Revista Española de Cardiología (English Edition) Revista Española de Cardiología (English Edition)
Rev Esp Cardiol. 2017;70:1028-9 - Vol. 70 Num.11 DOI: 10.1016/j.rec.2017.07.005

Remarks on the Position Paper on Cardio-Onco-Hematology and Remarks on the Review of Cardiac Imaging Modalities for the Detection of Cardiotoxicity

Virginia Pubul a,b,, Irene Casáns a,c, Santiago Aguadé a,d, Francisco Javier de Haro a,e

a Grupo de Trabajo de Cardiología Nuclear de la Sociedad Española de Medicina Nuclear e Imagen Molecular, Madrid, Spain
b Servicio de Medicina Nuclear, Hospital Clínico Universitario de Santiago de Compostela, A Coruña, Spain
c Servicio de Medicina Nuclear, Hospital Clínico Universitario, Valencia, Spain
d Servicio de Medicina Nuclear, Hospital Universitario Vall d’Hebron, Barcelona, Spain
e Servicio de Medicina Nuclear, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

Refers to

Remarks on the Position Paper on Cardio-Onco-Hematology and Remarks on the Review of Cardiac Imaging Modalities for the Detection of Cardiotoxicity. Response
Teresa López-Fernández, Paaladinesh Thavendiranathan, José Luis López-Sendón, Juan Carlos Plana Gómez
Rev Esp Cardiol. 2017;70:1029-30
Full text - PDF
Cardio-Onco-Hematology in Clinical Practice. Position Paper and Recommendations
Teresa López-Fernández, Ana Martín García, Ana Santaballa Beltrán, Ángel Montero Luis, Ramón García Sanz, Pilar Mazón Ramos, Sonia Velasco del Castillo, Esteban López de Sá Areses, Manuel Barreiro-Pérez, Rocío Hinojar Baydes, Leopoldo Pérez de Isla, Silvia Cayetana Valbuena López, Regina Dalmau González-Gallarza, Francisco Calvo-Iglesias, Juan José González Ferrer, Antonio Castro Fernández, Eva González-Caballero, Cristina Mitroi, Meritxell Arenas, Juan Antonio Virizuela Echaburu, Pascual Marco Vera, Andrés Íñiguez Romo, José Luis Zamorano, Juan Carlos Plana Gómez, José Luis López Sendón Henchel
Rev Esp Cardiol. 2017;70:474-86
Abstract - Full text - PDF
Emerging Cardiac Imaging Modalities for the Early Detection of Cardiotoxicity Due to Anticancer Therapies
Teresa López-Fernández, Paaladinesh Thavendiranathan
Rev Esp Cardiol. 2017;70:487-95
Abstract - Full text - PDF

Article

To the Editor,

The Nuclear Cardiology Working Group of the Spanish Society of Nuclear Medicine and Molecular Imaging would like to make some comments on the recent articles by López-Fernández et al.1, 2

In the first article, the authors state that “isotopic ventriculography should not currently be considered for monitoring onco-hematologic treatments due to the risk associated with ionizing radiation”, without providing any specific reference supporting this statement, whereas the second article does not even mention isotopic ventriculography.

Strong scientific evidence supports the effectiveness of nuclear cardiology techniques in assessing ventricular function, and isotopic ventriculography is the gold standard for evaluating chemotherapy-induced cardiotoxicity. Ventriculographic calculation of left ventricular ejection fraction using nongeometric methods does not suffer from the errors of other diagnostic techniques caused by changes in ventricular morphology or in regional wall motion.

Not only do classic studies of anthracycline-induced cardiotoxicity show that isotopic ventriculographic monitoring of left ventricular ejection fraction reduces the incidence of heart failure by up to 4 times, but, when it does occur, it is reversible and less severe.3 Based on this scientific evidence, ventriculography has been widely used in clinical practice since the 1980s, as well as in innumerable clinical trials monitoring cardiotoxicity.4

Because of its high reproducibility, ventriculography is an ideal technique to monitor cardiac function. Compared with echocardiography, ventriculography shows much lower intraobserver and interobserver variability, an essential consideration when tracking small variations in left ventricular ejection fraction and detecting early deterioration in the subclinical phase before heart failure development.4

The second article acknowledges the drawbacks of other diagnostic techniques that can be used to evaluate cardiotoxicity: low reproducibility (2D echocardiography), reduced availability, and few published data (3D echocardiography and global longitudinal strain), lack of availability (magnetic resonance), and lack of usefulness (computed tomography), but the article fails to include any information on isotopic ventriculography, which is superior to all of the previous techniques in terms of reproducibility, reliability, and use in clinical practice and also benefits from decades of scientific evidence.

The modality is unaffected by obesity, acoustic windows, claustrophobia, breast prostheses, and pacemakers and its cost is similar to that of the alternative modalities.5

Analysis of the scientific evidence on radiation and its associated risk is vital. There are no data on cancer induced by radiation exposure from nuclear cardiology studies. The radiation exposure from ventriculography is equivalent to that of 3 to 6 months exposure to background radiation. The natural incidence of cancer exceeds the theoretical rate of supposed radioinduced cancer and is lower than that caused by background radiation.6 The radiation from computed tomography and radiotherapy, commonly used in oncology patients, is much higher than that of ventriculography.7

Nuclear physicians adhere to ALARA (As Low As Reasonably Achievable) criteria, using the lowest dose possible and attempting to reduce it even further by using new systems and improved techniques. Thus, nuclear cardiology is a critical strategic component in the multimodality approach to cardio-oncology.8

Accordingly, the articles by López-Fernández et al. should have noted the crucial role played by isotopic ventriculography in cardiotoxicity detection due to its reliability, reproducibility, and low radiation, with clearly superior benefits for patients; all these benefits are supported by extensive scientific evidence. Monitoring of patients receiving cardiotoxic treatments should be multidisciplinary, with coordination among oncologists, cardiologists, and cardiac imaging specialists to ensure that the method with the best results is applied and that patients are not denied the gold standard technique without scientifically sound reasons.

Corresponding author: virginia.pubul.nunez@sergas.es

Bibliography

1. López-Fernández T, Martín García A, Santaballa Beltrán A, et al. Cardio-Onco-Hematology in Clinical Practice. Position Paper and Recommendations. Rev Esp Cardiol. 2017;70:474-86.
2. López-Fernández T, Thavendiranathan P. Emerging Cardiac Imaging Modalities for the Early Detection of Cardiotoxicity Due to Anticancer Therapies. Rev Esp Cardiol. 2017;70:487-95.
3. Schwartz RG, Jain D, Storozynsky E. Traditional and novel methods to assess and prevent chemotherapy-related cardiac dysfunction noninvasively. J Nucl Cardiol. 2013;20:443-64.
4. Russell RR, Alexander J, Jain D, et al. The role and clinical effectiveness of multimodality imaging in the management of cardiac complications of cancer and cancer therapy. J Nucl Cardiol. 2016;23:856-84.
5. Plana JC, Galderisi M, Barac A, et al. Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2014;15:1063-93.
6. Gerber TC, Gibbons RJ. Weighing the risks and benefits of cardiac imaging with ionizing radiation. JACC Cardiovasc Imaging. 2010;3:528-35.
7. Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ. Radiation dose to patients from Cardiac Diagnostic Imaging. Circulation. 2007;116:1290-305.
8. Alvarez JA, Russell RR. Cardio-oncology: the nuclear option. Curr Cardiol Rep. 2017;19:31.

1885-5857/© 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved

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