncology program and serving as co-medical director of the Cardiac Intensive care Unit (cardiac ICU). Richard Cheng, Associate Professor of Medicine/Cardiology and Adjunct Associate Professor of Radiology at University of Washington/Seattle Cancer Care Alliance, Program Director for the Advanced Heart Failure Fellowship, Director of the Cardio-oncology Program. Pearls Cardiovascular complications are a significant cause of morbidity and mortality in the cancer population, even though patients are usually young. Heart failure physician’s role starts from treating the very early stages of diagnosis of heart failure to everything that involves their heart failure care, including providing an evaluation for advanced heart failure therapies like goal-directed medical therapy (GDMT), suggesting device therapies and/or advanced heart failure therapies (LVAD, heart transplant)  and managing them after that. ·      Cardio-oncology can be thought of as a bi-directional specialty. There are, clearly, two subsets of patients for which an advanced heart failure provider can be helpful. The first ones are the cancer patients who develop heart failure subsequent to cancer therapies or the effects of cancer itself. The second subset involves pre-existing heart failure patients developing cancer and, thereby, needing evaluation for advanced therapies. ·      Checkpoint inhibitors are now coming in a big way and are being seen as effectively useful in malignancies like triple-negative breast cancers. The pathophysiology of heart issues in such medicines seems quite intriguing and shared with transplant rejection pathophysiology, and therefore, heart failure physicians can be very effective in this regard. ·    There are different concerns for managing advanced heart failure patients with cancer issues. The first one is the bridging option in these patients, either for treatments or for longer-term therapy. Another one is tackling the increased risk of thrombosis and bleeding in cancer patients when considering for LVADs, etc. ·  Heart transplantation is another domain in the management of advanced heart failure as that has several unanswered concerns for cancer patients.  Optimal timing for a heart transplant in pre-existing cancer and short and long-term follow-up of these cancer patients after a heart transplant is the first one. ·  Heart transplant patients as such, even though without pre-existing cancer, may develop cancers later on in life. ·  Adriamycin-associated or, for that matter, any cancer- or cancer treatment-associated cardiomyopathy patients should not be excluded or denied the option of heart transplant solely based on the cancer history. ·  Multidisciplinary teams involving cardiologists, oncologists, or healthcare providers especially at tertiary care centers would be ideal for taking care of cancer patients with heart failure. · Multidisciplinary approach to complex cases, including patients and caregivers as part of the decision-making team, and consider early palliative care consults in appropriate cases as well. Related articles: Richard Cheng et al. “Implications of cancer prior to and after heart transplantation” https://heart.bmj.com/content/early/2021/06/30/heartjnl-2020-318139 Richard Cheng et al. “Cardio-oncology and the intersection of cancer and cardiotoxicity: the role of palliative care” Cardio-Oncology and the Intersection of Cancer and Cardiotoxicity (jacc.org) Bhavadharini Ramu et al. “Heart transplantation in adriamycin-associated cardiomyopathy in the contemporary era of advanced heart failure therapies” Heart Transplantation in Adriamycin-Associated Cardiomyopathy in the Contemporary Era of Advanced Heart Failure Therapies | JACC: CardioOncology Show Notes provided by: Akhil Jain, MDResident PhysicianMercy Catholic Medical CenterDarby, PA 19023, USA.

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