Stratification and management of cardiovascular risk in cancer patients. A consensus document of the SEC, FEC, SEOM, SEOR, SEHH, SEMG, AEEMT, AEEC, and AECC.

Both cancer treatment and survival have significantly improved, but these advances have highlighted the deleterious effects of vascular complications associated with anticancer therapy. This consensus document aims to provide a coordinated, multidisciplinary and practical approach to the stratification, monitoring and treatment of cardiovascular risk in cancer patients. The document is promoted by the Working Group on Cardio Oncology of the Spanish Society of Cardiology (SEC) and was drafted in collaboration with experts from distinct areas of expertise of the SEC and the Spanish Society of Hematology and Hemotherapy (SEHH), the Spanish Society of Medical Oncology (SEOM), the Spanish Society of Radiation Oncology (SEOR), the Spanish Society of General and Family Physicians (SEMG), the Spanish Association of Specialists in Occupational Medicine (AEEMT), the Spanish Association of Cardiovascular Nursing (AEEC), the Spanish Heart Foundation (FEC), and the Spanish Cancer Association (AECC).

Abordaje de la fibrilación auricular en pacientes con cáncer activo. Documento de consenso de expertos y recomendaciones / Atrial fibrillation in active cancer patients: expert position paper and recommendations

La mejora en la supervivencia de los pacientes con cáncer ha puesto de manifiesto el impacto clínico que la cardiotoxicidad tiene en el pronóstico tanto cardiovascular como onco-hematológico, sobre todo cuando motiva la interrupción de terapias antitumorales altamente eficaces. La fibrilación auricular es una complicación frecuente en pacientes con cáncer activo y su tratamiento supone un gran reto. Estos pacientes tienen mayores riesgos tromboembólico y hemorrágico y, sin embargo, no se dispone de escalas específicas para guiar la atención clínica. El objetivo de este documento promovido por los grupos de Cardio-Onco-Hematología y Trombosis de la Sociedad Española de Cardiología y elaborado de manera conjunta con las diferentes áreas de conocimiento de la Sociedad Española de Cardiología y con expertos de la Sociedad Española de Oncología Médica, la Sociedad Española de Oncología Radioterápica y la Sociedad Española de Hematología y Hemoterapia, es proporcionar un enfoque multidisciplinario y práctico para la prevención y el tratamiento de la fibrilación auricular de pacientes con cáncer activo y basado en el consenso de expertos

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology

Atrial Fibrillation in Active Cancer Patients: Expert Position Paper and Recommendations.

Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.

Selección de lo mejor del año 2017 en cardio-oncología. ¿Qué debemos saber? / Selection of the best of 2017 on cardio-oncology. What should we know?

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Influencia del riesgo cardiovascular en la predicción y el momento de aparición de eventos cardiacos tras ecocardiograma de esfuerzo sin isquemia / Influence of cardiovascular risk in the prediction and timing of cardiac events after exercise echocardiogram testing without ischemia

Introducción y objetivos: La influencia del riesgo cardiovascular en el pronóstico de pacientes con ecocardiograma de esfuerzo (EE) sin isquemia inducible no se ha evaluado. El objetivo es determinar predictores de eventos, con especial atención al riesgo cardiovascular. Métodos: Se incluyó a 1.640 pacientes con EE sin isquemia: 1.206 sin cardiopatía isquémica (CI), cuyo riesgo de muerte cardiovascular se estimó según el SCORE (Systematic COronary Risk Evaluation) europeo, y 434 con CI. El objetivo primario fue la supervivencia libre de eventos (SLEv) (muerte cardiaca, síndrome coronario agudo no fatal y revascularización en el seguimiento). Resultados: Tras una mediana de seguimiento de 35 [23-54] meses, no hubo diferencias significativas entre la SLEv de los pacientes con SCORE ? 10 o diabetes y pacientes con CI (el 89,8 frente al 87,1%). Al año la SLEv era alta en todos los grupos (el 99,4% si SCORE < 5; el 100% si SCORE 5-9; el 98% si SCORE ? 10 o diabetes y el 97% si CI), con un descenso a los 3 años si SCORE ? 10 o diabetes (94,5%), similar al de los pacientes con CI (91,1%, diferencias no significativas). Las tasas de eventos anualizadas fueron del 2,8 y el 2,55% respectivamente, significativamente superiores a las de los grupos con SCORE < 5 (0,6%) y 5-9 (0,12%). Los eventos más frecuentes fueron el síndrome coronario agudo sin elevación del segmento ST no fatal y la revascularización. Fueron predictores de eventos cardiacos: la CI conocida, un SCORE ? 10 o diabetes, el aclaramiento de creatinina, la fracción eyección del ventrículo izquierdo y el dolor durante la EE. Conclusiones: Un EE sin isquemia implica buen pronóstico inicial, posteriormente modulado por el riesgo cardiovascular (AU)

