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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 surgery

  • Heart block: A-V sequential pacing is recommended because the ventricles are often stiff

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