This document outlines the agenda and guidelines for assessing cancer patients from a cardiac perspective before starting chemotherapy. It discusses performing a history, clinical exam, and investigations including ECG, echocardiogram, biomarkers and stress testing. Based on risk factors and test results, patients may be referred to a cardiologist. It also covers monitoring patients after chemotherapy, managing cardiovascular risks and treating acute cardiac issues that could arise during cancer treatment.

2. Hello!
Dr. Azim Anwar
Phase B Resident,
Cardiology, BSMMU
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3. Dr. Md. Khurshed Ahmed
Associate Professor. Department of Cardiology
CHAIRPERSON

4. Todays Agenda
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5. Todays Agenda
Assessment of Cancer patients before starting anticancer drugs
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6. Todays Agenda
Assessment of Cancer patients before starting anticancer drugs
CV toxicity prevention strategy
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7. Todays Agenda
Assessment of Cancer patients before starting anticancer drugs
CV toxicity prevention strategy
After chemotherapy management
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8. “
Assessment of cancer patients
from cardiac POV before
starting chemotherapy is Class I
Indication.
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9. Assessment before starting chemotherapy includes
History
Clinical Examination
Investigation
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10.  History of Cancer
 Past H/O Cancer therapy :
Type of drugs***
Duration of use
Side effects
History
History of Heart disease :
 Cardiomyopathy
VHD
MI, CCS
PCI, CABG
PVD, DVT
Arrythmia- AF, Long QTS
Drugs : Antiplatelet,
Anticoagulant
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11. CVRF Assessment:
 Age
10 Yr ASCVD Risk
DM, HTN, DL
Proteinuria
CKD
Family HO: Thrombophillia
Smoking , Obesity
. Clinical Examination:
*** BP
(VEGFi- Bevacizumab,
Monoclonal Ab-Ramucinumab)
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12. ▫ Anthracyclines
▫ HER2 inhibitor
▫ VEGFi
▫ BTK Inhibitor
(Bruton Tyrosine kinase)
 Proteosome Inhibitor
 RAFK & MAK Inhibitor
 (Rapidly accelereted fibrosarcoma,
 mitogen-activated protein kinase)
▫ Very High Risk
Chemotherapy
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13. Investigations
 cTn (1)
Nt Pro BNP (1)
Echocardiography (1)
ECG (1)
HBA1c
RFT
F. Lipid profile
CMR
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14. Echocardiography: What to look for ?
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15. ▫ Right Heart
 RV Dimension
 S’
 TAPSE
 FAC (Fractional Area Change)
 RV FWLS (Free Wall Long Strain)
 RA Area
 Peak TRV
 IVCd
 RV EF
▫ Left Heart
 LV Volume
 LV Mass
 LV EF
 Long & Circum strain
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16. All HO
Negative but
ECG +
No
Cardiovascul
ar disease but
CVRF +
Preexisting CVD / CTRCD
Arrythmia / IHD
Cardiologist
Referrel
(1)
Symptomatic,
but cTn & ETT- N
CPET ?
Management
of RF with life
style
modification
and
medications
(1)
Baseline & 10 Yr CVD risk
assessment with Score &
Score 2 is recommended. Do
necessary Inv
cTn
Nt pro BNP
TTE
CMR
& Refer to cardiologist (1) 16

17. Scenario:
Positive History but ECG, cTN, TTE Normal.
What to do ?
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18. Scenario:
Positive History but ECG, cTN, TTE Normal.
What to do ?
Ans: CPET
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19. CPET
Lung Function: Flow volume loops
Oxygen Consumption during exercise (VO2 max)
Anaerobic Threshold
Heart performance during exercise
Blood gas measurement from blood sample taken from the earlobe
Exercise 12 lead ECG
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20. All HO
Negative but
ECG +
No
Cardiovascul
ar disease but
CVRF +
Preexisting CVD / CTRCD
Arrythmia / IHD
Cardiologist
Referrel
(1)
Symptomatic,
but cTn & ETT- N
CPET
Management
of RF with life
style
modification
and
medications
(1)
Baseline & 10 Yr CVD risk
assessment with Score &
Score 2 is recommended. Do
necessary Inv
cTn
Nt pro BNP
TTE
CMR
& Refer to cardiologist (1) 20

21. 21
Mild to Moderate
Risk:
Education &
Counseling (1)
Lifestyle modification
Supervised exercise
therapy
Risk fc Mx
Cardioonclogy Rehab
Adherence to rx
High / Very
High Risk
Minimize the use
of cardiotoxic
drugs
ACEI /ARB, BB
Statins
 Dexrazoxane
(Anthracyclines)

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23. After Chemotherapy…………..
▫ Low Risk
1. F/Up after 1
year of Rx
completion
(2b) by cTn &
TTE
2. CVRF
assessment
after 1 year
▫ Intermediate
Risk
1. F/Up after 1 year
of Rx completion
(2a) by cTn &
TTE
2. CVRF
assessment
after 1 year & 5
year, and 5
yearly.
▫ High Risk
1. F/Up after 3
months & 1 year
of Rx completion
(1) by cTn & TTE
2. CVRF
assessment by
TTE at 1,3,5 years
and 5 yearly 23

24. ACS in Cancer patient(60Y), Receiving Anthracyclines…………………
▫ History:
1. Cancer Type
2. Type &
Duration of
chemo
3. CVRF
4. Active CD
▫ Examination
1. Peripheral
pulses
2. BP
3. HF
▫ Investigation
1. ECG
2. cTnI
3. Echo
4. Nt Pro BNP
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25. 25

26. 26
Management:
▫ CCU Admission
▫ Anti ischemic therapy
▫ Revascularization / Medical Mx
▫ Hold chemo upto clinically stable.
▫ MDT

27. Revascularization Noninvasive Mx (IIa)
 > 6 months survival
 High risk ST/NST ACS
 <6 months survival
 Low risk NST ACS
 Very high bleeding risk
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28. PCI CABG
 Cardiogenic shock
 HF
 Vent Arrythmia
 PC > 30,000
(POBA if thrombocytopenia)
 FFR, IVUS, OCT
 Radial route
 Lower heparin dose, 30-50U/kg
▫ Extensive CAD not amenable
to PCI
▫ >12 Months survival
▫ PC > 50,000
▫ LIMA & RIMA viability
assessment needed
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29.  Choice of DAPT: Preferred
▫ Aspirin (PC >10,000)
▫ Clopid (PC>30,000)
 DAPT Duration: 1-3 M [IIa]
 Tica (PC>50,000)
 Prasugrel (<75Y, >60Kg, Child
Pugh A-B hepatic impair)
[IIb]
▫ Anticoagulation:
▫ NOAC + DAPT, 1 week in
hospital
▫ Then, NOAC + Clopid
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30. 30
▫ Chemotherapy and CCS
▫ Chemotherapy and VHD
▫ Chemotherapy and arrythmia
▫ Chemotherapy and Implantable
devices
▫ Chemotherapy and HTN
▫ HSCT and cardiac risk