Cardiovascular Disease in Cancer
I. Cardiotoxicity of Radiation Therapy to the Thorax
II. Cardiotoxicity of Chemotherapy
Cardiovascular Disease
Executive Summary
This briefing document summarizes key information regarding cardiovascular health during pregnancy, drawing insights from "Pregnancy and Cardiovascular Disease - Cardiovascular Medicine Text - MKSAP 19.pdf". It highlights the increasing maternal mortality in the US due to cardiovascular disorders, the physiological changes during normal pregnancy, and the critical importance of prepregnancy evaluation, multidisciplinary management, and careful consideration of medication and anticoagulation therapies for women with pre-existing or pregnancy-related cardiovascular conditions. Special attention is given to high-risk conditions like peripartum cardiomyopathy and Marfan syndrome.
I. Maternal Mortality Trends and Primary Causes
Maternal mortality in the United States has increased over the past two decades, a trend contrasting with decreasing rates in other Western countries. The leading cause of maternal mortality is acquired cardiovascular disorders, specifically "cardiomyopathy, coronary artery disease, and aortic disorders."
II. Cardiovascular Changes During Normal Pregnancy
Understanding normal physiological changes is crucial for distinguishing between healthy and pathologic signs. Key cardiovascular adaptations during a normal pregnancy include:
Table 45 (Normal Versus Pathologic Signs and Symptoms in Pregnancy) provides a detailed comparison, distinguishing normal physiological changes from symptoms like orthopnea, chest pain, atrial fibrillation, heart rate >100/min, high blood pressure (≥140/90 mm Hg), systolic murmur grade ≥3/6, or any diastolic murmur/S4, which are considered pathologic.
III. Prepregnancy Evaluation and Risk Stratification
Mandatory Prepregnancy Counseling: "All women with cardiovascular disease should receive pregnancy counseling," including genetic counseling and testing if appropriate. Multidisciplinary Approach: A comprehensive evaluation involving a "cardiologist, a maternal-fetal medicine specialist, and an obstetric anesthesiologist" is essential to assess risks and formulate a management plan for labor and postpartum. Risk Assessment Tool: The modified World Health Organization pregnancy risk classification is currently the "most accurate system of risk assessment."
A. Low-Risk Conditions
Women with certain conditions generally experience no increased morbidity or mortality:
B. Extremely High-Risk Conditions (Require Expert Center Care)
Conditions conferring "extremely high risk for maternal mortality or severe morbidity" necessitate care and delivery at "an expert center for pregnancy and cardiac disease":
IV. Management of Cardiovascular Disease During Pregnancy
A. Valvular Lesions
B. Hypertrophic Cardiomyopathy
C. Arrhythmias
D. Delivery Method
V. Specific Cardiovascular Disorders
A. Peripartum Cardiomyopathy (PPCM)
B. Other Cardiovascular Disorders
Adult Congenital Heart Disease (ACHD)
Date: October 26, 2023
Purpose: This briefing document summarizes key themes, important ideas, and facts regarding Adult Congenital Heart Disease (ACHD) based on the provided source material.
Executive Summary
Medical and surgical advancements have led to a growing population of adults with congenital heart disease (CHD). This demographic requires specialized, multidisciplinary care due to common cardiovascular "residua" from previous interventions. The document highlights various specific CHD conditions, including Patent Foramen Ovale (PFO), Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), Patent Ductus Arteriosus (PDA), Pulmonary Stenosis (PS), Aortic Coarctation, and Tetralogy of Fallot (TOF), detailing their pathophysiology, clinical presentation, diagnostic evaluation, treatment, and post-closure follow-up. A significant theme across all conditions is the importance of specialized cardiology follow-up, careful consideration of activity restrictions, and comprehensive reproductive health counseling, especially regarding pregnancy risks and contraception. Additionally, the document addresses the unique challenges and management strategies for patients with cyanotic CHD, including Eisenmenger syndrome, emphasizing the need for highly specialized care for these complex cases.
