Cardio-oncology is a new field in cardiology. Cardio-oncologists are typically cardiologists who see cancer survivors or patients getting cancer treatment who develop side effects that affect the heart. Cardio-oncologists have a special interest in and knowledge about cardiac side effects of chemotherapy, targeted therapy and radiation to treat cancer. Since it is a fairly new field in cardiology, many U.S. cities do not yet have cardio-oncologists.

If you are having symptoms that you think could involve your heart, talk to your cancer doctor (oncologist) or primary care doctor. If your doctors are concerned, they can refer you to a cardiologist or a cardio-oncologist. Make sure to learn about what side effects can be caused by your cancer treatment. That way you can help to inform your health care team.

How Do I Find a Cardio-Oncologist?

You may find a cardio-oncologist at many academic medical centers and other centers across the United States. Searching the department of cardiology website of the medical school nearest you can help you find a cardio-oncologist. Also, ask your cancer doctor as he or she may know a cardio-oncologist in the area.

Exams and Tests

What types of heart tests might you receive before beginning your cancer treatment? Tests may include:

Electrocardiogram (ECG)

An electrocardiogram (ECG) is a picture of your heart’s electrical activity. Some cancer treatment makes certain measurements on an ECG change so you may have more than one ECG during treatment. An ECG can detect abnormal heart rhythms, called arrhythmias.

Studies to Measure Ejection Fraction

In many ways, your heart is a muscle like those in your arms or legs. The muscle of your heart is in the left ventricle. Every time your heart beats, it is expected that a certain amount of blood is pushed out of your left ventricle to the rest of your body with each heartbeat: This is known as your ejection fraction. In general, an ejection fraction of greater than or equal to about 55% is considered normal.

Some cancer treatments can lower your ejection fraction. If you have had chemotherapy or radiation in the area of the heart, you may receive several echocardiograms during treatment, for years after treatment or both. Studies for ejection fraction:

• Echocardiogram
• Multigated acquisition (MUGA) scan (involves your receiving a radioactive solution given through a vein using an intravenous (IV) line and then having an X-ray taken)
• Cardiac MRI

Cardiac Catheterization

During a cardiac catheterization, a thin tube or catheter is guided into an artery, usually in the wrist or leg, and up to the heart. The test goes into the body to directly evaluate the arteries of the heart.

Tips for Staying Healthy

As part of your cancer treatment, radiation may play a role. Depending on the type of cancer, stage of your cancer, location of your cancer, and other therapies (such as chemotherapy), you may have an increased risk of heart disease after completing therapy. Remember that it is very important to consider these treatment options with your doctor. It is crucial to understand the side effects and risks of your therapy, but to weigh these against the potential benefits in helping to control or cure your cancer.

After you complete your cancer treatment, it is not uncommon to feel as if you have no control over what happens to you or your body in the future. However, the good news is that there are in fact several steps you can take to decrease the risks of heart damage and stay healthy after cancer therapy.

Here are some tips to help you stay healthy:

1. Follow-up with your doctor. It is important to follow your oncologist’s recommendations for checkups after you finish your treatment. These follow-up visits are necessary to ensure the cancer has not returned as well as to watch for side effects from the treatment you received. Be sure to receive any lab tests or other tests that your doctor has ordered and follow up on your results. You may need an echocardiogram (an ultrasound of your heart; See Section 5 and link to echocardiography) after receiving certain chemotherapies or radiation, have blood tests or other cardiac imaging tests. Discuss this with your doctor and ask when and for how long you should receive these tests.

2. Stay active. Studies have shown that increased physical activity results in a decrease of heart disease after radiation therapy. Find something you enjoy doing such as jogging, walking, biking, swimming, yoga, or exercise classes. Get approval from your doctor, and follow a plan that keeps you active most days of the week for at least 30 minutes. Find a friend or family member who can help hold you accountable or make the activity more fun!

3. Eat healthful foods and keep a healthy weight. Eating a healthful diet can help decrease your risk of both heart disease and cancer. Try incorporating healthy foods slowly if making a big change to your diet right away is too difficult. Aim to have more vegetables and fruit in your daily meals and to decrease foods that are high in saturated fat or salt. Both Mediterranean and DASH diets are heart-healthy.

4. Stop smoking or never start! This is one of the most important steps you can take to decrease your risk of both cancer and heart disease. If you are a smoker, it is crucial that you quit. Speak with your doctor to ask about resources that can help you stop smoking.

