Optimal treatment of heart failure today
José López-Sendón
Servicio de Cardiología
Hospital Universitario La Paz. Madrid
Conflict of inmterest:
Research grants and honoraria from (research committees, clinical trials, personal, Institutional)
Aspen, Astra-Zeneca, Bayer, Boehringer Ingelheim, Gilead, Lilly / Daiichi-Sankyo, Menarini,
Merk, Novartis, Pfizer, Sanofi-Aventis, Servier,
Tratamiento óptimo de la insuficiencia cardiaca
en pacientes con cáncer

Optimal treatment of heart failure today
• El problema. Necesidad de trabajo en equipo
• Definición de IC por cardiotoxicidad
• Tratamiento
• Identificación precoz
Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure todayTratamiento Insuficiencia Cardiaca en Cancer
Insuficiencia cardiaca y Cancer
• IC antes de Cancer
• Aguda, al inicio de quimioterapia
• Durante quimioterapia
• Años post quimioterapia

Prevención de cardiotoxicidad. Nuevas promesas
Long-term survivors of childhood cancer
Comparison with siblings
Oeffinger et al. NEJM 2006;355:1572
Tratamiento Insuficiencia Cardiaca en Cancer

Teamwork needed!
Protocols to detect Ca
Cardinale D et al
JACC
2010;55:213

Optimal treatment of heart failure today
Need to tem work
• Some patiens arrive too late to the cardiologist
• Some patients visit the cardiologist to often
• Both are wrong, malpractice?
• Not really but need of team work is clear
Cancer and Heart Failure 2018Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure today
• El problema. Necesidad de trabajo en equipo
• Definición de IC por cardiotoxicidad
• Tratamiento
• Prevención
Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure today
Cardiopaty
Risk
Factors
Asymptomatic
LV Dysfunction
Refractory HF
Symptomatic HF
BNP, biomarkers
Symptoms
Cardiac Imaging
Risk
Cancer and Heart Failure 2018Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure today
Cardiopaty
Risk
Factors
Asymptomatic
LV Dysfunction
Refractory HF
Symptomatic HF
Control risk factors(hipertensión, …)
2º prevention (estatins…)
ACE-i
If LVEF < 40
ACE-i
BB
Aldo B
ARNI
Ivabradine
V asist
devices
Cancer and Heart Failure 2018Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure todayCancer and Heart Failure 2018
•Only higher Risk
•Early, reversible myocardial damage (NMR)
Edema, reversible myocardial damage
•Highy sensitivity Troponin
•Biomarkers
•GLS
•Other systolic VF parameters
•HFpEF
•HFmEF
•Asymptomatic LVD (NMR more reliable)
•Symptomatic LV dysfunction

Teamwork needed!
Protocols to detect Ca
Cardio-Oncology protocols in clinical practice
CARDIOTOX REGISTRY
Abnormal cardiac findings
•85% HsTn
•28% GLS
•10% LVEF
•4% Clinical HF
•0% basal LVEF if no CV disease and normal ECG
Cancer and Heart Failure 2018

Teamwork needed!
Protocols to detect Ca
Spanish congress of
cardiology 2014
High sensitive assays allow detection of more patients with positive Tn at all timepoints
Baseline 21 D 3 M 6 M
hs-cTnT 8,3 % 17,2 % 53,5 % 36,9 %
c-TnI 0 % 3,1 % 25 % 19,2 %
hs-cTnT at 6 months c-TnI at 6 months
LVEF 42% 24 %
GLS 36% 30 %
Patients with positive troponin values and without cardiotoxicity in ECHO
Cardio-Oncology protocols in clinical practiceCancer and Heart Failure 2018

Optimal treatment of heart failure today
• El problema. Necesidad de trabajo en equipo
• Definición de IC por cardiotoxicidad
• Tratamiento
• Identificación precoz
Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure today
Prevention of Heart Failure
• Statins, Betablockers, Ace-i
• Dexrazosane
Inconclusive data
Cancer and Heart Failure 2018

Optimal treatment of heart failure todayESC Guide 2016 Heart Failure
ESC
HF-Guide 2016

Optimal treatment of heart failure today
Drug treatmetn of HFrEF
Indications Controls
All patients
Alternative / intolerant to ACEi
All patients
All patients
Sinus HR ≥ 70
ACE-i
ARB
ß-blockers
Aldosterone-i
Ivabradine
TA, Cr, K+
, Na+
TA, Cr, K+
, Na+
TA, FC
Cr, K
+
, Na
+
FC
Fluid retentionDiuretics TA, Cr, K
+
, Na
+
Substitutes ACEi/ARBs
If persisting symptomsLCZ 696 TA, Cr, K
+
, Na
+
Cancer and Heart Failure 2018

Optimal treatment of heart failure today
• El problema. Necesidad de trabajo en equipo
• Definición de IC por cardiotoxicidad
• Tratamiento
• Identificación precoz
Tratamiento Insuficiencia Cardiaca en Cancer

Optimal treatment of heart failure todayCancer and Heart Failure 2018
Annals of Oncology 2012; 23:156-166

Optimal treatment of heart failure todayCancer and Heart Failure 2018

Teamwork needed!
Protocols to detect Ca
• Cancer
• Potentially toxic chemotherapy
• Thoracic radiotherapy
• Previous cardiotoxicity
• CV disease
• Any abnormal ECHO
• Smoker
• High cholesterol (Col LDL > 115)
• Hypertension (>BP<140/90 mm Hg)
• Diabetes (Glucose > 126; HbA1C > 6,5)
• Renal dysfunction CrCl < 60 ml/min
• Use of verapamil, diltiazem, antiarrhythmics…
• CV Symptoms (dyspnoea, angina, syncope, palpitations)
• Suspected PVD (Leg pain walking, other)
• High TnT
• Abnormal ECG
Any Yes
Cardio-Oncology
Consult
Follow guidelines /
local protocols
for each setting
yesNo
History
CV
Risk
Factors
Symptoms
Tests
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
yesNo
First Visit

Teamwork needed!
Protocols to detect Ca
• Previous cardiotoxicity
• CV disease
• Any abnormal ECHO
• CV Risk factors
• Suspected CV disease
• TnT in each chemo cycle
• ECG at the end of treatment
• ECG at the end of follow-up
• ECHO at the end of treatment
• Echo at the end of Follow-up
• Echo every 5 years
Any Yes
Cardio-Oncology
Consult
Follow guidelines /
local protocols
for each setting
YesNo
Follow-up
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Cardio-Oncology protocols in clinical practice

Optimal treatment of heart failure today
Conclusion
• Cardiotoxicidad término más amplio que insuficiencia cardiaca
• Trabajo en equipo para identificación precoz
• Protocolos de seguimiento locales según medios
• Tratamiento IC idéntico al de otras cardiopatías
Tratamiento Insuficiencia Cardiaca en Cancer