Main Themes and Key Insights
1. Growing ACHD Population and the Need for Specialized Care: * Key Fact: "Medical and surgical advances have resulted in more adults than children with congenital heart disease (CHD) in North America." * Importance: This highlights a fundamental shift in patient demographics, necessitating a focus on adult-specific management strategies and long-term care. * Implication: The specialized nature of ACHD management underscores the "importance of periodic follow-up by a team ideally consisting of the internist and a cardiologist trained in adult CHD." * Specifics: "Specialized care is critical for patients born with complex and cyanotic congenital cardiac disease, symptomatic patients, and patients who desire pregnancy."
2. Comprehensive Patient Counseling and Holistic Care: * Reproductive Health: "Patients with CHD should be offered reproductive health counseling." This includes discussions on contraception, balancing its use against pregnancy risks, and pre-pregnancy counseling for those on anticoagulation due to associated "maternal and fetal risks." * Psychological Well-being: "Anxiety and depression are prevalent but underrecognized in patients with CHD, and screening for these mood disorders should be a routine aspect of care." This emphasizes a holistic approach to patient management beyond purely cardiac issues. * Infectious Disease Prevention: Hepatitis C screening is recommended, and Hepatitis B vaccination is advised for non-immune individuals.
3. Common Cardiovascular Residua and Long-Term Follow-up: * General Principle: "Cardiovascular residua are common in patients with previous intervention for congenital cardiac lesions." This necessitates lifelong monitoring. * Condition-Specific Examples: * ASD: Atrial fibrillation risk persists after closure, and "Rare complications after device closure include device migration, erosion into the pericardium or aorta, and sudden death." * VSD: "Residual or recurrent VSD, arrhythmias, PH, endocarditis, and valve regurgitation are recognized complications following VSD closure." * PS: "Patients with previous PS intervention (balloon or surgical) often have severe pulmonary regurgitation; thus, long-term clinical and TTE follow-up is recommended." * Aortic Coarctation: "Following coarctation repair, hypertension occurs in up to 75% of patients and should be treated." * TOF: "Severe long-standing pulmonary regurgitation causes right heart enlargement, tricuspid regurgitation, exercise limitation, and both atrial and ventricular arrhythmias and is the most common reason for reoperation after TOF repair." The incidence of sudden cardiac death after TOF repair is "approximately 2% per decade."
4. Condition-Specific Management Strategies:
* **Patent Foramen Ovale (PFO):**
* **Diagnosis:** Typically by transesophageal echocardiography (TEE) with color flow Doppler or agitated saline injection.
* **Treatment:** Antiplatelet therapy for embolic stroke of undetermined source. PFO closure is recommended for patients under 60 with embolic-appearing infarcts and no other stroke mechanism, offering a "3.4% at 5 years" recurrent stroke risk reduction, but with a "3.9%" periprocedural complication rate and increased atrial fibrillation risk (0.33% per year). No treatment is needed for asymptomatic, incidentally detected PFO.
* **Associated Conditions:** Platypnea-orthodeoxia syndrome and Atrial Septal Aneurysm (ASA), which "reportedly increases the risk for stroke compared with PFO alone."
* **Atrial Septal Defect (ASD):**
* **Types:** Ostium secundum (most common), ostium primum, sinus venosus, and coronary sinus.
* **Clinical Features:** Suspected with unexplained right heart enlargement or atrial arrhythmias; "Atrial fibrillation is a common finding, particularly in older patients with an ASD."
* **Diagnosis:** TTE is preferred for secundum and primum defects; TEE, CMR, or CT for sinus venosus and coronary sinus defects.
* **Treatment:** Closure indicated for right-sided cardiac chamber enlargement and dyspnea. Percutaneous device closure for isolated ostium secundum ASDs; surgical closure for nonsecundum, large secundum, or anatomically unfavorable defects, or coexistent cardiovascular disease.
* **Pregnancy:** "Generally well-tolerated in patients with an ASD in the absence of PH."
* **Ventricular Septal Defect (VSD):**
* **Types:** Membranous (most common, 80%), muscular (often close spontaneously), subpulmonary, and inlet.
* **Presentation:** Small VSDs are asymptomatic with a "loud (often palpable) holosystolic murmur"; moderate shunts can cause LV volume overload and PH. Large, unrepaired VSDs can lead to "fixed PH within several years with subsequent development of Eisenmenger syndrome."