5. Manage your stress. You are undergoing or have just completed treatment for your cancer, which was undoubtedly one of the most stressful situations you have experienced. Understandably, adding the ordinary stresses of everyday life to a diagnosis of cancer may be overwhelming. Be sure to talk to family, friends, and/or your doctor for tips on effectively managing your stress. In addition, many cancer centers or local hospitals have support groups, where you can meet with patients and survivors affected by your cancer type or similar cancers. Engage in activities that you enjoy and that help reduce your stress, such as listening to music, reading, and practicing yoga and meditation.

6. Sleep. If you are not already doing so, start practicing healthy sleep habits. It is important to get enough sleep for your heart health and overall wellness for many reasons, including the fact that lack of sleep can increase blood pressure. Try a few changes such as setting a bedtime for yourself and decreasing screen time (television, smartphone, tablet use) a few hours before bed. These small changes may help you sleep better and more deeply. Please talk to your health care professional if you have more questions about this.

7. Always listen to your body. After a diagnosis of cancer, many people become more aware of aches, pains, and lumps/bumps on their body. If you are worried about any symptoms, never hesitate to call your doctor. Also, if you ever experience severe chest pain or any life-threatening concern, dial 911.

Exercise Basics:

In general, exercise can be broken down into a few basic elements. Having a general understanding of them can help ensure you safely maximize your benefits. The basic elements of exercise:

• Frequency: How often you exercise.
• Intensity: How hard you exercise.
• Time: How long you exercise.
• Type: What kind of exercise you perform.

Exercise Frequency

Ideally, you should make time to exercise most days of the week. This is important because, on top of missing out on the benefits of exercise, prolonged periods of inactivity are associated with negative changes throughout your body. This is especially relevant for cancer patients or survivors who may not feel well after their treatments and who are more likely to be inactive.

Exercise Intensity

Intensity matters! Exercise intensity is one of the most important considerations for exercise. Exercise intensities that are too low may not challenge your body enough to cause positive changes. Exercise intensities that are too high may not be safe for everyone.

According to the National Comprehensive Cancer Network, exercise intensity can be described as follows:

• Light exercise: No noticeable change in breathing pattern.
• Moderate exercise: Can talk, but not sing.
• Vigorous exercise: Can say only a few words without having to stop in order to catch a breath.

Exercise Time

Although some exercise is always better than no exercise, you need to sustain your exercise for at least 15 minutes or more to really benefit from its protective effects. However, don’t worry if you can’t maintain the activity for 15 minutes at first. By breaking your exercise time down into more manageable chunks — for example five minutes of an activity done three times throughout the day — you can still add up enough exercise in a day to benefit from it!

Exercise Type

The two main types of exercise that may help prevent and treat cancer-related cardiotoxicity are aerobic exercise training and resistance exercise training.

Aerobic Exercise Training

Aerobic exercise training is a type of physical activity that you can keep up for more than a couple minutes. It increases your heart rate and causes you to become short of breath (brisk walking, biking, swimming and dancing).

Resistance Exercise Training

Resistance exercise training requires your muscles to contract against resistance using either gravity (body weight, dumbbells) or resistance bands at a high enough intensity that you can perform 8-20 repetitions before feeling tired. Talk to your health care professional about how much weight would be a good amount for you to work with.

Making Progress:

Your body is incredibly resilient and adaptable! You will likely notice that the more you exercise the easier it becomes. This is a good sign! However, to get the most out of your exercise, you need to keep challenging your body. Although this may sound intimidating, it really is not that difficult. Remember the basic elements of exercise: frequency, intensity, time, and type. Any time you notice an exercise getting easier, all you need to do is change one of these basic elements. Here are some examples:

• Try adding an extra bike ride or walk into your schedule. Take an extra 15-minute walk before or after work — or even at lunch.
• Try walking a little faster or changing your route from a flatter path to one with a few small hills.
• Try increasing your exercise time by a few minutes or adding a few blocks to your route.
• Try changing up your exercise. If you are used to walking, try jogging for a few minutes during your walks. If you are used to working with resistance bands, try adding some dumbbells or body-weight exercises.

The key here is to remember to keep it safe and simple: Only change one thing at a time. Doing so will help ensure that you do not injure yourself by overtraining. It also will help you keep track of what changes work best for you. If you have any concerns with exercise or unclear how to star, talk with you healthcare team and they may create an exercise prescription for you.

Take time to rest:

Rest is an important part of every exercise program! There are actually two types of recovery to keep in mind: passive rest and active rest:

• Passive rest involves breaking up your exercise routine to give yourself a day off from exercise, about one to two days per week.
• Active rest involves mixing up your exercise intensity and time so that you are still being active but not pushing yourself as hard.

Building both types of rest into your routine will help you get the most out of your exercise by lower your risk of injury and giving your body more time to recover.

