Table 1. Chemotherapeutic Agents Associated with Myocardial Ischemia
|Incidence||Presentations||FDA-approved cancer therapy|
Angina, vasospasm, MI, Takotsubo cardiomyopathy
Colorectal, breast cancer
Angina, vasospasm, MI
Breast, ovarian, non- small lung cancer, Kaposi sarcoma
Testicular cancer, Hodgkinâs and non- Hodgkinâs lymphoma, Kaposiâs sarcoma, Mycosis fungoides, breast cancer, and choriocarcinoma
Angina, vasospasm, MI, coronary thrombosis, progression of CAD
Bladder, cervical, ovarian, testicular, squamous cell of head and neck, non-small cell lung cancer, and mesothelioma
Angina, vasospasm, MI
Testicular, squamous cell cancer of the vulva, cervix, or head and neck, Hodgkinâs and Non-Hodgkinâs lymphoma
Angina, MI, Takotsubo cardiomyopathy
Renal cell, colorectal, cervical, non-small cell lung cancer, glioblastoma
Angina, MI, cardiac arrest
Gastric/ gastroesophageal junction adenocarcinoma
Vasospasm, angina, MI, Takotsubo cardiomyopathy
Non-Hodgkinâs lymphoma, Chronic lymphocytic leukemia
Arterial thromboembolic events
Tyrosine kinase inhibitors
Vasospasm, angina, MI
Renal cell, liver, thyroid cancer
Angina, MI, Takotsubo cardiomyopathy, progression of CAD
Renal cell, pancreas cancer, gastrointestinal stromal tumor
Renal cell cancer, so tissue sarcoma
Angina, MI, progression of CAD, peripheral arterial disease
Chronic myeloid leukemia (CML)
Angina, myocardial infarction, progression of CAD
Aromatase inhibitors (e.g., anastrozole)
1%â2% (12%â17% w/IHD)
Anti-androgens (e.g., bicalutamide)
Angina, MI, progression of CAD
Estrogen/nitrogen mustard (Estramustine)
Gonadotropin- releasing hormone antagonists (goserelin)
Gonadotropin- releasing hormone antagonists (degarelix)
Table 2. Peripheral Arterial Disease Associated with Radiation Therapy
Type of Radiation
Peripheral arterial disease
Head and neck
CVA/TIA, carotid arterial disease
Supraclavicular and mediastinal
CVA/TIA, carotid, and subclavian arterial disease
Abdominal and pelvic
Renal arterial disease, lower extremity PAD
Table 3. Cardiovascular Screening Recommendations for Cancer Patients
Cardiovascular screening recommendations for cancer survivors
Referral to a survivorship center/cardio-oncology program is recommended for cancer survivors who are not being actively followed by hematology/oncologist.
Medical record documentation of the patientâs chemotherapy and radiotherapy treatment course with cumulative doses should be retrieved.
Transthoracic echocardiography (TTE) should be performed on patients with a history of significant anthracycline dose exposure (>240 mg/m2) or chest radiation exposure (>30 Gy) starting no later than 2 years after completion of therapy, at 5 years a er diagnosis and continued every 5 years thereafter.
In high-risk groups (known coronary artery disease, age >60, one or more CV risk factors) screening after chest radiation therapy should be initiated 2 years after radiation therapy as outlined in Figure 2.
Coronary angiography is indicated for symptomatic patients with a history ofradiotherapy, risk factors for RIHD, and noninvasive testing (i.e., stress MPI/ echo/MRI, CCTA) that suggest a high likelihood of severe ischemic heart disease.
Coronary angiography is reasonable to consider for the evaluation of LV systolic dysfunction after chest radiation and to evaluate for radiation-induced ischemic heart disease.
Right and left heart catheterization is reasonable to evaluate the presence of pericardial constriction and restrictive cardiomyopathy if noninvasive imaging (echocardiography, CT, MR) is insufficient to provide a diagnosis.
Right and/or left heart catheterization and coronary angiography is reasonable to perform as per ACC/AHA guidelines for preoperative planning for patients with severe RIHD.
There is a known association between accelerated coronary artery disease and elevated cardiovascular events and mortality after chest radiation, particularly in high-risk populations such as those with Hodgkinâs lymphoma who have undergone mantle field radiation. For these patients, functional imaging and/or CAC/CCTA is a reasonable to perform â¥5 years post-radiotherapy, and further workups (e.g., coronary angiography, functional testing) is indicated for risk stratification if there is concern for severe ischemic heart disease.
Table 4. Special Considerations for Cancer Patients with Thrombocytopenia Undergoing Cardiac Catheterization
Prophylactic platelet transfusion is not recommended in patients undergoing cardiac catheterization with thrombocytopenia, unless recommended by the oncology/hematology team for one of the following indications:
- Platelet count <20,000/mL and one of the following:
- a. High fever
- b. Leukocytosis
- c. Rapid fall in platelet count
- d. Other coagulation abnormality
- Platelet count <20,000/mL and one of the following:
- Platelet count <20,000/mL in solid tumor patients receiving therapy for bladder, gynecologic, or colorectal tumors, melanoma, or necrotic tumors.
