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Chapter 101: The Diagnosis and Management of Cardiovascular Disease in Patients with Cancer

A 55-year-old woman, with a prior history of Hodgkin lymphoma diagnosed at the age of 19 years and treated with radiation therapy, presented to the emergency department complaining of dyspnea on minimal exertion. Her physical examination revealed a 3/6 crescendo decrescendo systolic ejection murmur and a chest wall scar from prior radiation injury. Initial investigations including blood test and ECG were unremarkable. Chest radiography showed interstitial lung fibrosis. An echo was obtained and revealed severe aortic stenosis. Which of the following is not a predisposing factor facilitating the development of radiation-induced aortic stenosis?

A. Total radiation dose

B. Dose per fraction

C. The volume of heart irradiated

D. Female sex

E. Younger age at the time of irradiation

The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 101) Multiple predisposing factors facilitating the development of radiation-induced cardiotoxicity have been recognized thus far, including total radiation dose (option A) and dose per fraction (option B), the volume of heart irradiated (option C), and the concurrent administration of additional cardiotoxic agents, such as anthracyclines and trastuzumab. Younger age at the time of irradiation (option E) and the presence of other risk factors for coronary heart disease, such as hypertension, diabetes, and smoking, are patient-specific dynamics that may heighten the risk of radiation-induced cardiotoxicity.1 Patient sex is not a predisposing factor (option D).

Radiation-induced cardiotoxicity may affect a number of different cardiac structures. Which of the following cardiac structures is the most sensitive to irradiation?

A. Pericardium

B. Myocardium

C. Heart valves

D. Conduction system

E. Cardiac vasculature

The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 101) The pericardium (option A) is the most sensitive cardiac structure with regard to irradiation because it consists of tissue with rapid cell turnover. The cardinal manifestation of pericardial irradition injury is constrictive pericarditis, which often presents with signs and symptoms of right heart failure. The myocardium (option B), heart valves (option C), conduction system (option D), and cardiac vasculature (option E) are all less sensitive to the effects of irradiation than the pericardium.

A 60-year-old man with a prior history of chest wall radiation therapy was referred to the cardiology clinic complaining of progressive exertional chest pain noted upon moderately vigorous physical activity. The chest pain resolves after a few minutes’ rest. ...

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