Kasia Hryniewicz, MD

1. Minneapolis Heart Institute® at
Abbott Northwestern Hospital
Cardio-Oncology at MHI
Innovation Summit
Kasia Hryniewicz, MD
September 26th, 2015

2. • No disclosure

3. Why cardio-oncology?

4. Background
• The advent of modern cancer therapy has
considerably improved the outcome of
patients with cancer and, for the first
time, has introduced "survivorship" as a
theme in the management of cancer
patients.
• These therapies may have cardiovascular
consequences that may affect continued
therapy of the cancer and cause short-
and long-term morbidity or mortality.

5. Potential offenders
Trastuzumab
(herecptin)
Cyclophosphamide
Busulfan
Melphalan
Carfilzomib
Adriamycin
Imatinib (Gleevec)
Avastin (bevacizumab)

6. Cardiotoxicity
• Cardiomyopathy
• HTN
• Acute coronary syndrome/myocardial
infarction
• Thrombosis,
• Electrocardiographic changes
• Arrhythmias,
• Myocarditis, pericarditis

7. Risk factors
- age (> 50, > 65)
- female gender
- history of or pre-existing cardiovascular disorders
- mediastinal/chest radiation
- cumulative dose
- total dose administered during a day or a course
- rate of administration
- concurrent administration of cardiotoxic agents
- prior anthracycline chemotherapy
- electrolyte imbalances

8. Chemo-induced CM - prognosis

9. Diagnosis
• Echo  EF, diastolic function, global
longitudinal strain
• Troponin
• BNP
• Cardiac MRI
• Standard cardiac evaluation

10. Therapies
• Prevention
- carvedilol
- spironolactone
- allopurinol
- statin
• Treatment
- standard HF therapy
- dextrazoxane

11. Evolution of Cardio-Onc Clinic at MHI
1 MD,1 RN
Risk factor
list
Reach out to
Minnesota
Oncology
Prevention/
therapy and
f/u protocols
Imaging
protocols
(strain)

12. Cardio-Oncology Clinic at MHI
Kasia
Hryniewicz, M.D.
Elizabeth Grey,
M.D.
Mosi Bennett,
M.D.
Michelle Vanhove,
NP
Rebecca Giraldo,
RN

13. Our philosophy
• Physicians and NPs available to see new
referrals within 24 hours.
• Education provided by nurse coordinator
at initial visit.
• Close follow up including visits and phone
calls.
• Efficient uptitration of medications to
allow the shortest time off chemotherapy
“ We like to be bothered and we like to bother”

14. Standardized 2D echocardiogram
- Designated machine
- All techs trained
- All patients have longitudinal strain
measurements
- All patients have 3D LV systolic function
assessment
- Report generator updated to include
strain and 3D measurements

15. Our Stats
• 117 patients
• 90 (77%) women
• Mean age 68 years (31-88)
• Most common diagnosis  breast cancer
(39%)
 lymphoma
(12%)
8/117 (7%) presented with low EF, able to
restart chemotherapy after 4-6 weeks of
HF treatment

16. When to refer?
• Early!
• Ideally before chemotherapy started if
any of the risk factors present
• If any decrement in LVEF during
therapy
• Symptoms of heart failure and side
effects of chemotherapy are very
similar – refer when in doubt!

17. Future directions
• Clinical trials
- stem cells in chemo induced CM
(SENECA trial), starting this fall
- Prevention and screening
- Provider manual
- Patient information booklet
- Expanding to outreach clinics
- NP involvement

18. Thank you!