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Success in the treatment of childhood cancers has increased over the years. However, the treatment of cancer may have longstanding effects. The heart is particularly vulnerable to many cancer treatments such as chemotherapy and radiation.
The important anatomic structures of the heart include:
• Heart Muscle
• Coronary Arteries
• Electrical System
Each of these may be negatively affected by cancer treatments such as chemotherapy and radiation.
Doxorubicin (Adriamycin) is a common chemotherapeutic agent that is useful for the treatment of many cancers. It is a drug in the class called anthracyclines. Its most serious side effect is damage to the heart muscle. The risk of damage rises with increasing doses of medication. Those individuals who have received more than 400 mg/m2 are at higher risk of weakened heart muscle (cardiomyopathy). Other risk factors for developing heart damage from Adriamycin include chest radiation and treatment at a very young age (less than 4 years old).
The damage to the heart muscle sometimes happens at the time of treatment but more commonly, the abnormalities are noted many years after treatment. The heart damage caused by these agents can be seen on an echocardiogram (heart ultrasound).
Currently, the heart is monitored during treatment so that if damage is detected, the treatment can be modified to use another medication. However, because heart damage may happen after cancer treatment, life-long follow-up with echocardiograms and check-ups with a health care provider is important. In some cases, a stress echo may be useful to detect milder forms of heart damage.
Many treatments are available for individuals who develop heart damage due to cancer treatment. Your health care provider will determine the best treatment for you. In general, the basic treatments include:
• Medications: ACE Inhibitors, Diuretics, Digoxin, Beta blockers
• Heart transplant or other devices for the most severe cases
Radiation is an effective treatment for a variety of cancers. However, radiation to the chest even without chemotherapy can lead to heart damage. Most often the heart abnormalities are seen many years after treatment. Damage is due to inflammation and scarring of blood vessels, valves, pericardium (sac surrounding the heart) and heart muscle. Heart damage from radiation has been seen most often in patients treated for Hodgkin’s disease.
The specific effects of radiation on the heart include:
• Weakening of the heart muscle (cardiomyopathy)
• Calcification of the heart valves leading to stenosis (narrowing) or regurgitation (leakage)
• Conduction abnormalities (abnormalities of the heart’s electrical system) leading to a slow heart beat
• Thickened pericardium/pericardial effusions (scar tissue in the sac around the heart/fluid in the sac surrounding the heart)
• Coronary artery disease
Because these abnormalities are usually detected many years after treatment, close follow-up with a healthcare provider and echocardiograms is important. If any of these abnormalities are detected, the appropriate treatment will be determined by your health care provider.
Diabetes Mellitus is a lifelong disease marked by high levels of blood sugar in the blood. Symptoms of diabetes may include:
• Blurry vision
• Frequent urination
• Frequent thirst
• Frequent hunger
• Weight loss
• Tingling of the feet
Patients with mild forms of diabetes may have no symptoms, so regular check ups with a health care provider is important so that diabetes can be detected early. The diagnosis of diabetes is made by measuring the blood sugar level in the blood.
After many years, diabetes may lead to problems with many organs including the heart, brain, kidneys, nerves, eyes, and blood vessels in the legs. The risk is highest in patients with diabetes that has not been well controlled.
Diabetes may cause problems with the heart and the legs by causing blockages (plaque) in the arteries. Plaque formation in the arteries of the heart is called coronary artery disease. Symptoms of coronary artery disease may include:
• Chest discomfort
• Shortness of breath
• Unexplained nausea or sweating
Plaque formation in the arteries of the legs is called peripheral artery disease (PAD). Symptoms of PAD often include pain or burning in the legs with walking. This type of pain is often called claudication.
The diagnosis of plaque formation in the heart arteries can be made using heart ultrasound (echocardiography) combined with a stress test (stress echo). Plaque formation in the arteries in the legs can be seen using vascular ultrasound.
Patients with diabetes often have other risk factors for plaque formation such as high blood pressure and high cholesterol.
Treatment of diabetes includes control of the blood sugar with a combination of diet, exercise, maintaining a normal body weight and medications to lower the blood sugar. Treatment of all other risk factors is also important to reduce complications.
