Radiation‐Induced Cardiovascular Disease: Review of an Underrecognized Pathology

Abstract

Radiation therapy demonstrates a clear survival benefit in the treatment of several malignancies. However, cancer survivors can develop a wide array of cardiotoxic complications related to radiation. This pathology is often underrecognized by clinicians and there is little known on how to manage this population. Radiation causes fibrosis of all components of the heart and significantly increases the risk of coronary artery disease, cardiomyopathy, valvulopathy, arrhythmias, and pericardial disease. Physicians should treat other cardiovascular risk factors aggressively in this population and guidelines suggest obtaining regular imaging once symptomatology is established. Patients with radiation‐induced cardiovascular disease tend to do worse than their traditional counterparts for the same interventions. However, there is a trend toward fewer complications and lower mortality with catheter‐based rather than surgical approaches, likely because radiation makes these patients poor surgical candidates. When appropriate, these patients should be referred for percutaneous management of valvulopathy and coronary disease.

Risk of Cardiometabolic Risk Factors in Women With and Without a History of Breast Cancer: The Pathways Heart Study

“…Chemotherapy and endocrine therapy can potentially cause alterations in blood pressure and metabolism, leading to the development of cardiometabolic risk factors. 8,35 Radiation therapy to the heart has been shown to induce a local proinflammatory state, 36,37 which we hypothesize might cause systemic changes to the cardiovascular system.…”

Management of Acute Coronary Syndrome in Cancer Patients: It’s High Time We Dealt with It

“…A direct endothelial injury can be induced by radiotherapy, since it has been well shown that a radiotherapy-related coronary artery disease (CAD) causes micro- and macrovascular progressive injuries. Involvement of the Ostia of the left main and right coronary artery is considered typical [ 65 ], with a prevalence of 85%, and it is related to the radiation field [ 66 ]. However, radiotherapy damages remain clinically silent for a long period after radiotherapy, therefore ACS is unlikely to occur during the treatment [ 67 ].…”

The risk of cardiovascular toxicity caused by cancer radiotherapy—a narrative review

“…A major risk factor for subsequent development of cardiovascular toxicity is the total dose of mediastinal radiation received (13). The dose of radiation per fraction, the volume of heart irradiated, and the extent to which the coronary arteries are exposed in the radiation field are also critical risk factors for development of cardiovascular toxicity (9,14,15). Generally, radiation doses are fractionated into smaller daily doses of <2 Gy because it has been suggested that fractions of >3 Gy are implicated in a greater risk of developing cardiotoxicity, particularly pericardial effusions (15).…”

“…In fact, complications can be seen with any dose. The number of cancer survivors who diagnosed with premature heart disease is increasing despite the patients with no preexisting cardiovascular disease or presence of other cardiac risk factors such as hypertension, dyslipidemia, and diabetes mellitus (9).…”