Elsevier

The American Journal of Cardiology

Volume 137, 15 December 2020, Pages 118-124
The American Journal of Cardiology

Temporal Trends of Cardiac Outcomes and Impact on Survival in Patients With Cancer

https://doi.org/10.1016/j.amjcard.2020.09.030Get rights and content

To evaluate the temporal relations of cardiovascular disease in oncology patients referred to cardio-oncology and describe the impact of cardiovascular disease and cardiovascular risk factors on outcomes. All adult oncology patients referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were included in the study. Comprehensive clinical information were collected. The impact on survival of temporal trends of cardiovascular disease in oncology patients were assessed with a Cox proportional hazards model and time-varying covariate adjustment for confounders. In total, 6,754 patients were included in the study (median age, 57 years; [interquartile range, 47 to 65 years]; 3,898 women [58%]; oncology history [60% - breast cancer, lymphoma, and leukemia]). Mortality and diagnosis of clinical cardiac disease peaked around the time of chemotherapy. 2,293 patients (34%) were diagnosed with a new cardiovascular risk factor after chemotherapy, over half of which were identified in the first year after cancer diagnosis. Patients with preexisting and post-chemotherapy cardiovascular disease had significantly worse outcomes than patients that did not develop any cardiovascular disease (p < 0.0001). The highest 1-year hazard ratios (HR) of post-chemotherapy cardiovascular disease were significantly associated with male (HR 1.81; 95% confidence interval 1.55 to 2.11; p < 0.001] and diabetes [HR 1.51; 95% confidence interval 1.26 to 1.81; p < 0.001]. In conclusion, patients referred to cardio-oncology, first diagnosis of cardiac events peaked around the time of chemotherapy. Those with preexisting or post-chemotherapy cardiovascular disease had worse survival. In addition to a high rate of cardiovascular risk factors at baseline, risk factor profile worsened over course of follow-up.

Section snippets

Methods

All adult patients with cancer referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were included. The study protocol was reviewed and approved by the Cleveland Clinic Institutional Review Board with waiver of patient informed consent. Patients or public were not directly involved in the design, conduct, reporting, or dissemination plans of our research.

The patient pool in this study represents oncology patients seen by oncology specialists at our

Results

Total 6,754 oncology patients referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were analyzed. Table 1 details baseline patient characteristics for the total cohort relative to start of chemotherapy (time zero). Despite a relatively young cohort (median age was 57 (SD, 47 to 65 years), 5,144 patients (76%) had 1 or more of these risk factors at baseline; 2,767 patients (41%) had 2 or more, whereas 908 patients (13%) had preexisting CVD. Breast

Discussion

First diagnosis of CVD events in patients referred to cardio-oncology peaked around the time of chemotherapy. In Figure 1, it appears that vast majority of events occurred at time zero - that is, at start of chemotherapy, but when time on the x-axis is spread out over months (Supplemental Figure 1), it can be seen that this increased event rate is normally distributed. The number of echocardiograms performed also dramatically peaked around this time which would account for some new diagnoses (

Declarations

Conflicts of interest/ Competing interests: None

Ethics approval: Reviewed and approved by the Institutional Review Board with waiver of individual informed consent

Consent to participate: Yes

Consent for publication: Yes

Availability of data and material: Upon request

Code availability: Upon request

Authors contribution

1. Conception or design of the work- MH, YH, BH, SN, BG, FC, PC.

2. Data collection- MH, YH, BH, FC, PC.

3. Data analysis and interpretation- MH, YH, BH, FC, PC.

4. Drafting the article- MH, YH, BH, FC, PC.

5. Critical revision of the article- MH, YH, CW, RM, CS, JA, TB, WT, EF, KJ, JE, BX, BH, PCr, CJ, RG, NG, ZP, LC, MD, SN, SK, LS, BG, FC, PC.

6. Final approval of the version to be published- MH, YH, CW, RM, CS, JA, TB, WT, EF, KJ, JE, BX, BH, PCr, CJ, RG, NG, ZP, LC, MD, SN, SK, LS, BG, FC, PC.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study.

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  • This work was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) under Award Number K99 HL138272 and R00 HL138272 to F.C.

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    These authors are joint first authors on this work.

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