Expert Consensus for Multi-Modality Imaging Evaluation of Cardiovascular Complications of Radiotherapy in Adults: A Report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Abstract

Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

Comprehensive review on cardio-oncology: Role of multimodality imaging

“…Although acute development of carotid artery stenosis has not been reported, later development of increased intima-media thickness (IMT) has been observed, with more extensive carotid artery stenosis, involving longer segments and atypical areas. 46 A historical prospective cohort study of head and neck cancer survivors observed a higher incidence of carotid artery stenosis in the irradiated neck, with increased risk in those patients who had undergone an ipsilateral neck dissection. 59 A recent comprehensive review by Plummer et al observed that head and/or neck radiotherapy exposed the patient to at least twice the risk of TIA or ischemic stroke.…”

“…46 The location of irradiation influences the site of the peripheral artery disease development. Stroke, transient ischemic attack (TIA), and carotid artery disease are associated with head and neck radiation, as well as supraclavicular and mediastinal radiation, which also increased the risk of subclavian artery disease.…”

“…47 Risk factors for radiation-induced HD include daily radiation doses [2 Gy, cumulative radiation dose [30 Gy, patient age \50 years, anterior or left chest irradiation, and concomitant chemotherapy, such as anthracyclines. 46 Radiation induces CV damage via injury to the endothelium, micro-and macrovascular systems, with resultant myocardial ischemia and fibrosis, pericardial Table 3. Figure 1).…”

“…117 Subsequent publication of expert consensus documents issued jointly by the ASE and the EACVI addressed the use of multimodality imaging for evaluation of patients during and after chemotherapy 17 and/or radiation therapy. 46 Clinical algorithms were also provided for patients receiving potentially cardiotoxic therapy, including agents associated with type I and type II cardiotoxicity. [Figures 4 and 5] 17 More recently, SCAI issued an expert consensus statement on the evaluation and management of cardiooncology patients in the cardiac catheterization laboratory, with recommendations for screening patients after potentially vasotoxic therapy ( Figure 6).…”

Management of Asymptomatic Severe Degenerative Mitral Regurgitation

“…Once symptom develops or other surgical criteria are met, prompt attention, ideally in the form of a multidisciplinary Heart Team is sought. 41 An important argument that supporters of early surgery often bring up is that early surgery could benefit patients that default follow-up and consequently surgical triggers were missed. It is true that prophylactic surgery may have a role in parts of the world where healthcare is not easily accessible and the attrition during follow-up is high.…”