For example, instead of going for the same brisk 45-minute walk after dinner each night (seven days a week), mix it up a little. Try walking the route a little faster 1-2 times a week (complete your regular route in 30 to 35 minutes), a little slower 1-2 times a week (give yourself 55-60 minutes), and adding 1-2 days of rest into your schedule.

Finding Help:

Cancer really does change everything, but figuring out how to keep moving and incorporating exercise into your life is a vital part of recovery. By working with your health and exercise team, you can stay active without exposing yourself to unnecessary risks!

Speaking with your surgeon and medical/radiation oncologist are great ways to get informed about these risks. However, beyond safety issues, they may not know much about the best way to incorporate exercise into your life.

**We also recommend seeking advice from, or working with, a cancer-experienced exercise specialist (for example clinical exercise physiologist, kinesiologist, physiotherapist) before initiating a new exercise program after a cancer diagnosis.

How do you find someone who is qualified? Exercise oncology is a relatively new area of expertise, so finding someone with the training and experience may not be easy.

Here are a few tips/questions to aid in your search.

Look for cancer exercise programs near you.

• Are there any professional support services or organizations/cancer exercise programs in your area (e.g., LIVESTRONG at the YMCA)? As the awareness of the benefits of exercise for cancer patients and survivors grows, so too will the number of exercise support services in your community. Check out community centers, local gyms, and patient/survivor support services in your area to learn more about the services that may be available to you.

Seek the advice of a trained professional/specialist.

• Take the time to get to know them and ask about their background and training. Don’t worry. Anyone with the right experience won’t take offense to being asked questions.
• The American College of Sports Medicine has a specialized certification training course for professionals wanting to work with cancer patients/survivors. It’s called the Cancer Exercise Trainer Certification. Ask if the person has completed this training.
• If not, ask if the person at least has an undergraduate/graduate degree in clinical exercise physiology, kinesiology, physiotherapy, or a related field of study.
• Make sure you find out if the person has previous experience — or other specialized training — working with people with cancer. Do not be shy to ask for the details.

If there is a cost for the service or consultation, ask if the professional/specialist can provide a receipt for your insurance company.

• If they can provide a receipt, it is also a good idea to check with your insurance provider to verify that it will accept the claim.

Ask if the professional/specialist has any professional liability insurance to work with cancer patients/survivors.

• Liability insurance protects both the practitioner and yourself in the event that you become injured.
• This is especially important if you are seeking help privately from an individual practitioner and not through a larger non-profit or corporation.

You may have been given medicine or therapies that target your cancer cells, but did you know that some cancer treatments also can damage your heart and blood vessels? This is called cardiotoxicity. The most common forms of cardiotoxicity include:

• Cardiomyopathy and heart failure (heart muscle is damaged so that it can’t pump or receive blood normally)
• Coronary artery disease (major sources of blood supply to the heart are damaged)

Your risk of cardiotoxicity depends on the treatments you receive (type and dosage). It also depends on certain risk factors — some of which you can’t control, and some you can.

Risk factors that can’t be controlled include your sex, age, and family history. Some examples of controllable risk factors are inactivity, obesity, and smoking. You are more likely to develop cardiotoxicity after a cancer diagnosis if you:

• Are overweight 
• Smoke 
• Have diabetes, high blood pressure or high cholesterol
• Don’t exercise regularly
• Already have heart disease

The good news is that exercise can help control your risks. Use this condition center to learn about the benefits of exercise for patients with cancer, what questions you should ask your care team, and how to get started. 

Benefits of Exercise

Studies in cancer patients have shown that regular exercise or physical activity can help prevent deaths from cardiovascular disease (CVD). For example, survivors of breast cancer and Hodgkin’s lymphoma who did at least 150 minutes per week of physical activity had a 23% and 51% reduction in cardiovascular events respectively compared with those who did less.

This research suggests that you do not need to be running marathons to benefit from exercise!

What is Physical Activity?

Physical activity is defined as anything that makes you move your body and burns calories, such as gardening or playing a sport.

What is Exercise?

Exercise is a type of physical activity that is planned and structured. It aims to improve or maintain your physical fitness and health.

Although exercise is good for most people, how you exercise will depend on some factors, such as your health, goals and overall fitness level.

What Increases Your Risk?

You may need to check with your doctor before starting an exercise program. Whether you need to talk to your health care team can depend on several factors including:

• Your cancer history
• Your cancer treatments (chemotherapy and chest radiation)
• Your non-cancer medical history
• Other factors

Cancer History

It’s important to consider your history of cancer before starting or restarting an exercise program.

Do you have early stage disease or are you living with advanced disease?

