Can a Heart Attack Affect Your Cancer?

This article was written in collaboration with Yan Liu, MD, Ph.D., Director of Cardio-Oncology Ascension Seton, Medical Director, Ascension Texas Cardiovascular Seton Northwest, Assistant Professor of Medicine, Dell Medical School, The University of Texas at Austin, Ascension Texas.

The intersection between cancer and cardiovascular disease occurs at multiple levels and includes genetic as well as common risk factors (unhealthy diet, tobacco use, obesity, DM and HTN), cardiotoxicity of cancer treatment, and shared molecular biology mechanisms (chronic inflammation, oxidative stress, angiotensin ll, and catecholamines). This is a paradigm shift that has clinical implications for the >16 million Americans who are cancer survivors in 2019 and are projected to be 26 million by 2040. Moreover, cardiovascular events such as myocardial infarction can have direct interaction and increase the risk of recurrence and cancer-specific mortality in patients with early-stage breast cancer.

How Does Cancer Treatment Affect Your Blood Vessels?

Traditional chemotherapy and radiation therapy remain the cornerstone of many treatment protocols, and their vascular effects are diverse and often unpredictable. The advent of new cancer therapies often targets the interaction between cancer and the blood vessels feeding them and may result in more predictable vascular effects.

Antimetabolites such as fluoropyrimidines (5-FU) can cause coronary spasm with myocardial ischemia without the obstruction of the coronaries.

Vinca alkaloids such as vincristine as well as other alkylating agents such as cisplatin can be associated with chest pain, HTN, myocardial infarction, and ischemia leg pain (claudication).

Antitumor antibiotics such as bleomycin has been associated with the Raynaud phenomenon, myocardial infarction, and pulmonary hypertension.

Radiation therapy can affect the vascular structures within the field treated. Radiation can cause damage to the blood vessels. Long-term, it can increase the risk of premature coronary artery disease and is linearly related to the dose used. 

How About the New Targeted Cancer Therapies?

These new therapies can target specific signals of particular cancer cells and result in precision medicine in clinical oncology. Small-molecule kinase inhibitors, which can be administered orally, can change drastically the natural history of several malignant tumors but may also cause cardiovascular sequelae. VEGF (Vascular Endothelial Growth Factors) inhibitors, either as a monoclonal antibody  (bevacizumab) or as a small-molecule (ponatinib or dasatinib) can lead to an increase in blood pressure within a few days of starting therapy. HTN has been reported in up to 50% of patients treated with pazopanib for renal cell carcinoma. Treatment with angiotensin-converting enzyme inhibitors has been associated with better outcomes.

Challenges in Treating a Cancer Patient With an Acute Coronary Syndrome or Heart Attack

There are as many as 1.5 million patients with acute coronary syndrome and myocardial infarction in the US each year with approximately 5-10% of patients having concomitant cancer. Several cancer survivors have a low blood count and low platelets which makes them at increased risk of bleeding. Approximately 10% of cancer patients have a platelet count of <100,000/ml.

The preferential use of the radial approach for coronary diagnostic and interventions can limit complications. In addition, the placement of a coronary stent is usually followed by treatment of antiplatelets for sometimes up to 1 year. The judicial use of intracoronary imaging and coronary physiology (like flow reserve FFR or IFR) will not only assure better results from optimal percutaneous interventions (PCI) but allow for earlier and safer discontinuation of antiplatelets.

A platelet count of >30,000/ml is usually sufficient for PCI and >50,000/ml for surgical intervention (CABG).

This article was written in collaboration with Yan Liu, MD, Ph.D., Director of Cardio-Oncology Ascension Seton, Medical Director, Ascension Texas Cardiovascular Seton Northwest, Assistant Professor of Medicine, Dell Medical School, The University of Texas at Austin, Ascension Texas.

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