Increase in CV admissions among Americans with cancer

UK – The cardiotoxicity of cancer treatments is well known, but a US analysis highlights the burden of CVD-related hospitalizations in this vulnerable population.

The results show that between 2004 and 2017, CD-related admissions increased by 23.2% in patients diagnosed with cancer, while admissions decreased by 10.9% in patients without cancer.

Admissions rose steadily for all cancer types except prostate cancer, with heart failure the most common reason for admission.

“Hospital admissions are very important because we know that this group is growing in size as they live longer and many of the treatments we offer cause cardiovascular disease or increase the risk of developing heart disease. So in terms of care planning, I think it’s very important to know what the likely burden is going to be in the next few years,” the lead author opined. Dr. Mamas Mamas, from Keele University, England, at | Medscape Cardiology.

For doctors and the general population, he added, the findings underscore the need to change from saying that cancer patients have an increased risk of CVD to asking how to mitigate the risk. “Because I would say that this increase in cardiovascular admissions is a failure from a prevention standpoint.”

The study was published on August 1 in the European Heart Journal: Quality of Care & Clinical Outcomes [1].

The different types of cancer

The researchers, led by the Dr Ofer Koboalso from Keele University, used the national inpatient sample to identify 42.5 million weighted cases of CV admissions for acute myocardial infarction (AMI), pulmonary embolism, ischemic stroke, heart failure, atrial fibrillation (AF) or atrial flutter and intracranial hemorrhage from January 2004 to December 2017. Among them, 1.9 million had a file notifying cancer.

Cancer patients were older; they had a higher incidence of valvular disease, anemia, and coagulopathy; and a lower incidence of hypertension, diabetes mellitus and obesity than patients without cancer.

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The most common type of cancer was hematological cancers (26.1%), followed by lung cancers (18.7%), gastrointestinal cancers (12.4%), prostate cancers (11.6%), breast (6.7%) and other cancers (24.4%).

The admission rate increased for all six causes of admission – between 7% for MI and ischemic stroke and 46% for AF.

Heart failure was the main reason for admission among all patients. Annual rates per 100,000 US population increased in cancer patients (from 13.6 to 16.6; P for trend = 0.02) and decreased in others (from 352.2 to 349.8; P for trend < 0.001).

“In the past, patients were put on treatment and the importance of monitoring left ventricular function was perhaps not as well known, whereas today we are much more aggressive in investigating this function and in prevention efforts,” Mamas said. “But even with this better identification and trying to change treatment regimens, we’re still getting a pretty big increase in heart failure admissions in this population. And what really surprised me was that it wasn’t just in the breast cancer population, it was almost everywhere . »

He pointed out that patients are at greatest risk for CV events in the first two years after cancer diagnosis. “So that’s when you have to be really aggressive in researching and building their cardiovascular profile. »

Patients with hematologic (9.7–13.5), lung (7.4–8.9), and gastrointestinal (4.6–6.3) cancers had the highest crude admission rates of CV hospitalizations per 100,000 population in the United States.

The CV admission rate increased from 2.5 to 3.7 per 100,000 US population for breast cancer, and for prostate cancer the rate decreased from 5.8 to 4.8 per 100,000 people in the United States.

“Constellation of Cardiotoxic Therapies”

Of note, patients with hematologic cancers also had the highest heart failure hospitalization rate of any cancer type, which, along with their increased admission rate, likely reflects their exposure to a “constellation of cardiotoxic therapies” as well as pathologic processes associated with the cancers. itself, the authors suggest.

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In-hospital mortality rates were higher among cancer patients than others, ranging from 5% for breast cancer patients to 9.6% for breast cancer patients.lung, versus 4.2% for the others.

Among patients with cancer, the odds ratio for mortality was highest in those admitted for AF (4.43), followed by pulmonary embolism (2.36), AMI (2.31), ischemic stroke (2.29), and heart failure (2.24).

Consistent with previous work and general population trends, in-hospital mortality during primary CV care admissions tended to be lower in cancer patients over the study period.

Reduce risks

Commenting on the study, the Dr Joerg Herrmann, director of the cardio-oncology clinic at Mayo Clinic in Rochester, Minnesota, said the data are “extremely important” because they reflect admissions during a new era of cancer therapy. “Targeted therapies all came about around the turn of the millennium, so we’re not really looking at cancer patients who have only been treated with old strategies. »

This may be one of the reasons for the increase in admissions, but as the study did not have information on specific cancer treatments and the date of cancer diagnosis, it is not possible to disentangle between a related increase due to the cardiotoxicity of the treatments or due to the fact that the patients are in remission and/or cured in full growth, he added.

A clear implication, however, is that anyone working in a hospital ward will see more patients diagnosed with cancer, Herrmann observed.

Better estimate the CV risk of patients with cancer

Hence the need to address the problem. “And this plays out especially in patients who have been diagnosed with active cancer. »

Herrmann and colleagues previously reported that patients with active leukemia or lymphoma who were hospitalized with acute coronary syndrome were less likely to receive targeted therapies, even at the Mayo Clinic.

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Similarly, in a 2020 report, Mamas and colleagues found that patients with a variety of active cancers experienced similar benefit from primary percutaneous coronary intervention for ST-segment elevation myocardial infarction as non-cancer patients. , but receive the treatment less often.

Although there is increasing recognition that cancer patients also benefit from aggressive treatment, much more can be done to mitigate CV risk, said Dr. Mamas noticed. Valuable coronary information gathered by MRI and CT scans as part of cancer screening is often overlooked. For example, “we know that breast calcification and vascular calcification in the breast are very strong predictors of cardiovascular outcomes and yet people don’t use that information.”

There are many common risk factors in the development of cancer and coronary artery disease, and patients with cancer often have much worse CV risk profiles but are not consistently stratified for CV risk, he added.

Mamas said his team is evaluating coronary heart disease risk prediction tools such as the Framingham Risk Score, which are derived from non-cancer populations, and wondering if they work as well in cancer patients. “Often, when you look at the performance of these instruments in underserved populations, they are much worse. »

“Many cancer survivors worry about their cancer coming back and will religiously go for repeat scans, rigorous examinations and all the necessary tests, but don’t think about the real risk that is greater for them knowing the cardiovascular risk,” he added. .

The authors report no funding for the study or any relevant financial relationships.

The article originally appeared on as CV Admissions on the Rise in Americans With Cancer. Translated by Stephanie Lavaud.

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