* **Treatment:** Closure indicated for Qp:Qs ≥ 1.5 with LV volume overload and no PH. Surgical closure is most common, but percutaneous options exist. Closure is *not* indicated for small shunts or for Eisenmenger syndrome due to risk of "clinical deterioration."
* **Pregnancy:** "Generally well-tolerated in the absence of PH; patients with VSDs and associated fixed PH should be counseled to avoid pregnancy."
* **Patent Ductus Arteriosus (PDA):**
* **Presentation:** Typical "continuous 'machinery' murmur." Large unrepaired PDAs can cause PH and "Eisenmenger syndrome; characteristic features... are clubbing and oxygen desaturation affecting the feet but not the hands (differential cyanosis)."
* **Treatment:** Closure indicated for left-sided cardiac chamber enlargement if pulmonary artery systolic pressure is less than 50% systemic. Percutaneous closure is usual.
* **Pulmonary Stenosis (PS):**
* **Associated Syndrome:** Noonan syndrome.
...
Peripheral Arterial Disease
I. Overview and Epidemiology
Peripheral Artery Disease (PAD) is primarily characterized by the narrowing of the aortic bifurcation and arteries of the lower extremities, including the iliac, femoral, popliteal, and tibial arteries. The most common cause is atherosclerosis. PAD is a significant health concern, considered a "coronary heart disease risk equivalent," meaning both asymptomatic and symptomatic patients face an elevated risk for ischemic events such as myocardial infarction, stroke, and cardiovascular death. Early detection is crucial for risk factor modification.
Key Facts:
Risk Factors:
Screening Guidelines (AHA/ACC):
Screening with an Ankle-Brachial Index (ABI) is "reasonable in asymptomatic persons" with specific risk factors:
Note: The U.S. Preventive Services Task Force finds insufficient evidence to support routine ABI screening for lower extremity PAD.
II. Clinical Presentation
PAD presents with a wide spectrum of clinical manifestations, as it is defined by an abnormal ABI rather than solely by symptoms.
A. Intermittent Claudication (IC)
B. Atypical Exertional Leg Pain
C. Asymptomatic PAD
D. Chronic Limb-Threatening Ischemia (CLTI) / Critical Limb Ischemia
III. Evaluation
A comprehensive evaluation, including history, physical examination, and diagnostic testing, is essential for suspected PAD.
A. History and Physical Examination
B. Diagnostic Testing
IV. Medical Therapy
Treatment of PAD focuses on "reducing cardiovascular risk, improving functional status and quality of life, decreasing claudication symptoms, and preventing tissue injury and amputation."
A. Risk Factor Modification
Aortic Diseases: A Comprehensive Briefing
Date: October 26, 2023
Purpose: This briefing document provides a detailed overview of various aortic diseases, including chronic conditions like aneurysms and acute, life-threatening syndromes such as dissection and rupture. It consolidates key information on definitions, causes, risk factors, symptoms, diagnosis, surveillance, and treatment strategies, drawing from provided medical sources.
1. Introduction to Aortic Diseases
Aortic diseases encompass a spectrum of conditions affecting the aorta, the body's largest artery. These conditions range from chronic issues like thoracic and abdominal aortic aneurysms and aortic atheromas to acute, highly perilous events such as aortic dissection and aneurysm rupture. Prompt diagnosis, appropriate treatment, and vigilant surveillance are crucial for preventing disease progression, complications, and mortality.
2. Thoracic Aortic Aneurysm (TAA)
2.1. Definition and Characteristics
TAA is defined as an increase in the thoracic aortic diameter greater than 50% relative to the expected or normal dimension, which varies by age, sex, and body type. TAAs can occur at the aortic root, ascending aorta, aortic arch, or descending aorta, most commonly affecting the root and ascending aorta, often linked to atherosclerosis.
2.2. Causes and Risk Factors
2.3. Symptoms
TAAs are frequently asymptomatic and detected incidentally. When symptoms occur, they may include:
2.4. Diagnosis and Surveillance
2.5. Treatment
3. Abdominal Aortic Aneurysm (AAA)
3.1. Definition and Risk Factors
AAA is an abnormal dilatation of the abdominal aorta with an anteroposterior diameter greater than 3.0 cm.
