The pathophysiology of hypertension and cancer are intertwined. Hypertension has been associated with an increased likelihood of developing certain cancers and with higher cancer-related mortality. Moreover, various anticancer therapies have been reported to cause new elevated blood pressure or worsening of previously well-controlled hypertension. Hypertension is a well-established risk factor for the development of cardiovascular disease, which is rapidly emerging as one of the leading causes of death and disability in patients with cancer. In this review, we discuss the relationship between hypertension and cancer and the role that hypertension plays in exacerbating the risk for anthracycline- and trastuzumab-induced cardiomyopathy. We then review the common cancer therapies that have been associated with the development of hypertension, including VEGF inhibitors, small molecule tyrosine kinase inhibitors, proteasome inhibitors, alkylating agents, glucocorticoids, and immunosuppressive agents. When available, we present strategies for blood pressure management for each drug class. Finally, we discuss blood pressure goals for patients with cancer and strategies for assessment and management. It is of utmost importance to maintain optimal blood pressure control in the oncologic patient to reduce the risk of chemotherapy-induced cardiotoxicity and to decrease the risk of long-term cardiovascular disease.
A 65-year-old man with treatment-resistant psoriatic arthritis, hypertension, dyslipidaemia and benign prostatic hyperplasia (BPH) presented with herpes simplex virus (HSV) oral ulcers and a recent 15 lb weight loss due to reduced consumption. Five weeks previously, his methotrexate was tapered and he had begun taking azathioprine. The patient's thiopurine S-methyltransferase (TPMT) activity level was normal prior to starting azathioprine. He was found to have pancytopenia with normal folate levels and azathioprine was discontinued. His pancytopenia worsened, with a nadir 8 days after stopping azathioprine, before returning to normal levels. His oral ulcers improved and he was able to tolerate solid food. This case illustrates that decreased TPMT activity is not the only risk factor for pancytopenia as an adverse reaction to azathioprine. Furthermore, HSV stomatitis may be the presenting symptom of pancytopenia. The timeline of improvement in cell counts illustrated in this patient has implications for the management of suspected azathioprine-induced pancytopenia.
Background:There have been significant advances in the treatment of patients with
cardiomyopathy with reduced ejection fraction (EF < 40%). However, there
is a dearth of information in the treatment of patients with cardiomyopathy
and midrange EF (40–50%). Current guidelines state to treat these patients
similarly to patients with cardiomyopathy and preserved EF. Data from the
Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE)
trial were used to elucidate whether angiotensin-converting enzyme (ACE)
inhibitors improve clinical outcomes in patients with ischemic
cardiomyopathy and midrange EF.Methods:A post hoc subgroup analysis of the PEACE trial was
conducted to evaluate the effect of ACE inhibitors in a subgroup of patients
with ischemic cardiomyopathy and midrange EF (40–50%). A Chi-square test and
a Student‘s t-test were used to examine and compare the
binary and continuous variables of baseline characteristics and outcomes
between experimental and comparison groups.Results:We studied a subgroup of patients from the PEACE trial with ischemic
cardiomyopathy and midrange EF (n = 2512 of 8290 total
patients). Patients were assigned to either the interventional group
(n = 1247) or the placebo group (n =
1265). There were no significant differences in baseline demographic and
health characteristics between the two groups. During a total of 7 years
(mean 4.7 years) of follow up, the risk of composite outcomes [all-cause
mortality, nonfatal myocardial infarction, and stroke; relative risk (RR)
0.79, 95% confidence interval (CI) 0.63–0.98; p = 0.03] and
all-cause mortality (RR 0.85, 95% CI 0.73–0.99; p = 0.03)
was reduced in patients treated with trandolapril.Conclusion:This study revealed the benefit of ACE inhibitors among patients with
ischemic cardiomyopathy and midrange EF.
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