Introduction and objectives: There have been no analyses of the influence of cardiovascular risk as a predictor of events in patients with exercise echocardiography (EE) without ischemia. Our objective was to determine the predictors of cardiac events, paying special attention to cardiovascular risk. Methods: This study included 1640 patients with EE without ischemia. Of these,there were 1206 with no previously known coronary artery disease (CAD), whose risk of a fatal cardiovascular disease event was estimated according to the European SCORE (Systematic COronary Risk Evaluation) risk assessment system, and 434 with known CAD. The primary endpoint was cardiac event-free survival (EFS) (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization). Results: After a median follow-up of 35 [23-54] months, no differences were found in cardiac EFS between patients with a SCORE 10 or diabetes and patients with previous CAD (89.8% vs 87.1%). In the first year, cardiac EFS was high in all groups (99.4% if SCORE < 5; 100% if 5-9; 98% if 10 or diabetes and 97% in patients with CAD). In the third year, cardiac EFS was similar in the group with SCORE 10 or diabetes (94.5%) and patients with CAD (91.1%, P = NS). In these patients, the annualized event rate was 2.8% and 2.55%, respectively, and was significantly higher than in groups with SCORE < 5 (0.6%) and SCORE 5-9 (0.12%). The most frequent events were non—ST-segment elevation acute coronary syndrome and late revascularization. Predictors of cardiac events were previous CAD, SCORE 10 or diabetes mellitus, creatinine clearance, left ventricular ejection fraction, and chest pain during EE. Conclusions: Initial outcome after an EE without ischemia is favorable but is subsequently modulated by cardiovascular risk (AU)

Cardio-Onco-Hematología en la práctica clínica. Documento de consenso y recomendaciones / Cardio-Onco-Hematology in clinical practice. Position paper and recommendations

Los avances en la detección precoz y el tratamiento del cáncer han reducido de manera significativa la mortalidad de los pacientes. Sin embargo, mejorar el pronóstico no es solo curar el tumor, sino prevenir, diagnosticar y tratar eficazmente las complicaciones derivadas de las terapias onco-hematológicas. La toxicidad cardiovascular es un problema ampliamente reconocido con múltiples esquemas terapéuticos; sin embargo, la evidencia científica en el manejo de las complicaciones cardiovasculares de pacientes onco-hematológicos es escasa, pues sistemáticamente se ha excluido de los ensayos clínicos a estos enfermos y las recomendaciones actuales están basadas en consensos de expertos. Es imprescindible crear equipos multidisciplinarios locales para optimizar los resultados en salud de los supervivientes al cáncer. Una preocupación excesiva por la aparición de toxicidad cardiovascular puede impedir terapias potencialmente curativas, mientras que la subestimación de este riesgo compromete el pronóstico vital a largo plazo. El objetivo de este documento, elaborado en colaboración con la Sociedad Española de Cardiología, la Sociedad Española de Oncología Médica, la Sociedad Española de Oncología Radioterápica y la Sociedad Española de Hematología, es actualizar los conocimientos aplicables a la práctica clínica diaria de la cardio-onco-hematología y promover el desarrollo de equipos multidisciplinarios locales que mejoren la salud cardiovascular de los pacientes con cáncer (AU)

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However survival not only depends on effectively cure cancer, but prevention, diagnosis and treatment of cancer-related complications is also needed. Cardiovascular toxicity is a widespread problem across many classes of therapeutic schemes, however scientific evidence in the management of cardiovascular complications of onco-hematological patients is scarce, as these patients have been systematically excluded from clinical trials and current recommendations are based on expert consensus. Multidisciplinary teams are mandatory to decrease morbidity and mortality from both cardiotoxicity and cancer itself. An excessive concern for the occurrence of cardiovascular toxicity, can avoid potentially curative therapies, while underestimating this risk, increases long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration of the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology and the Spanish Society of Hematology, is to update the necessary concepts and expertise on cardio-onco-hematology that enable its application in daily clinical practice and to promote the development of local multidisciplinary teams, to improve the cardiovascular health of patients with cancer (AU)

Influence of Cardiovascular Risk in the Prediction and Timing of Cardiac Events After Exercise Echocardiogram Testing Without Ischemia.

