Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of Hodgkin lymphoma treated with radiation therapy
Valvular dysfunction and carotid, subclavian, and coronary artery disease in survivors of Hodgkin lymphoma treated with radiation therapy
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DOI：
10.1001/jama.290.21.2831
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发表时间：
2003-12-03
影响因子：
120.7
通讯作者：
Mendenhall, NP
中科院分区：
文献类型：
--
作者：
Hull, MC;Morris, CG;Mendenhall, NP
背景：大多数霍奇金淋巴瘤患者都很年轻，治愈率很高。这就需要关注预防、诊断，目的明确和量化霍奇金淋巴瘤放射治疗后长期心脏和血管并发症的发生率和影响因素。设计和设置回顾性研究比较1962年至1998年在一所大学接受放射治疗的患者，患者：415名连续患者，符合至少2年随访的纳入标准（中位数，11.2岁），其辐射野包括心脏或颈动脉或锁骨下动脉。根据监测、流行病学和最终结果（SEER）和全国出院调查（NHDS）数据，我们预测了心脏瓣膜手术、冠状动脉旁路移植术、经皮冠状动脉介入治疗或两者的预期比率。（10.4%）在治疗后中位数9年发生冠状动脉疾病，30例患者（7.4%）在治疗后中位数17年发生颈动脉和/或锁骨下动脉疾病，25例患者（6.2%）在治疗后中位数22年发生临床显著的瓣膜功能障碍。最常见的瓣膜病变是主动脉瓣狭窄，发生在14个瓣膜中。瓣膜手术的预测与预期比率为8.42（95%置信区间[CI]，3.20-13.65），冠状动脉旁路移植术或经皮冠状动脉介入治疗的预测与预期比率为1.63（95% CI，0.98-2.28）。在所有发生冠状动脉疾病的患者中至少存在1种心脏风险因素。与冠状动脉疾病发生相关的唯一治疗相关因素是使用放射技术，导致心脏部分总剂量较高（相对危险度，7.8; 95% CI，1.1-53.2; P= 0.04）。没有特定的治疗相关因素与颈动脉或锁骨下动脉疾病或瓣膜功能障碍相关。无任何心血管疾病的发病率为88%，在15年和84%，在20 years.Conclusions在霍奇金淋巴瘤放射治疗的患者中，有统计学高于预期率的瓣膜手术和冠状动脉血运重建程序在未来10至20年。冠状动脉血管疾病与较高的辐射剂量和传统的冠心病危险因素有关。非冠状动脉血管疾病和临床上重要的瓣膜功能障碍是辐射后15至20年不太清楚的并发症，需要监测和进一步研究。
Context The majority of patients with Hodgkin lymphoma are young and highly curable. This necessitates concern for prevention, diagnosis, and optimal management of potential treatment-related complications.Objective To identify and quantify the incidence of and factors contributing to long-term cardiac and vascular complications after radiation therapy for Hodgkin lymphoma.Design and Setting Retrospective study comparing patients treated from 1962 to 1998 at a university-based referral center with a matched general population.Patients Four hundred fifteen consecutive patients who fulfilled the inclusion criteria of a minimum 2-year follow-up (median, 11.2 years) and whose radiation fields included the heart or carotid or subclavian arteries.Main Outcome Measures Multivariable analyses of potential risk factors and observed-to-expected ratios for cardiac valve surgery, coronary artery bypass graft surgery, percutaneous coronary intervention, or both based on Surveillance, Epidemiology, and End Results (SEER) and National Hospital Discharge Survey (NHDS) data.Results Forty-two patients (10.4%) developed coronary artery disease at a median of 9 years after treatment, 30 patients (7.4%) developed carotid and/or subclavian artery disease at a median of 17 years after treatment, and 25 patients (6.2%) developed clinically significant valvular dysfunction at a median of 22 years. The most common valve lesion was aortic stenosis, which occurred in 14 valves. The observed-to-expected ratio for valve surgery was 8.42 (95% confidence interval [CI], 3.20-13.65) and the observed-to-expected ratio for coronary artery bypass graft surgery or percutaneous coronary intervention was 1.63 (95% Cl, 0.98-2.28). At least 1 cardiac risk factor was present in all patients who developed coronary artery disease. The only treatment-related factor associated with the development of coronary artery disease was utilization of a radiation technique that resulted in a higher total dose to a portion of the heart (relative risk, 7.8; 95% Cl, 1.1-53.2; P=.04). No specific treatment-related factor was associated with carotid or subclavian artery disease or valvular dysfunction., Freedom from any cardiovascular morbidity was 88% at 15 years and 84% at 20 years.Conclusions Among patients treated with radiation therapy for Hodgkin lymphoma, there are statistically higher than expected rates of valve surgery and coronary revascularization procedures over the next 10 to 20 years. Coronary vascular disease is associated with higher radiation doses and traditional coronary heart disease risk factors. Noncoronary vascular disease and clinically important valvular dysfunction are less well understood complications at 15 to 20 years after radiation, requiring surveillance and further study.