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Programas de rehabilitación cardiaca en pacientes onco-hematológicos

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Ponencia presentada por la Dra. Almudena Castro Conde en el sexto webinar del programa COH18 (Cardio-onco-hematología), titulado ‘Cardio-oncología en la práctica clínica’ y realizado en la SEC el 20 de junio de 2018.

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Programas de rehabilitación cardiaca en pacientes onco-hematológicos

  1. 1. cardiotoxicidad - rehabilitación cardiaca Almudena Castro Unidad de Rehabilitación Cardiaca Servicio de Cardiología Hospital Universitario La Paz
  2. 2. Integrative Cancer Therapies 2011 10(1) 47–57 SED TM WR 10 weeks exercise preconditioning period DOX vs SAL
  3. 3. Integrative Cancer Therapies 2011 10(1) 47–57 P < .05 P < .05 P < .05- 21% Echocardiographic parameters * ** * P< .05 * * * * P< .05 48%% 37% 47% 38%
  4. 4. SED 2 weeks EXE DOX vs SAL Muscles, Ligaments and Tendons Journal 2017;7 (3):418-425
  5. 5. Muscles, Ligaments and Tendons Journal 2017;7 (3):418-425 Myogenic Regulatory Factor Expression Soleus (A) Extensor digitorum longus (B) Diaphragm (C) † Main exercise effect (p<0.05) ‡ Main drug effect (p<0.05) * Significantly greater than SED+DOX
  6. 6. Miotoxicity Cardiotoxicity
  7. 7. Circulation Research. 2016;118:1008-1020
  8. 8. Antioxid Redox Signal. 15(9): 2543-2563
  9. 9. VO2 = Q x A-VO2 Dif VO2 = Q x A-VO2 Dif Hypothesis: Exercise could prevent direct cardiotoxic effects of cancer therapy Exercise May be protective against the harmful effects of chemotherapy
  10. 10. strongest predictor VO2 peak and risk of cancer- related deathAll cause mortality Decreased mortality VO2 peak N Engl J Med. 2002;346:793–801 Med Sci Sports Exerc. 2009;41:742–8 JAMA. 1995;273:1093–8 Evidence of a relationshipVO2 peak Non-cancer populations
  11. 11. After treatment completionThe course of chemotherapy 12 to 24 weeks J Clin Oncol. 2007;25:4396–404 Lancet Oncol. 2009;10:598–605 Circulation. 2001;104:1358–66 5–10 % VO2 22 % VO2 VO2 30 y of normal agingsedentary controlswomen breast cancer
  12. 12. Paciente de 45 años: No hábitos tóxicos Linfoma de Hodgkin 2002: 6 ciclos de ABVD en remisión Eco 2015: FEVI normal Consulta CardioTox:
  13. 13. Eco feb/2017: DSVI ( 28%)
  14. 14. Feb/2017: GF II- III NYHA Optimización de tratamiento NT-ProBNP 2557 Consulta CardioTox: Abril/2017: Persisten síntomas NT proBNP en descenso Se remite a RhC
  15. 15. Rehabilitación Cardiaca VT1 1’18’’ 91 lpm 9,2 ml/min/kg 43% predicho VT2 5’51’’ 103 lpm 12 ml/min/kg 57% predicho
  16. 16. Pronóstico cpet según V02 en IC WEBER Gravedad VO2 max/kg/min Vo2/kg/min en UA Clase funcional Índice cardiaco (l/min/m2) Ninguna >20 >14 A >8 Leve 16-20 11-14 B 6-8 Moderada 10-16 8-11 C 4-6 Grave 6-10 5-8 D 2-4 Muy grave <6 <4 E <2 VT1
  17. 17. Rehabilitación Cardiaca VT1 6’01’’ 99 lpm 11,1 ml/min/kg 52% predicho VT2 máx 10´01’’ 117 lpm 18,2 ml/min/kg 68 % predicho
  18. 18. Pronóstico cpet según V02 en IC WEBER Gravedad VO2 max/kg/min Vo2/kg/min en UA Clase funcional Índice cardiaco (l/min/m2) Ninguna >20 >14 A >8 Leve 16-20 11-14 B 6-8 Moderada 10-16 8-11 C 4-6 Grave 6-10 5-8 D 2-4 Muy grave <6 <4 E <2 VT1
  19. 19. Eco mayo /2017: DMVI
  20. 20. JAMA Intern Med. doi:10.1001/jamainternmed.2016.1548
  21. 21. Ejercicio físico sí ….pero ¿ Cuándo? ¿Cuánto? ¿ Dónde?
  22. 22. ¿ Cuándo ?
  23. 23. J Clin Oncol 2015 (33):1918-1927 Cardiorespiratory fitness Upper muscle strength Lower muscle strength Fatigue Primary outcome measures: Randomly assigned (n = 230) OnTrack (n = 76) Onco-Move (n = 77) Usual care (n = 77)
  24. 24. Cancer Epidemiol Biomarkers Prev 2005;14(7).
  25. 25. J Clin Oncol 2015 (33):1918-1927(P .002) Rates of and Reasons for Chemotherapy Dose Reduction
  26. 26. Curr Oncol Rep (2016) 18: 12 Direct evidence of the benefit of exercise is currently limited. Improvements in: • cardiorespiratory fitness • muscle strength and lean mass • body composition • cardiovascular risk factors • bone health
  27. 27. ¿ Cuánto ?
  28. 28. Summary of the ACSM Exercise Guidelines for Ca Survivors J Support Oncol. 2012 Sep-Oct; 10(5): 171–177
  29. 29. Rating the evidence-base supporting the ACSM Exercise Guidelines for Cancer Survivors. J Support Oncol. 2012 Sep-Oct; 10(5): 171–177
  30. 30. ¿ Dónde ?
  31. 31. Leclerc et al. Archives of Public Health (2016) 74:50 Supportive care interventions Psychological and behavioral Physical activity/rehabilitation Physiotherapy Diet
  32. 32. Supervised Home- Based Program Psychological and behavioral
  33. 33. https://www.cancer.org/treatment/survivorship-during-and-after- treatment/staying-active/physical-activity-and-the-cancer-patient.html
  34. 34. A supervised, moderate to high-intensity + resistance and aerobic exercise program is most effective A home-based, low-intensity physical activity program represents a viable alternative RCTs with long-term follow-up are required to confirm that the beneficial effect of exercise For patients with cancer undergoing adjuvant Ctx and/or Rtx:

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