INTRODUCTION AND OBJECTIVES: There have been no analyses of the influence of cardiovascular risk as a predictor of events in patients with exercise echocardiography (EE) without ischemia. Our objective was to determine the predictors of cardiac events, paying special attention to cardiovascular risk. METHODS: This study included 1640 patients with EE without ischemia. Of these, there were 1206 with no previously known coronary artery disease (CAD), whose risk of a fatal cardiovascular disease event was estimated according to the European SCORE (Systematic COronary Risk Evaluation) risk assessment system, and 434 with known CAD. The primary endpoint was cardiac event-free survival (EFS) (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization). RESULTS: After a median follow-up of 35 [23-54] months, no differences were found in cardiac EFS between patients with a SCORE ≥ 10 or diabetes and patients with previous CAD (89.8% vs 87.1%). In the first year, cardiac EFS was high in all groups (99.4% if SCORE < 5; 100% if 5-9; 98% if ≥ 10 or diabetes and 97% in patients with CAD). In the third year, cardiac EFS was similar in the group with SCORE ≥ 10 or diabetes (94.5%) and patients with CAD (91.1%, P = NS). In these patients, the annualized event rate was 2.8% and 2.55%, respectively, and was significantly higher than in groups with SCORE < 5 (0.6%) and SCORE 5-9 (0.12%). The most frequent events were non-ST-segment elevation acute coronary syndrome and late revascularization. Predictors of cardiac events were previous CAD, SCORE ≥ 10 or diabetes mellitus, creatinine clearance, left ventricular ejection fraction, and chest pain during EE. CONCLUSIONS: Initial outcome after an EE without ischemia is favorable but is subsequently modulated by cardiovascular risk.

Cardio-Onco-Hematology in Clinical Practice. Position Paper and Recommendations.

Improvements in early detection and treatment have markedly reduced cancer-related mortality. However survival not only depends on effectively cure cancer, but prevention, diagnosis and treatment of cancer-related complications is also needed. Cardiovascular toxicity is a widespread problem across many classes of therapeutic schemes, however scientific evidence in the management of cardiovascular complications of onco-hematological patients is scarce, as these patients have been systematically excluded from clinical trials and current recommendations are based on expert consensus. Multidisciplinary teams are mandatory to decrease morbidity and mortality from both cardiotoxicity and cancer itself. An excessive concern for the occurrence of cardiovascular toxicity, can avoid potentially curative therapies, while underestimating this risk, increases long-term mortality of cancer survivors. The objective of this consensus document, developed in collaboration of the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology and the Spanish Society of Hematology, is to update the necessary concepts and expertise on cardio-onco-hematology that enable its application in daily clinical practice and to promote the development of local multidisciplinary teams, to improve the cardiovascular health of patients with cancer.

Utilidad de la resonancia magnética cardiaca en el diagnóstico de los pacientes con síndrome coronario agudo y coronarias normales / The value of cardiac magnetic resonance in patients with acute coronary syndrome and normal coronary arteries

Introducción y objetivos. Diferentes enfermedades pueden presentar síntomas similares a los del síndrome coronario agudo (SCA): dolor torácico, cambios en el ECG y elevación de marcadores de daño miocárdico. Incluso después de realizar una coronariografía, a veces es difícil establecer el diagnóstico. El objetivo del estudio fue valorar la utilidad de la resonancia magnética cardiaca (RMC) en el diagnóstico de los procesos que se presentan como un SCA y tienen coronarias normales. Métodos. Estudiamos a 80 pacientes con sospecha de SCA y coronarias normales. La media de edad fue 48 ± 15 años. La troponina T media fue 1,8 ± 0,9 ng/ml. Realizamos un estudio de RMC incluyendo secuencias potenciadas en T2 para detectar edema y secuencia I-R de realce tardío (RT) a los 10 min de la administración de gadolinio. Resultados. El diagnóstico final fue miocarditis aguda en 51 pacientes (63%). En todos estos casos observamos RT localizado en el subepicardio y las porciones medias de miocardio. En 12 pacientes (15%) el diagnóstico final fue infarto agudo de miocardio, todos ellos con RT subendocárdico o transmural. En 9 pacientes (11%) con alteraciones de la contractilidad en el ecocardiograma basal y normalización posterior, el estudio con RMC no mostró RT de contraste y se les diagnosticó síndromes de tako-tsubo. En 4 pacientes el diagnóstico final fue pericarditis aguda y en 4 no se pudo establecer un diagnóstico. Conclusiones. La miocarditis aguda y el síndrome de tako-tsubo pueden presentarse en la clínica de forma similar al SCA. La presencia y el patrón de RT de contraste en el estudio de RMC nos ayudan de forma importante a establecer el diagnóstico (AU)

