Symptomatic coronary artery disease after mantle irradiation for Hodgkin's disease
Symptomatic coronary artery disease after mantle irradiation for Hodgkin's disease
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DOI：
10.1016/s0360-3016(96)00295-7
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发表时间：
1996-11-01
影响因子：
7
通讯作者：
Rubin, P
中科院分区：
文献类型：
--
作者：
King, V;Constine, LS;Rubin, P
目的：a）评估在单一机构接受霍奇金病治疗的所有患者中与年龄相关的心脏病事件的发病率，包括心源性死亡（CD）、非致命性心肌梗死（MI）和心绞痛（AP）; B）检查受累患者中心脏病危险因素的患病率和冠状动脉疾病（CAD）的存在。方法和材料：1954年至1989年，我院共收治霍奇金病患者475例，其中97%的患者是通过1992年至1993年的就诊和检查、个人电话联系或死亡记录确定的。其中326名接受过套照射（RT）并存活3年的患者构成了研究人群。评估了继发于CAD的AP、MI或CD患者是否存在特定心脏风险因素。心导管检查和尸检数据进行了审查，以确定冠状动脉狭窄的存在和程度。结果：326例患者中有18例（5.5%）有一个病态的心脏事件直接相关的CAD。7例患者患有CD。7例患者发生非致死性MI，4例患者发生AP。从RT到病态心脏事件的平均间隔为13.1年（范围：4.4-27.0），事件发生时的平均年龄为39.4岁（范围：24-65）。这些患者中有4例在24-29岁之间发生了病态心脏事件。基于MI继发CD的美国统计数据，治疗组CD的相对风险为2.8（男性为3.1，女性为1.8）。值得注意的是，在按接受RT的年龄十分位数或随访时间分层的患者中，没有发现发生病态心脏终点的风险存在差异。仅1例发生事件（AP）的患者接受了蒽环类药物治疗。受影响患者的中心心脏体积的平均RT剂量为44.3戈伊（范围：35-60.4）。15例患者的尸检或导管插入术数据显示，11例患者（73%）至少有一条主要血管狭窄90-100%，没有一条动脉更常见狭窄。具体而言，15例患者中有10例（67%）的左前降支和右冠状动脉狭窄均大于或等于60%，15例患者中有5例（33%）的左主干或回旋支狭窄大于或等于50%; 7例患者存在三支血管病变。所有发生病态心脏事件的患者的风险因素数据均可用：72%吸烟，72%为男性，78%有高胆固醇血症，61%肥胖，28%有阳性家族史，33%有高血压，6%（1例）有糖尿病。每例患者的危险因素平均数为2.9; 7例患者至少有4个危险因素，所有患者至少有1个危险因素。这种风险因素的频率升高时相比，美国population.Conclusions：在我们的机构，5.5%的霍奇金病治疗的患者经历了一个病态的心脏事件RT后，中央心脏容积。所给予的剂量比今天常用的剂量大。一些患者在年轻时发生事件，与一般人群相比，发生CD的可能性增加。这一观察结果与RT作为诱导病态心脏事件的额外风险因素一致。适当的心脏屏蔽和辐射剂量，仔细的随访，包括监测心脏功能，以及合理的饮食习惯，运动和不吸烟的预防计划可能有助于降低霍奇金病长期幸存者的心脏病发病率。版权所有（C）1996 Elsevier Science Inc.
Purpose: a) To assess the age-related incidence of morbid cardiac events including cardiac death (CD), nonfatal myocardial infarction (MI), and angina pectoris (AP) in all patients treated for Hodgkin's disease at a single institution; b) to examine the prevalence of cardiac risk factors and presence of coronary artery disease (CAD) in affected patients.Methods and materials: 475 patients were treated for Hodgkin's disease in our institution between 1954 and 1989, The status of 97% of the cohort was established either by patient visit and examination in 1992-1993, personal telephone contact, or documentation of death. The 326 of these patients who had mantle irradiation (RT) and survived 3 years formed the study population. Patients who experienced AP, MI, or CD secondary to CAD were assessed for the presence of specific cardiac risk factors. Cardiac catheterization and necropsy data were reviewed to determine the presence and degree of coronary artery stenosis.Results: Eighteen of 326 patients (5.5%) have had a morbid cardiac event directly related to CAD. Seven patients had CD. Seven patients experienced nonfatal MI, and four patients had AP. The mean interval from RT to morbid cardiac event was 13.1 years (range: 4.4-27.0), and the mean age at the time of the event was 39.4 years (range: 24-65). Four of these patients had morbid cardiac events between ages 24-29 years. Based on US statistics of CD secondary to MI, the relative risk of CD for the treated group was 2.8 (3.1 for males and 1.8 for females). Remarkably, no difference was found in the risk of experiencing a morbid cardiac endpoint in patients stratified by either decile of age at which RT was given, or by duration of follow-up. Only one patient experiencing an event (AP) had received an anthracycline. The mean RT dose to the central cardiac volume for the affected patients was 44.3 Gy (range: 35-60.4). Autopsy or catheterization data were available on 15 patients and revealed 90-100% stenosis of at least one major vessel in 11 patients (73%), and no single artery was more commonly stenosed. Specifically, the left anterior descending and right coronary arteries were each greater than or equal to 60% stenosed in 10 out of 15 patients (67%), and either the left main or circumflex arteries were greater than or equal to 50% stenosed in 5 out of 15 patients (33%); triple vessel disease was present in seven patients. Risk factor data were available on all patients experiencing morbid cardiac events: 72% smoked, 72% were male, 78% had hypercholesterolemia, 61% were obese, 28% had a positive family history, 33% had hypertension, and 6% (one) had diabetes. The average number of risk factors per patient was 2.9; seven patients had at least four risk factors, and all patients had at least one risk factor. This frequency of risk factors is elevated when compared to the US population.Conclusions: In our institution, 5.5% of patients treated for Hodgkin's disease experienced a morbid cardiac event following RT to the central cardiac volume. The doses given were greater than commonly used today. Some patients experienced events at a young age, and the likelihood of experiencing CD was increased compared to the general population. This observation is consistent with RT as an additional risk factor in the induction of morbid cardiac events. Appropriate cardiac shielding and radiation doses, careful follow-up, which includes monitoring of cardiac function, and a preventative program of sensible dietary habits, exercise, and nonsmoking may be beneficial in reducing cardiac morbidity in long-term survivors of Hodgkin's disease. Copyright (C) 1996 Elsevier Science Inc.