Cardiovascular screening recommended for at-risk patients who have received chest radiation

Cancer patients who receive chest radiation should be screened for heart disease every 5 to 10 years, according to the European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology (ESC) and the American Society of Echocardiography (ASE).

These recommendations, which were published in European Heart Journal – Cardiovascular Imaging (2013; 14(8):721-740), are the first expert consensus recommendations on screening for radiation-induced heart disease (RIHD).

“The prevalence of radiation-induced heart disease is increasing because the rate of cancer survival has improved. It's a long-term risk, and RIHD manifests 5 to 20 years after the radiation dose,” said Professor Patrizio Lancellotti, MD, chair of the expert task force and president of the EACVI.

Old treatment regimens included high doses of radiation to the chest for survivors of Hodgkin's lymphoma and breast cancer. Over time, these patients can develop RIHD in the heart valves, myocardium, and vessels, which include the aorta, pericardium, and coronary arteries. These patients have an increased risk for death from coronary artery disease, myocardial ischemia, and myocardial infarction.

Now, patients receive radiotherapy at lower doses, but survivors are still at increased risk for RIHD, particularly when their heart was in the radiation field. Risk for RIHD is increased for survivors of lymphoma, breast cancer, esophageal cancer, and neck cancer. In the case of neck cancer, lesions can develop on the carotid artery, which increases  the risk for stroke.

About 10% to 30% of patients who receive chest radiotherapy develop RIHD within 5 to 10 years after treatment. Though screening can detect early cardiac structural and functional changes after radiation, it is not routine practice.

The expert group recommends that, before initiating any chest radiotherapy, patients should be screened for RIHD factors, receive a clinical examination, and have a baseline echocardiographic evaluation.  Patients who receive chest radiation for cancers, including breast cancer or lymphoma, should receive cardiac screening five years post-treatment if they have any cardiac abnormality or are at high risk; otherwise, they should receive cardiac screening 10 years post-treatment. Depending on the presence of cardiac abnormalities and the level of risk, cardiovascular screening should be repeated every 5 to 10 years. All patients who had chest radiation for cancer in the past should receive a cardiac examination, starting with echocardiography.

RIHD risk is high for patients who have had radiation for left-sided breast cancer, a high dose of radiation (as is often used in young people), no shield on the irradiated area, a high dose of anthracyclines, or cardiovascular risk factors that include smoking, obesity, and inactivity.

“We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored,” said Lancellotti.
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