Andersons pediatric cardiology 1693
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (142.23 KB, 3 trang )
DevelopmentofCancerTreatment–Related
Cardiotoxicity
PatientRelated
■Youngerage(especially<5years)
■Femalegender
■African-Americanrace
■Trisomy21
■Cardiovascularriskfactors(hypertension,hyperlipidemia,diabetes,
obesity)
■Underlyingheartdisease(congenitalheartdisease,cardiomyopathy)
■Geneticfactorsa
TreatmentRelated
■Totalcumulativeanthracyclinedoseb
■Chestradiationc
■Timesincetreatment
■Premodernprotocols(before1975)
■Concomitanttherapywithcyclophosphamide,bleomycin,vincristine,
amsacrine,mitoxantrone,immunotherapy
aMultiplegenotypesidentifiedasriskfactors.
bDosecut-offfrequentlycitedas>250mg/m2doxorubicinequivalent.
cDosecut-offfrequentlycitedas>15–30Gychestradiation.
FIG.62.3 Cumulativeincidenceand95%confidenceintervalofcardiac
disordersamongchildhoodcancersurvivors.(FromMulrooneyDA,Yeazel
MW,KawashimaT,etal.Cardiacoutcomesinacohortofadultsurvivorsof
childhoodandadolescentcancer:retrospectiveanalysisoftheChildhood
CancerSurvivorStudycohort.BrMedJ.2009;339:b4606.)
SurveillanceofPatientsThrough
TherapyandBeyond
Severalguidelinesexistformonitoringadultpatientsundergoingcancertherapy,
withpathwaysincludingrobustcardiovascularassessmentfromdiagnosis
throughsurvivorship.15,16,19,20Inpediatricandadolescentpatientsthereareno
standardizedguidelinesformonitoringduringtherapy,andthereisvariation
betweentreatmentprotocols.21Moreregimentedsurveillanceistakenuponce
therapyiscompleted,withlong-termfollow-updirectedbytheChildren's
OncologyGroup(COG)(www.survivorshipguidelines.org).Theseguidelines
callfor:yearlyhistoryandphysicalexambyaphysician;laboratory
investigationsincludinglipidprofileandbloodglucoseevery2years;
electrocardiogramatentryintolong-termfollow-upandrepeatedasnecessary;
andechocardiogramatintervalsofevery1to5yearsbasedonanumberof
factorsincludingageattreatment,totalcumulativedose,andwhetherradiation
treatmentwasconcomitant.Asyet,thereisnoinclusionofcardiacserum
biomarkersorimagingbeyondbasicmeasuresofsystolicfunction.If
abnormalitiesariseorapatienthassymptomsconcerningforcardiovascular
disease,referraltoacardiologistisrecommended.CostanalysisoftheCOG
guidelinesbasedontheCCSScohortshowedthatacertainportionofthecohort
couldundergoless-frequentscreeningthancurrentlyrecommendedatasimilar
healthbenefitbutthatthecurrentrecommendationsdofallwithinrangeofvalue
generallyacceptedasreasonable.22
Studiesinadultpatientshaveshownthatdetailedsurveillanceduringand
immediatelyafteranthracyclinetreatmentdemonstratessubclinical
asymptomaticventriculardysfunctioninapproximately10%ofpatients,withthe
highestincidenceinthefirstyearoftreatment.23Theimportanceofearly
identificationofcancertreatment–relatedcardiotoxicitywasillustratedin
anotherstudyofadultpatientswhohadimprovedresponsetocardiovascular
treatmentfollowingearlydiagnosisandinitiationoftreatment,withdelayin
treatmentofjust1to2monthssignificantlyreducingtheproportionofpatients
responsivetotherapy.23,24
Electrocardiography