Inflammatory bowel disease (IBD) is a disorder that is caused by inflammation of the digestive tract. The two main types of IBD are Ulcerative Colitis and Crohn’s disease. The exact cause of IBD is not known. The typical symptoms of IBD include abdominal pain and cramping and bloody diarrhea. Symptoms may also include poor appetite and weight loss. The loss of appetite combined with frequent diarrhea may result in insufficient vitamins and nutrients.
Patients with IBD may also have increased activity of the blood clotting system that increases the risk of forming blood clots in the blood vessels. The formation of blood clots in IBD is rare, but is important to recognize since it may be life threatening. This risk of forming clots is highest during an IBD flare or after abdominal surgery. The most common place for blood clots is in the veins of the legs and the lungs. Clots in other veins happen less often. Clots in the arteries may also occur, but less often than in the veins. Clots have been reported to occur in various arteries such as the aorta and the arteries of the brain, eyes, abdomen, arms, legs and the heart.
Health care providers and patients with IBD need to be aware of the risk of clots so that diagnosis and treatment can occur quickly. The most common location for a clot to form is in the veins of the legs or the lungs. Symptoms of a clot in the legs include swelling or pain of the leg. Symptoms of clots in the lungs include shortness of breath or chest pain.
The diagnosis of a blood clot requires looking at the blood vessel where the clot is thought to be. Vascular ultrasound is a test that makes pictures of the blood vessels using harmless sound waves. Clots in the blood vessels of the legs, arms, abdomen, aorta, neck can be easily seen using ultrasound. The blood vessels in the lungs, brain and heart require other tests to look for clots since those arteries and veins are not seen using ultrasound outside of the body.
If a clot is found, treatment with blood thinners is then started. Ultrasound may then be useful to see if the clot decreases in size or disappears with treatment.
Patients with renal disease may have a variety of different clinical presentations. Majority of the patients have no complaints or symptoms and are noted to have abnormalities on routine lab work. In the minority of patients who have symptoms or signs, they are directly related to the kidney such as blood in urine or flank pain; or to associated extra renal symptoms such as edema or swelling, hypertension and signs suggestive of uremia.
Many of the kidney diseases can affect the heart adversely. Some of the cardiovascular findings include hypertension or high blood pressure; heart failure, abnormalities in the cholesterol profile, increased incidence of atherosclerotic coronary disease, valvular heart disease, and accelerated peripheral vascular disease.
Cardiovascular disease accounts for almost 50% of deaths in patients with end stage renal disease and confers an increased risk of morbidity and mortality in this population. In addition to the traditional risk factors such as diabetes, hypertension, smoking, abnormal cholesterol, left ventricular hypertrophy by electrocardiographic criteria, increased age, and physical inactivity, there are unique risk factors in this population. These include that presence of chronic kidney disease by itself, disorders of mineral metabolism, uremia and renal replacement therapy.
The most important causes of kidney disease include a personal history of diabetes, hypertension or cardiovascular disease, hyperlipidemia, obesity, metabolic syndrome, smoking, HIV or hepatitis C virus infection, certain autoimmune diseases, polycystic kidney disease, family history of chronic kidney disease, age >60 yr, treatment with nephrotoxic drugs, and malignancy.
A wide range of disorders may develop as a consequence of the loss of renal function. These include disorders of fluid and electrolyte balance, such as volume overload (too much fluid in the body), hyperkalemia (elevated potassium level in the blood), metabolic acidosis (too much acid in the blood), and hyperphosphatemia (elevated phosphorus level), as well as abnormalities related to hormonal or systemic dysfunction such as loss of appetite, nausea, vomiting, fatigue, elevated blood pressure, anemia, malnutrition, abnormal cholesterol, and bone disease. Attention needs to be paid to all of these issues.
An evaluation for coronary artery disease (blockages in the arteries that supply blood to the heart muscle) should also be performed in dialysis patients with symptoms and signs of coronary artery disease including recurrent low blood pressure and heart failure.
Evaluation and testing
A careful history and physical examination, complemented by an electrocardiogram and an echocardiogram, should be performed. The echocardiogram is very useful in the evaluation of the heart’s structure and function along with an assessment fluid collection in the pericardial sac around the heart. Based upon this initial assessment, the patient may require additional studies, such as stress studies and/or coronary angiography.