A 64-year-old male patient with a history of tobacco use (30-pack-year history; quit 5 years prior), hypertension, and dyslipidemia presents to your cardio-oncology clinic after being hospitalized for acute coronary syndrome (ACS). He was diagnosed 2 months prior with stage IIIB non-small cell lung cancer and was initiated on cisplatin and gemcitabine therapy. He tolerated his chemotherapy well, but approximately 4 weeks prior he developed sudden onset of chest pain, dyspnea, and diaphoresis while at home. Upon presentation to the emergency department, he was found to have ST-segment elevations in leads II, III, and aVF with positive troponin-I biomarker elevation with a clinical presentation consistent with an ST-segment elevation myocardial infarction (MI).
Emergent cardiac catheterization demonstrated complete occlusion of his mid-right coronary artery with no significant coronary artery disease in his other territories. He underwent percutaneous coronary intervention (PCI) with a drug-eluting stent to his right coronary artery without complications. A post transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 40-45% with inferior wall hypokinesis and no significant valvular or pericardial disease. He was discharged 2 days later on aspirin, clopidogrel, carvedilol, atorvastatin, and lisinopril, with plans to continue his chemotherapy.
He is asymptomatic from his MI and is undergoing cardiac rehabilitation as an outpatient, although sessions are limited due to his fatigue and side effects from chemotherapy. He is tolerating his post-MI cardiac medications well. You continue to uptitrate his cardiac medications as tolerated. He asks which factors have contributed to his presentation of ACS and what this means for his overall prognosis.
In this patient with advanced lung cancer receiving chemotherapy, what risk factors increased his risk of ACS, and what is his overall prognosis?
Show Answer
The correct answer is: D. Baseline cardiac risk factors, lung cancer, and platinum-based chemotherapy contributed to his ACS event. His non-cardiac mortality risk is elevated, but his cardiac mortality risk is unchanged.
Both venous and arterial thrombotic events are associated with malignancy, and certain chemotherapeutic agents through unclear mechanisms can lead to both cardiac and vascular events, complicating the course of cancer treatment.1 This can be compounded by baseline cardiac risk factors, which may be present in older adults2 and can all trigger the thrombogenic cascade from Virchow's triad of hypercoagulability, stasis, and endothelial/vessel wall injury.
The risk of MI is higher in patients with cancer overall (2.0% compared with 0.7% in controls) at 6 months, with the highest incidence occurring in patients with lung cancer (3.2%).3,4 Cisplatin, a platinum-based chemotherapeutic agent commonly used in the treatment of lung cancer, has been associated with a high incidence of MI, with an incidence of 1.6-8.7% depending on the study.5
A study from the National Heart, Lung, and Blood Institute Dynamic Registry demonstrated that a history of cancer was a significant predictor of death and MI at 1 year in patients who underwent PCI for a diagnosis of MI. More recently, regarding cardiac mortality, a retrospective study of 261 patients with a history of cancer in the Mayo Clinic PCI registry who underwent PCI for a diagnosis of ST-segment elevation MI were found to have up to threefold higher risk of acute in-hospital and long-term non-cardiac mortality but no increased acute or long-term cardiac mortality risk with evidence-based cardiac treatment and care.5
PCI and antiplatelet agents are critical to the treatment of acute coronary events in both patients with cancer and non-cancer patients. Compared with patients without malignancy, patients with cancer have been reported to have higher in-stent thrombosis rates.6 At the same time, these patients often have increased bleeding risks due to cancer- or chemotherapy-related thrombocytopenia. Patient treatment, therefore, often requires a multidisciplinary discussion, with careful assessment of risks and benefits for each patient. Based on a recent expert consensus statement from the Society for Cardiovascular Angiography and Interventions, aspirin monotherapy is reasonable for patients undergoing cardiac catheterization with platelet counts of >10,000/ml, and dual antiplatelet therapy with aspirin and clopidogrel is reasonable for patients with platelet counts <50,000/ml but >30,000/ml.7
References
Herrmann J, Yang EH, Iliescu CA, et al. Vascular Toxicities of Cancer Therapies: The Old and the New--An Evolving Avenue. Circulation 2016;133:1272-89.
Lowe GD. Common risk factors for both arterial and venous thrombosis. Br J Haematol 2008;140:488-95.
Navi BB, Reiner AS, Kamel H, et al. Risk of Arterial Thromboembolism in Patients With Cancer. J Am Coll Cardiol 2017;70:926-38.
Wang F, Gulati R, Lennon RJ, et al. Cancer History Portends Worse Acute and Long-term Noncardiac (but Not Cardiac) Mortality After Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction. Mayo Clin Proc 2016; 91:1680-92.
Tuzovic M, Herrmann J, Iliescu C, Marmagkiolis K, Ziaeian B, Yang EH. Arterial Thrombosis in Patients with Cancer. Curr Treat Options Cardiovasc Med 2018;20:40.
Gross CM, Posch MG, Geier C, et al. Subacute coronary stent thrombosis in cancer patients. J Am Coll Cardiol 2008;51:1232-3.
Iliescu CA, Grines CL, Herrmann J, et al. SCAI Expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologıa intervencionista). Catheter Cardiovasc Interv 2016;87:E202-23.
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