Introduction and objectives. A number of different conditions can present with symptoms similar to acute coronary syndrome (ACS): chest pain, electrocardiographic changes, and elevated levels of markers of myocardial damage. Even after coronary angiography has been performed, differential diagnosis can be challenging. The aim of this study was to evaluate the usefulness of cardiac magnetic resonance (CMR) for diagnosing conditions that present like ACS but in which the coronary arteries are normal. Methods. The study involved 80 patients with suspected ACS and normal coronary arteries. Their mean age was 48 (15) years and their mean troponin-T (TnT) level was 1.8 (0.9) ng/mL. A CMR study, which involved T2 weighted imaging to detect edema and delayed contrast-enhancement (DCE) imaging 10 minutes after gadolinium administration, was performed. Results. In 51 patients (63%), the final diagnosis was acute myocarditis. In all these cases, DCE was observed in subepicardial and middle segments of the myocardium. The final diagnosis was acute myocardial infarction in 12 patients (15%), all of whom exhibited subendocardial or transmural DCE. In the 9 (11%) who exhibited abnormal contractility on baseline echocardiography with subsequent normalization, CMR did not show DCE, a finding that is characteristic of Takotsubo cardiomyopathy. In addition, 4 patients had a final diagnosis of pericarditis, while no diagnosis could be established in another 4. Conclusions. The clinical presentation of acute myocarditis and Takotsubo syndrome can be similar to that of ACS. The presence and distribution of DCE on CMR are of great help in establishing a diagnosis (AU)

The value of cardiac magnetic resonance in patients with acute coronary syndrome and normal coronary arteries.

INTRODUCTION AND OBJECTIVES: A number of different conditions can present with symptoms similar to acute coronary syndrome (ACS): chest pain, electrocardiographic changes and elevated levels of markers of myocardial damage. Even after coronary angiography has been performed, differential diagnosis can be challenging. The aim of this study was to evaluate the usefulness of cardiac magnetic resonance (CMR) for diagnosing conditions that present like ACS but in which the coronary arteries are normal. METHODS: The study involved 80 patients with suspected ACS and normal coronary arteries. Their mean age was 48+/-15 years and their mean troponin-T (TnT) level was 1.8+/-0.9 ng/ml. A CMR study, which involved T2-weighted imaging to detect edema and delayed contrast-enhancement (DCE) imaging 10 minutes after gadolinium administration, was performed. RESULTS: In 51 patients (63%), the final diagnosis was acute myocarditis. In all these cases, DCE was observed in subepicardial and middle segments of the myocardium. The final diagnosis was acute myocardial infarction in 12 patients (15%), all of whom exhibited subendocardial or transmural DCE. In the 9 (11%) who exhibited abnormal contractility on baseline echocardiography with subsequent normalization, CMR did not show DCE, a finding that is characteristic of Takotsubo cardiomyopathy. In addition, 4 patients had a final diagnosis of pericarditis, while no diagnosis could be established in another 4. CONCLUSIONS: The clinical presentation of acute myocarditis and Takotsubo syndrome can be similar to that of ACS. The presence and distribution of DCE on CMR are of great help in establishing a diagnosis.

[Update on cardiac imaging techniques: echocardiography, cardiac magnetic resonance, and multidetector computed tomography]. / Actualización en técnicas de imagen cardiaca: ecocardiografía, resonancia magnética en cardiología y tomografía computarizada con multidetectores.

This article contains a review of the most important publications on cardiac imaging that have appeared during 2008. During the year, we assisted with the clinical implementation of three-dimensional real-time transesophageal echocardiography, with the use of echocardiography for selecting patients for and monitoring those who underwent percutaneous aortic valve replacement (the majority of centers performing the technique were still in the learning phase), and with the emergence in the clinic of techniques for studying myocardial deformation. Also reviewed are the most significant developments in the application of echocardiography to coronary heart disease and cardiac resynchronization therapy and in 2 other techniques whose use is constantly increasing: cardiac magnetic resonance and multidetector cardiac computed tomography. The review ends with a description of the current state of the art in contrast echocardiography, with particular emphasis on safety in the context of recommendations made by the US Food and Drug Administration at the end of 2007.

