Skip to Content

Published on May 01, 2018

Echo Detects Cardiotoxicity in Patients Undergoing Cancer Therapy

EchoMyocardial strain imaging technique
(shown in colored pattern) detects cardiac deformities.

Rajya L. Malay, MD, FACC, a cardiovascular disease specialist with Meritas Health Cardiology, is using two echocardiography techniques — Speckle tracking/strain and 3D imaging — to identify early signs of cardiotoxicity in patients being treated with cancer therapy.

By employing this type of imaging in echocardiography, Dr. Malay can measure minor changes in myocardial contraction to detect abnormalities early on and, thus, make treatment adjustments in partnership with her oncology colleagues at The University of Kansas Cancer Center, Maureen H. Sheehan, MD, and Deepti Satelli, MD. Both also are assistant professors of internal medicine at the University of Kansas School of Medicine.

“By coordinating our efforts, we can provide the best possible treatment for our patients,” Dr. Malay said, adding that NKCH is one of very few hospitals in the nation providing this specialized care.

Patient Monitoring

There are several types of cardiotoxicity described in the literature, and the most common are:

  • Type I causes irreversible damage to cardiac muscle cells, is typically seen after use of anthracycline-like drugs and is dose-dependent.
  • Type II is more reversible, is seen with the use of targeted therapies such as trastuzumab or Herceptin® in breast cancer treatment, and is not dose dependent.

Myocardial Strain Imaging for Early Detection of Cardiotoxicity

There is a paucity of large randomized clinical trials, but a 2014 expert consensus published by American Society of Echocardiography shed light on use of advanced echocardiographic techniques, such as strain, with patients receiving potentially cardiotoxic cancer therapy. Many studies of early myocardial changes with chemotherapy demonstrated that alterations of myocardial deformation preceded significant change in left ventricular ejection fraction.

A 10%-15% early reduction in global longitudinal strain by speckle tracking echocardiography during therapy appeared to be the most useful parameter for the prediction of cardiotoxicity, defined as a drop in LVEF of more than 10% from baseline or an EF of <53%.

Source: “Expert Consensus for Multimodality Imaging Evaluation of Adult Patients During and After Cancer Therapy: A Report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging,” Journal of the American Society of Echocardiography, 2014.

Some of these therapies have been revolutionary in the treatment of cancer. For example, trastuzumab decreases cancer recurrence in HER2-positive breast cancer by about 50% and reduces mortality by more than 33%. But, it affects the heart’s repair mechanism, increasing a patient’s chances for cardiomyopathy. “The FDA recommends patients have a baseline assessment of cardiac function prior to initiation of any potential cardiotoxic cancer therapy. Certain drugs, such as Herceptin, have a specific recommendation for left ventricle ejection fraction measurement every three months during therapy,” Dr. Malay said.

Pointing to the HER2-targeted therapy Herceptin, Dr. Satelli said, “We routinely monitor these patients. If we find a significant change in their cardiac function, we will formulate a further management plan in collaboration with our cardiology team. Sometimes, this involves discontinuation of cancer therapy.”

Treatment adjustments may include use of heart failure medications and cholesterol drugs — ACE inhibitors, beta blockers and statins — to protect the patient’s compromised heart. “Small studies have proven it’s beneficial to get patients with cardiotoxicity on cardioprotective medications,” Dr. Malay added.

Joining Forces

NKCH and The University of Kansas Cancer Center joined forces in January 2014 to build a cancer program in the Northland. The hospital’s oncology partnership with The University of Kansas Cancer Center provides patients with access to clinical trials only available at the nation’s leading cancer centers.

“Many of our patients who have had cancer are surviving and living longer, and so they can have cardiac repercussions,” Dr. Sheehan said. “We are appreciative of the opportunity to be a part of a team with North Kansas City Hospital, and I think we’ve built a strong oncology program here.”

For Dr. Satelli, this relationship provides people in the Northland with excellent cancer care. “The services hematology-oncology provides benefit greatly from North Kansas City Hospital services, including cardiology and other specialties,” Dr. Satelli said. “We have a strong working relationship with open communication, which allows us all to provide expert care.”

Rajya L. Malay, MD, FACC

Rajya L. Malay, MD, FACCDr. Malay received her medical degree from Osmania Medical College in Hyderabad, India. At the University of Connecticut, Farmington, she completed an internal medicine residency and cardiology fellowship.

Deepti Satelli, MD

Deepti Satelli, MDAfter earning her medical degree from Gandhi Medical College, Secunderabad, India, Dr. Satelli was a resident in internal medicine and a fellow in hematology/oncology at the University of Kansas Medical Center, Kansas City.

Maureen H. Sheehan, MD

Maureen H. Sheehan, MDDr. Sheehan earned her medical degree from the University of Kansas School of Medicine. She then was an internal medicine resident at Butterworth Hospital, Grand Rapids, MI, and a hematology/oncology fellow at the University of Kansas Medical Center, Kansas City.