Cardio Oncology
Muhummad Sohaib Nazir, PhD
NIHR Clinical Lecturer in Cardiology
King's College London, United Kingdom
Muhummad Sohaib Nazir, PhD
NIHR Clinical Lecturer in Cardiology
King's College London, United Kingdom
Theodore Murphy, MD
Consultant Cardiologist
Royal Brompton Hospital, United Kingdom
Emmanuel Androulakis, MD
Cardiology SpR
Royal Brompton Hospital, England, United Kingdom
Nana Poku
Cardiology SpR
Royal Brompton & Harefield NHS Foundation Trust, United Kingdom
Maria Sol Andres, MD
Clinical Research Fellow
Royal Brompton Hospital, United Kingdom
Tharshini Ramalingam
GP with specialist interest in Cardio-Oncology
Royal Brompton Hospital, United Kingdom
Stuart Rosen, PhD
Professor of Cardiology
Royal Brompton Hospital, United Kingdom
Sven Plein, MD, PhD
Professor
University of Leeds
Leeds, England, United Kingdom
Raad Mohiaddin, MD, PhD
Professor/Radiologist
Royal Brompton Hospital, Imaging Centre, Guy’s and St Thomas’ NHS Foundation Trust, United Kingdom and National Heart and Lung Institute, Imperial College London, London, United Kingdom
London, England, United Kingdom
John Baksi, MBBS PhD
Consultant Cardiologist
Royal Brompton Hospital, England, United Kingdom
Dudley Pennell, FSCMR
Professor
Guy's and St Thomas' NHS Foundation Trust
London, England, United Kingdom
Amedeo Chiribiri, MD PhD FHEA FSCMR
Professor of Cardiovascular Imaging; Consultant Cardiologist
King's College London
London, England, United Kingdom
Alexander Lyon
Senior Clinical Lecturer and Honorary Consultant Cardiologist
Royal Brompton Hospital, United Kingdom
Stress myocardial perfusion CMR has proven diagnostic and prognostic evidence for the assessment of ischemia in patients with coronary artery disease (CAD) and microvascular dysfunction (MVD). However, cancer patients are often excluded or underrepresented in clinical studies, and therefore the clinical value of stress perfusion CMR in this cohort is not well understood. Therefore, the objective of this study was to determine the clinical utility and prognostic value of stress perfusion CMR in cancer patients.
Methods:
In this prospective single center study, we recruited patients with underlying cancer who underwent stress myocardial perfusion CMR as part of clinical care. The presence or absence of inducible ischemia was determined according to normal gadolinium contrast uptake or a perfusion defect at peak vasodilatory stress. Regional perfusion defects with >2 segments of inducible ischemia were considered to have significant ischemia related to epicardial CAD. Global stress perfusion defects with circumferential involvement were considered to have MVD. Patients were followed up for a median of 13 months (interquartile range 4 – 24) for major adverse cardiovascular events (MACE) defined as non-fatal myocardial infarction or urgent unplanned revascularization. The study was approved by the institutional review board.
Results:
The mean age of patients (n=124) was 63±12 years with 72 (58%) female. The most common indications for the stress perfusion scan were for symptoms suggestive of possible ischemia (chest pain and/or shortness of breath) (47%), etiology of left ventricular dysfunction (26%) and for pre-operative/pre chemotherapy/pretransplant (21%).
26 (21%) patients had evidence of inducible ischemia. In this subgroup, 14 (53.8%) were regional perfusion defects suggestive of epicardial CAD and 12 (46.2%) were global reduction in perfusion suggestive of MVD. In patients with no ischemia, there was a very low incidence (0.8%) of MACE at follow up. 100% of patients were able to continue taking prognostically important cancer therapy following this CMR guided care.
Conclusion:
Stress myocardial perfusion CMR can be used to guide the management of CAD and MVD in cancer patients. The absence of ischemia with stress CMR in cancer patients is associated with a low risk of MACE at intermediate time follow up. Stress CMR can be helpful to rule out significant ischemia and guide the continuation of prognostic cancer therapy. The findings of this study are particularly relevant to the cardio-oncologist who may use stress CMR in clinical decision making when faced with the wide plethora of adverse cardiovascular events associated with nascent cancer therapeutics in patients at risk of cardiovascular disease.