3.2. Screening and Surveillance
3.3. Treatment
Pericardial Disease Briefing Document
1. Acute Pericarditis
Definition: Acute pericarditis is the inflammation of the pericardium, the fibrous sac surrounding the heart.
Key Characteristics & Diagnosis (at least two of four criteria):
Causes (most often idiopathic or presumed viral):
Evaluation Support:
Management:
2. Pericardial Effusion and Cardiac Tamponade
2.1. Pericardial Effusion
Definition: Accumulation of fluid within the pericardial space. Causes: Often idiopathic, but malignancy, infections (tuberculosis in endemic areas), autoimmune disease, hypothyroidism, and iatrogenic causes should be considered. Management:
2.2. Cardiac Tamponade
Definition: "Cardiac tamponade occurs when fluid accumulation within the pericardial space compresses the heart and impedes diastolic filling." It can arise rapidly with low volumes (trauma, aortic dissection) or slowly with large volumes (neoplastic disease, hypothyroidism).
Clinical Presentation & Evaluation:
Management:
3. Constrictive Pericarditis
Definition: Characterized by "pericardial thickening, fibrosis, and sometimes calcification that impair diastolic filling and limit total cardiac volume."
Causes: Most commonly idiopathic in developed countries. Other causes include cardiac surgery, chest irradiation, autoimmune disease, and tuberculosis (major cause in developing countries).
Clinical Presentation & Evaluation:
Myocardial Disease
1. Hypertrophic Cardiomyopathy (HCM)
1.1 Overview and Clinical Presentation
1.2 Evaluation
1.3 Risk Stratification and Management
1.4 Surveillance
1.5 Role of Genetic Testing and Counseling
Valvular Heart Disease
1. Summary
Valvular Heart Disease (VHD) is a significant cardiac condition affecting approximately 20 million people in the United States, primarily age-dependent. It involves structural or functional valve abnormalities leading to either regurgitation (failure to close competently) or stenosis (failure to open effectively). VHD progression is slow, often causing patients to unconsciously limit activity, emphasizing the need for careful history and detailed physical examination. Diagnosis relies on ECG, chest radiography, and transthoracic echocardiography (TTE), with classification into four stages (A-D) to guide monitoring and intervention. While medical therapy offers symptom palliation, surgical or transcatheter interventions are crucial for improving long-term survival, especially in severe cases. A multidisciplinary "heart team" approach is recommended for intervention considerations. Specific VHDs discussed include Aortic Stenosis, Aortic Regurgitation, Bicuspid Aortic Valve Disease, Mitral Stenosis, Mitral Regurgitation, Tricuspid Valve Disease, and conditions related to Prosthetic Valves and Infective Endocarditis (IE).
2. General Principles of Valvular Heart Disease (VHD)
3. Specific Valvular Heart Diseases
3.1. Aortic Stenosis (AS)
3.2. Aortic Regurgitation (AR)
3.3. Bicuspid Aortic Valve (BAV) Disease
Arrhythmias
I. Introduction to Arrhythmias
Cardiac arrhythmias are disruptions in the heart's rhythm or rate, manifesting in seven basic patterns: early beats, bigeminal beats, grouped beats, pauses, bradycardia, tachycardia, and chaotic rhythms. This document will detail the diagnosis and management of specific rhythm disorders.
II. Approach to the Patient With Bradycardia
Bradycardia is defined as a heart rate below 50 beats per minute (<50/min). While it can be a normal finding in trained athletes or during sleep, it can also be symptomatic, presenting as "light-headedness, syncope, exertional intolerance, dyspnea, or fatigue."
Clinical Presentation and Evaluation
Diagnosis involves a "thorough history, physical examination, focused laboratory testing (electrolyte levels, thyroid function testing), and resting 12-lead ECG." It's crucial to identify severe or unstable conduction abnormalities requiring urgent intervention and to investigate "extrinsic and reversible causes," such as ischemia, hypothyroidism, infections, electrolyte imbalances, and medication use (e.g., AV nodal blockers). Echocardiography, exercise stress testing, and ambulatory ECG monitoring may also be helpful. Sleep apnea should be considered for nocturnal bradycardia.
