Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ History of mediastinal radiation therapy, usually for Hodgkin’s disease or left breast cancer Pericarditis early or within 10 years after radiation therapy Cardiomyopathy, especially if also treated with anthracyclines Coronary artery disease after a 15- to 20-year latency period Valvular regurgitation; occasionally stenosis Heart block; occasionally tachyarrhythmias +++ GENERAL CONSIDERATIONS ++ Radiation cardiac injury is a broad spectrum that includes direct effects, indirect effects (lung irradiation), and augmentation of the effects of chemotherapy, such as with anthracyclines The initial injury is characterized by micro- and macrovascular inflammation, which subsides and transitions to a latent phase of progressively increasing fibrosis from ischemia until clinical disease is evident in the late stage Macrovascular disease is enhanced by the patient’s risk profile (eg, elevated low-density lipoprotein cholesterol) Radiation injury can involve any cardiac structure The incidence of cardiac injury with anterior mediastinum radiation therapy has been estimated to be up to 30% over 10 years Newer radiation therapy techniques have lowered this incidence +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Pericarditis: pleuritic chest pain, dyspnea Cardiomyopathy: dyspnea, fatigue Coronary artery disease: angina pectoris, dyspnea Valve disease: dyspnea Conduction disease: syncope, fatigue, palpitations +++ PHYSICAL EXAM FINDINGS ++ Pericarditis: friction rub, jugular venous distention Cardiomyopathy: signs of heart failure Valve disease: predominantly mitral regurgitation and mixed aortic valve disease +++ DIFFERENTIAL DIAGNOSIS ++ Pericarditis from other causes, especially hypothyroidism (thyroid in field) Cardiomyopathy from other causes, especially anthracyclines Coronary artery disease from other causes Valvular heart disease from other causes Cardiac arrhythmias from other causes +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ Thyroid function Lipid panel +++ ELECTROCARDIOGRAPHY ++ ST-T–wave changes of acute ischemia or pericarditis Q waves of myocardial infarction Chamber hypertrophy Conduction abnormalities +++ IMAGING STUDIES ++ Chest x-ray: may show cardiomegaly Echocardiography: to assess pericardial effusion, myocardial function, and valve pathology +++ DIAGNOSTIC PROCEDURES ++ Ambulatory ECG monitoring to detect arrhythmias Exercise or pharmacologic stress testing with echocardiography preferred to detect coronary artery disease – Myocardial perfusion imaging may be falsely positive due to radiation fibrosis Coronary angiography and cardiac hemodynamic study may be necessary +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Suspected cardiac disease Syncope +++ HOSPITALIZATION CRITERIA ++ Heart failure Acute coronary syndromes Significant rhythm disturbances +++ MEDICATIONS ++ Pharmacologic therapy for pericarditis, heart failure, arrhythmias, valve disease, and coronary artery disease as appropriate +++ THERAPEUTIC PROCEDURES ++ Coronary artery disease: angioplasty is less successful than bypass ... Your MyAccess profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth