Download ACS in cancer patients

Special Considerations for
the Management of Cancer
Patients in the Cath Lab
Konstantinos Marmagkiolis MD, MBA, FACC, FSCAI
STEMI Medical Director
Citizens Memorial Hospital, Heart and Vascular
Institute, Bolivar, MO
Clinical Assistant Professor of Medicine, University
of Missouri, Columbia, MO
Presentation Outline
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Introduction
Chemotherapy - induced vascular toxicity
Radiation – induced vascular toxicity
Special considerations for thrombocytopenic patients
ACS in cancer patients
Vascular access for cancer patients
Optimizing PCI results in cancer patients
Non-coronary cardiac interventions in cancer patients
Introduction
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14.5 million cancer survivors
expected to increase to 20 million
by 2020
Chemotherapy toxicity
Radiotherapy toxicity
Traditional cardiovascular risk
factors
Cancer patients have been
excluded from most PCI
registries and RCTs
Chemotherapy-induced Vascular Toxicity
(Mechanisms)
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Abnormal vasoreactivity (5-FU)
Severe vasospasm resulting in ACS (Paclitaxel and
Docetaxel)
Acute coronary thrombosis, even in multiple territories
(Cisplatin)
Endothelial dysfunction (Bleomycin)
Endothelial apoptosis (Vinblastine)
Prinzmetal’s angina (Cyclophosphamide)
Accelerated atherosclerosis (nilotinib and ponatinib)
Takotsubo cardiomyopathy
Radiation therapy - induced
Vascular Toxicity (Mechanism)
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50% of cancer patients receive
radiation
Oxidative stress and inflammation
Cholesterol plaques formation and
thrombosis can appear within days
Fibrosis in all three layers of the
vessel wall
Radiation therapy – induced
coronary toxicity
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Extensive mantle radiation (HL or esophageal cancer) =>
ostial and multivessel stenoses.
10 years after RTX for Hodgkin severe stenosis of the LM or
RCA ostium in 30% without symptoms
Radiation therapy – induced
coronary toxicity
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Focal radiation (i.e. breast cancer) => focal
disease in the mid to distal LAD (left breast),
=> proximal RCA (right breast).
Radiation – Induced PAD
Type of Radiation
Peripheral Arterial Disease
Head and Neck radiation
CVA/TIA, carotid arterial disease
Supraclavicular&mediastinal radiation
CVA/TIA, carotid & subclavian arterial disease
Abdominal and pelvic
Renal arterial disease, lower extremity PAD
Cancer patients with thrombocytopenia
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10% of cancer patients have platelet counts
<100,000/mm3
Most cancer patients become thrombocytopenic during
therapy
Traditional Approach for cancer patient with ACS
- “Cannot start dual antiplatelet therapy or
anticoagulation due to thrombocytopenia”
- “Cannot send the patient to the cath lab due to
thrombocytopenia”
- “Let’s give some morphine”
SCAI Consensus Recommendations
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ASA only when platelet count > 10,000/ml
DAPT with clopidogrel only when platelet count >
30,000/ml
30-50 U/kg Unfractionated heparin dose is the
initial recommended dose for thrombocytopenic
patients with platelets < 50,000/ml undergoing PCI
We recommend against the use of prasugrel,
ticagrelor and IIB-IIIA inhibitors in patients with
platelet count < 50,000
ACS in cancer patients
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The presenting symptoms of ACS in cancer
patients are:
Dyspnea (44%)
 Chest pain (30.3%)
 Hypotension (23%).
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ACS in cancer patients
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Case series (465 patients): Cancer patients with ACS
treated conservatively -> 1-year survival 26%
Case series: STEMI in patients with recent cancer
diagnosis (<6 months) treated with PCI -> 3x increased
mortality
NHLBI registry: in ACS patients undergoing PCI ,
cancer was one of the strongest independent predictors of
in hospital death ( OR 3.2; CI 1.12-9.4) and one year
mortality (OR 2.15; 1.3-3.4)173.
Velders MA, Boden H, Hofma SH, Osanto S, van der Hoeven BL, Heestermans AA, et al. Outcome after ST elevation myocardial
infarction in patients with cancer treated with primary percutaneous coronary intervention. Am J Cardiol 2013;112(12):1867-72.
Yusuf SW, Daraban N, Abbasi N, Lei X, Durand JB, Daher IN. Treatment and outcomes of acute coronary syndrome in the cancer
population. Clin Cardiol 2012;35(7):443-50.
General considerations before cath
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There is not a low platelet threshold for coronary
angiogram
If expected survival is < 1 year, PCI should only be done
for STEMI or high risk NSTEMI
With chemotherapy, DAPT may need to be extended due
to the delayed re-endothelialization of the stent
Some cancer and chemotherapy may increase the risk of
stent thrombosis
In GI tumors the post PCI GI bleed increases from 2.4%
to 5.8%. Staged intervention (POBA and later stent) may
be considered
Vascular Access Considerations
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Femoral preferred in:
Abnormal Allen’s test
 Multiple radial procedures
or a-lines
 Dialysis or pre-dialysis
patients
 Bilateral mastectomy
 When a complex
intervention is anticipated
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Micropuncture, smaller sheaths, frequent sheath
flush, angiogram after access, early ambulation
Decision making in the cath lab
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Before PCI: FFR is recommended
When PCI is indicated:
a. POBA in 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 is recommended in patients with platelet count > 30,000/ml
needing a non-cardiac procedure or surgery which can be postponed
for >4 weeks.
c. Third-generation DES is recommended in patients with platelet
count > 30,000/ml who are not in immediate need for a non-cardiac
procedure or surgery.
After PCI: OCT/IVUS is recommended to assure optimal
apposition and absence of complications
Right Heart Cath
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Left ventricular systolic or diastolic heart failure
Restriction or constriction physiology
Valvular dysfunction
5F (French) Swan catheter from the right
forearm may be preferred to reduce the risk of
bleeding complications
Endomyocardial Biopsy
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Unexplained ventricular
dysfunction with suspected
anthracycline cardiomyopathy
(IIa, Level of evidence C)
Fulminant myocarditis
Pericardiocentesis
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We recommend that pericardiocentesis
should be performed in the
catheterization laboratory under
fluoroscopic AND echocardiographic
guidance.
Micro-puncture access is encouraged
2/3 of the malignant effusions reaccumulate within 24 – 48 hours
The pericardial drain should be
maintained for a minimum of 3 days
(optimally 5 days).
BAV/TAVR
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A 6-patient case series showed the feasibility of
BAV in cancer patients as a bridge to SAVR
Surgeons are reluctant to operated due to
mediastinal fibrosis, lung disease, porcelain aorta,
and prior thoracic surgeries
TAVR?
Key points
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Cancer patients should be referred to the CCL due
to their atypical presentation, increased ACS
mortality and acceptable bleeding risk
There NO low platelet threshold for a diagnostic
cath
OK for ASA if PLT>10K, DAPT if PLT>30K
FFR before stent and OCT/IVUS after stent
because DAPT may need to de discontinued early
Thank you