Therapeutic platelet transfusions are recommended in thrombocytopenic patients who develop bleeding during or after cardiac catheterization.
Repeat platelet counts are recommended after platelet transfusions.
30â50 U/kg unfractionated heparin is the initial recommended dose for thrombocytopenic patients undergoing PCI who have platelets <50,000/mL. ACT should be monitored.
For platelet counts <30,000/mL, revascularization and DAPT should be decided a er a preliminary multidisciplinary evaluation (interventional cardiology/ oncology/hematology) and a risk/bene t analysis.
Aspirin administration may be used when platelet counts are >10,000/mL.
DAPT with clopidogrel may be used when platelet counts 30,000â50,000/mL. Prasugrel, ticagrelor and IIB-IIIA inhibitors should NOT be used in patients with platelet counts <50,000.
If platelet counts are <50,000, the duration of DAPT may be restricted to 2 weeks following PTCA alone, 4 weeks a er bare-metal stent (BMS), and 6 months a er second or third generation drug-eluting stents (DES) if optimal stent expansion was confirmed by IVUS or OCT .
There is no minimum platelet count to perform a diagnostic coronary angiogram.
Table 5. Access Considerations for Cancer Patients Undergoing Cardiac Catheterization
For cancer patients who are excellent candidates for both access types, the radial artery is preferred. Femoral access is the preferred approach for cancer patients on hemodialysis, those with abnormal Allenâs tests in both arms, multiple radial procedures or a-lines, bilateral mastectomy or when a complex intervention is anticipated.
The use of smaller sheath sizes, prompt removal of sheaths and early ambulation is recommended.
A lower dose of intra-arterial or intravenous unfractionated heparin at a dose of
50 U/kg or 3.000 units is recommended for cancer patients with thrombocytopenia and platelet count <50k undergoing cardiac catheterization via radial access.
A femoral angiogram is recommended after transfemoral access to promptly identify and address potential access complications.
Table 6. Indications for Non-Coronary Interventional Procedures in Cancer Patients
Procedure and Indications
- Right heart catheterization
- Evaluation of heart failure, constrictive or restrictive cardiomyopathy, valvular heart disease, pulmonary hypertension, and pericardial disease.
- Endomyocardial biopsy
- Evaluation of intracardiac tumors, unexplained heart failure associated with suspected anthracycline cardiomyopathy, infiltrative cardiomyopathies, and myocarditis.
- Evaluation of pericardial effusion and symptomatic relief.
- Balloon pericardiotomy
- Prevention of large malignant pericardial effusion, especially in poor surgical candidates
- Balloon aortic valvuloplasty and transcatheter aortic valve replacement (TAVR)
- Palliative measure for symptomatic aortic stenosis (or as a bridge for surgical aortic valve replacement (SAVR)/TAVR)
Table 7. Special Considerations for Cancer Patients Undergoing Cardiac Catheterization
Decision-making regarding revascularization in patients with active cancer must take into consideration the overall prognosis of the patient.
For cancer patients with an acceptable prognosis:
- The general revascularization criteria for appropriate use must be carefully evaluated and only the most appropriate indications (scores â¥7) should be considered.
For cancer patients with an expected survival <1 year:
- Percutaneous revascularization may be considered for patients with acute STEMI and high-risk NSTEMI. For patients with stable angina, every e effort must be made to maximally optimize medical therapy before resorting to an invasive strategy. Is approach must include addressing other cancer-related comorbidities that potentially exacerbate ischemia, such as anemia, infection, hypoxia, etc. Should the patient continue to experience persistently severe angina (CCS Class III or IV), consideration may be given to percutaneous revascularization as a palliative option.
- FFR is recommended before non-urgent PCI to justify the need for revascularization.
When invasive approach is indicated:
a. Balloon angioplasty should be considered for cancer patients who are not candidates for DAPT (platelets <30,000/mL) or when a non-cardiac procedure or surgery is necessary as soon as possible.
b. BMS should be considered for patients with platelet counts >30,000/ mL who need a non-cardiac procedure, surgery or chemotherapy which can be postponed for >4 weeks.
c. Newer generation DES should be considered for patients with platelet counts >30,000/mL who are not in immediate need for a non-cardiac procedure, surgery or chemotherapy.
d. Bivalirudin and/or radial approach should be considered to minimize the risk of bleeding.
- Intravascular imaging such as IVUS or optical coherence tomography (OCT) is recommended a er stent placement to ensure optimal expansion and an absence of complications given the potential for early DAPT interruption.