Actualización en técnicas de imagen cardiaca: ecocardiografía, resonancia magnética en cardiología y tomografía computarizada con multidetectores / Update on cardiac imaging techniques: echocardiography, cardiac magnetic resonance, and multidetector computed tomography

En este artículo se revisan las publicaciones más relevantes sobre la imagen cardiaca que han aparecido en2008. Hemos asistido a la introducción en la clínica de la ecocardiografía transesofágica tridimensional en tiempo real a la selección de casos y la monitorización ecocardiográfica de pacientes sometidos a sustitución percutánea de la válvula aórtica, aún en fase de aprendizaje para la mayoría de los centros que la practican, y a la irrupción en el campo clínico de las técnicas de estudio de deformación miocárdica. Se realiza también un resumen de lo más relevante en el ecocardiograma de la cardiopatía isquémica y la resincronización y de dos técnicas en expansión constante: la cardiorresonancia magnética y la tomografía computarizada cardiaca con multidetectores. Este trabajo de revisión termina con la descripción del estado de los contrastes ecocardiográficos, con especial énfasis en cuanto a su seguridad, tras las recomendaciones realizadas a finales de 2007 por la Food and Drug Administration (AU)

This article contains a review of the most importantpublications on cardiac imaging that have appearedduring 2008. During the year, we assisted with theclinical implementation of three-dimensional realtimetransesophageal echocardiography, with the useof echocardiography for selecting patients for andmonitoring those who underwent percutaneous aorticvalve replacement (the majority of centers performingthe technique were still in the learning phase), andwith the emergence in the clinic of techniques forstudying myocardial deformation. Also reviewed arethe most significant developments in the application ofechocardiography to coronary heart disease and cardiacresynchronization therapy and in 2 other techniqueswhose use is constantly increasing: cardiac magneticresonance and multidetector cardiac computedtomography. The review ends with a description of thecurrent state of the art in contrast echocardiography,with particular emphasis on safety in the context ofrecommendations made by the US Food and DrugAdministration at the end of 2007 (AU)

[Update on cardiac imaging techniques. Echocardiography, cardiac magnetic resonance imaging, and multidetector computed tomography]. / Actualización en técnicas de imagen cardiaca. Ecocardiografía, resonancia magnética en cardiología y tomografía computarizada con multidetectores.

This article contains a review of the most significant publications on non-invasive recent cardiac imaging techniques in 2005. The increasing importance of technological innovation in echocardiography is reflected in the sections on three dimensional echocardiography, contrast echocardiography, and myocardial deformation measurement techniques (i.e., strain echocardiography). The most important developments affecting cardiology in the techniques of magnetic resonance imaging and multidetector computed tomography are also summarized. This review ends with a detailed description of the contributions made by imaging techniques to the diagnosis of aortic disease.

Actualización en técnicas de imagen cardiaca. Ecocardiografía, resonancia magnética en cardiología y tomografía computarizada con multidetectores / Update on cardiac imaging techniques. Echocardiography, cardiac magnetic resonance imaging, and multidetector computed tomography

En este artículo realizamos una selección de las publicaciones más relevantes en técnicas de imagen cardiaca recientes. La creciente importancia de las nuevas tecnologías en ecocardiografía queda reflejada en los apartados de ecocardiografía tridimensional (ECO 3D), en la ecocardiografía de contraste y en el estudio de la deformación (strain) para el análisis de la función miocárdica. En un breve resumen se mencionan las aportaciones más significativas de la resonancia magnética (cardio-RM) y de la tomografía computarizada con multidetectores (cardio-TC) en el terreno cardiológico. Esta revisión concluye con una detallada descripción de la contribución de las técnicas de imagen al diagnóstico de las enfermedades de la aorta

This article contains a review of the most significant publications on non-invasive recent cardiac imaging techniques in 2005. The increasing importance of technological innovation in echocardiography is reflected in the sections on three dimensional echocardiography, contrast echocardiography, and myocardial deformation measurement techniques (i.e., strain echocardiography). The most important developments affecting cardiology in the techniques of magnetic resonance imaging and multidetector computed tomography are also summarized. This review ends with a detailed description of the contributions made by imaging techniques to the diagnosis of aortic disease