Types of Bradycardia
Management of Bradycardia
III. Approach to the Patient With Tachycardia
Tachycardia is defined as a heart rate above 100 beats per minute (>100/min). Symptoms range from "tachypalpitations" to "syncope," or it may be discovered incidentally.
Clinical Presentation and Evaluation
"Documentation of tachycardia on ECG and correlation with symptoms is the key component of the diagnostic evaluation." Tachyarrhythmias are broadly categorized as supraventricular (originating above the AV node, normal QRS) or ventricular (originating below the AV node, widened QRS). History, medication review, physical exam, thyroid function testing, and echocardiography are part of the evaluation.
Antiarrhythmic Drugs
Antiarrhythmic agents are often classified by the Vaughan-Williams system (Classes I-IV), though many have multiple mechanisms. "Class I and class III agents are the most effective antiarrhythmic drugs; however, due to their membrane-active effects, they carry some paradoxical risk of inducing arrhythmia."
Types of Tachycardia
Supraventricular Tachycardias (SVTs)
Rapid heart rhythms originating from the atrium or requiring AV node conduction. They are common, often in younger patients and women, and typically occur without structural heart disease. ECG usually shows a narrow-complex tachycardia.
Heart Failure
I. Overview of Heart Failure
Heart failure (HF) is a complex clinical syndrome resulting from structural or functional impairment in blood ejection or ventricular filling. It manifests with signs of fluid overload and/or decreased cardiac output.
Key Characteristics:
Types of Heart Failure based on Left Ventricular Ejection Fraction (LVEF):
II. Screening and Diagnosis
A. Screening for Asymptomatic Patients at Risk:
B. Clinical Evaluation and Diagnosis:
C. Classification of Heart Failure Severity:
III. Management of Heart Failure
A. General Principles:
Diagnostic Testing in Cardiology
I. Foundational Principles of Diagnostic Testing
The document begins by establishing the "diagnostic cornerstone" of CVD as the "clinical history and physical examination." This initial assessment is critical for ensuring a "focused and appropriate diagnostic evaluation." Subsequent cardiovascular testing serves both "diagnostic and prognostic information," and its application should be judicious, considering:
II. Diagnostic Testing for Atherosclerotic Coronary Artery Disease (CAD)
Diagnostic tests for CAD are broadly categorized into those providing functional evidence (ischemia, blood flow, wall motion abnormalities) and anatomic information (atherosclerotic burden).
A. Functional Studies (Detection of Ischemia and Blood Flow)
These studies reveal the presence, extent, and severity of ischemia.
B. Anatomic Information (Atherosclerotic Burden)
These studies visualize the coronary arteries.
C. Cardiac Stress Testing General Considerations:
Coronary Artery Disease (CAD)
This briefing summarizes key information regarding Coronary Artery Disease, covering stable angina pectoris, acute coronary syndromes (ACS), and management in specific patient populations.
I. Stable Angina Pectoris
Definition and Diagnosis: Stable angina pectoris is characterized as "reproducible angina (discomfort or pressure of the chest, neck, or arms) of at least 2 months' duration that is precipitated by a stable level of exertion or emotional stress and is relieved with rest." In contrast, unstable angina is defined by "new-onset angina or angina occurring at a relatively low level of exertion, occurring at rest, or accelerating in frequency or severity," carrying an increased short-term risk for acute myocardial infarction (MI).
The evaluation of angina involves a focused history to elicit details on:
General Approach to Treatment: Treatment for stable angina involves a multi-pronged approach, encompassing:
Coronary Revascularization: Revascularization aims to "lessen angina and improve quality of life" in stable syndromes. In high-risk cases (left main CAD, large ischemic burden, heart failure), it's indicated for "prevention of future events and improved survival."
After Revascularization:
II. Acute Coronary Syndromes (ACS)
General Considerations: ACS results from "acute or subacute plaque rupture or erosion and coronary blood flow impairment, manifesting as acute-onset chest pain or an angina equivalent." It's characterized by serum biomarkers of myocardial injury (elevated troponin T or I).
Reperfusion (for STEMI): "Prompt reperfusion with primary PCI (PPCI) or thrombolytic therapy is indicated in all patients with STEMI who do not have limited life expectancy from other nonreversible disease." Shorter reperfusion times correlate with improved outcomes.