Remote monitoring of cardiac function in childhood cancer survivors

摘要 心血管并发症是儿童癌症幸存者发病率和死亡率的主要原因。 这些幸存者患心力衰竭(HF)的风险是年龄的四倍以上。 与对照组相匹配，并存在强烈的剂量依赖关系之间的接触和蒽环类药物 心力衰竭的风险。心衰的预后很差，强调了早期检测心脏疾病的重要性。 心脏功能障碍(如左心室射血分数[EF]异常)和启动 临床显性疾病发生前的药物治疗。不幸的是，这段时间 幸存者患心力衰竭的风险最大的时间也对应于他们风险最小的时间- 以生存护理为基础。临床护理和慢性病管理需要新的范式 这些幸存者。最近移动技术的进步促进了一个新的部门的发展 移动医疗诊断(MHealth)有可能将心脏护理标准的效用结合在一起 通过超声心动图进行监测，具有更先进的诊断成像(心脏磁学)的准确性 共振[CMR])。然而，无论是可重复性还是成本效益，这种mHealth技术 对于癌症幸存者的前瞻性临床或家庭心脏监测是已知的。要解决这些问题 知识缺口，我们将招募200名长期的儿童癌症幸存者，他们之前经历了一次 通过超声心动图、CMR和支持蓝牙的手持设备(Vivio)评估心脏EF 在临床环境中验证Vivio EF的准确性，并确定其在家庭中的重复性(目标1)。我们 还将利用我们调查团队的专业知识来确定基于Vivio的 使用马尔可夫模型进行筛选(目标2)。这项研究将：1)提供一个重要的后续时间点 确认使用Vivio在暴露于蒽环类药物的幸存者中测量的EF的准确性；2)展示 在可能不再存在的幸存者中，自我给药的家庭心功能测量的可重复性 能够在癌症中心维持以生存为重点的护理；以及3)确定基于Vivio的 筛查是目前标准的心脏成像方法的一种经济有效的替代方法。信息 从当前研究中获得的可用于制定促进筛查和管理的策略 在癌症治疗期间或在其他高危癌症人群完成治疗后的心脏功能障碍 (例如，淋巴瘤的成年幸存者接受已知的心脏毒性[蒽环类药物、胸部放射]疗法或 较新的免疫疗法，使用蒽环类药物和/或曲妥珠单抗治疗的乳腺癌成年幸存者) 在长期随访中面临类似的挑战。不断增长的长期癌症幸存者面临着 心血管疾病使得制定筛查和预防战略势在必行，以确保 这些幸存者在完成癌症治疗后，活得很长很健康。

Abstract Cardiovascular complications are a leading cause of morbidity and mortality in survivors of childhood cancer. These survivors have a greater than four-fold risk of developing heart failure (HF) when compared to age- matched controls, and there is a strong dose-dependent association between anthracycline exposure and the risk of heart failure. Outcome following HF is poor, emphasizing the importance of early detection of cardiac dysfunction (e.g. abnormal left ventricular ejection fraction [EF]) with cardiac imaging and initiation of pharmacologic therapy prior to the development of clinically overt disease. Unfortunately, the period in time when survivors are at the greatest risk of HF also corresponds to the time when they are least engaged in risk- based survivorship care. New paradigms in clinical care and chronic disease management are needed for these survivors. Recent advances in mobile technology have facilitated the development of a new sector of mobile healthcare diagnostics (mHealth) that has the potential to combine the utility of standard of care cardiac monitoring by echocardiography with the accuracy of more advanced diagnostic imaging (cardiac magnetic resonance [CMR]). However, neither the reproducibility nor the cost-effectiveness of this mHealth technology for prospective clinic- or home-based cardiac monitoring in cancer survivors is known. To address these knowledge gaps, we will enroll 200 long-term childhood cancer survivors who previously underwent a one-time assessment of cardiac EF by echocardiography, CMR, and a handheld Bluetooth-enabled device (Vivio) to validate the accuracy of Vivio EF in the clinic setting, and to determine its reproducibility at home (Aim 1). We will also leverage the expertise of our investigative team to determine the cost-effectiveness of Vivio-based screening using Markov modeling (Aim 2). This study will: 1) provide an important follow-up timepoint that will confirm the accuracy of EF, as measured using Vivio, in anthracycline-exposed survivors; 2) demonstrate the reproducibility of self-administered home-based measures of cardiac function in survivors who may no longer be able to maintain survivorship-focused care at the cancer center; and 3) establish whether Vivio-based screening is a cost-effective alternative to current standard of care cardiac imaging approaches. Information obtained from the current study can be used to develop strategies that facilitate screening and management of cardiac dysfunction during cancer treatment, or after completion of therapy in other at-risk cancer populations (e.g. adult survivors of lymphoma treated with known cardiotoxic [anthracyclines, chest radiation] therapies or newer immunotherapies, adult survivors of breast cancer treated with anthracyclines and/or trastuzumab) who face similar challenges in long-term follow-up. The growing population of long-term cancer survivors at risk for cardiovascular disease makes development of screening and prevention strategies imperative, to ensure that these survivors live long and healthy lives well after completion of their cancer treatment.