The goals of someone living with (or recovering from) early stage disease will likely be different from those of someone living with advanced disease. Also, certain exercises — such as high intensity aerobic exercise or resistance exercise — may not be safe for everyone, especially if you are living with advanced disease.

Has your cancer spread to your bones or nervous system?

Exercise may still be safe for people living with advanced disease, even if your bones or nervous system have been affected. However, it is important to speak to your doctor and an exercise specialist before exercising to ensure you lower your risk of falls and fractures!

Cancer Treatments

Before starting to exercise, the types of cancer treatments — whether you had surgery and what type of therapy you may have had — also should be considered.

If you received surgery:

❱❱ How long ago did you have surgery? If less than 3 or 4 months ago, it may not be safe for you to begin all types or intensities of exercise. Ask your surgeon or oncologist if it is safe for you to start reintroducing exercise into your life.

❱❱ Did you have major or minor surgery? More invasive surgeries take longer to heal than less invasive ones. Check with your surgeon to make sure it is safe for you to start to exercise again.

❱❱ Did you have lymph nodes removed? If so, and if the nodes were in or near the arms (shoulders) or legs (pelvis), you may be at higher risk for swelling of the arms or legs (lymphedema). Although lymphedema can be prevented and treated, it can’t be cured. If you had any lymph nodes removed as part of your cancer treatment talk with your surgeon or health care provider before starting to exercise.

❱❱ Do you have other surgery-related considerations? Patients in the process of, or who recently completed, reconstructive procedures need to be careful not to irritate the affected area to avoid infections. If you are in having, or recently had, a reconstructive procedure, check with your surgeon before starting to exercise.

❱❱ Have you had an ostomy? The major concerns around exercising with an ostomy include infection and herniation risks. An ostomy is a surgical procedure done to help the body remove waste when your digestive system is not working properly. An ostomy bag worn outside the body collects the waste. If you are living with an ostomy, you should avoid contact sports and water sports. However, you may be able to do other exercises safely, for example brisk walking and cycling. You also should avoid exercises that cause high levels of abdominal strain and obtain medical clearance before doing resistance exercise.

If you received chemotherapy, hormone therapy, or a targeted therapy:

❱❱ Is the treatment linked to higher risk of cardiotoxicity? If so, ask your provider whether it is safe to begin exercise. Make sure there is a plan to monitor your heart health during and after treatment. If you had more than one such treatment, be sure to ask about possible combined risks for the treatments you are receiving or received.

❱❱ How much of the medication did you receive, and how long were you taking it? In many cases, cardiotoxicity risk adds up over time. The more medication you receive, or the longer you are taking the medication, the greater the risk. If you are concerned about your risks, talk to your oncologist to learn more about your treatment options.

If you received radiation therapy:

❱❱ What area of the body was affected? Radiation may hurt your heart, lungs, blood vessels, nerves, and bones. Speak with your radiation oncologist to learn more about your radiotherapy-related risks.

❱❱ How much radiation therapy did you receive? The amount of radiation therapy you receive or received also influences your cardiotoxicity and exercise risks. Again, speak with your radiation oncologist to learn more. Are your blood counts stable?

❱❱ Some treatments can affect components of your blood, such as red blood cells, white blood cells, platelets, or plasma volume. These levels can influence your safety and ability to exercise. If you are on — or recently completed — treatment, it’s a good idea to check with your oncologist to see if your blood counts are in a safe range before exercising.

Non-Cancer History

In addition to your cancer history and treatments, your non-cancer health history is also important to keep in mind before starting an exercise program.

Have you been diagnosed with or are you living with a chronic health condition other than cancer?

If you have a preexisting or uncontrolled heart condition or cardiovascular disease, you need to check with your doctor to make sure it is safe for you to exercise.

Does heart disease run in your family?

If so, make sure you tell your oncologist at your next health visit.

Other Factors

Other health considerations may factor into whether you start an exercise program.

Your pre-cancer activity level or fitness.

The more active and physically fit you were before your cancer diagnosis, the more you may be able to do after a cancer diagnosis. However, this is not always the case. Make sure you ask your oncologist if it’s safe for you to return to your pre-diagnosis exercise program.

Your current condition and energy levels.

Energy conservation is important — especially if you are feeling fatigued. Although it is important to challenge yourself, it is similarly important not to over-do it!

How to Exercise

In general, the exercise guidelines for cancer patients and survivors are similar to the guidelines for the general public. According to the Office of Disease Prevention and Health Promotion, you should:

1. Be active

2. Perform aerobic exercise

• New to exercise? Work up to or perform either 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity aerobic physical activity each week.
• Regular exerciser? Try increasing your moderate-intensity physical activity to 300 minutes or your vigorous-intensity physical activity to 150 minutes each week.

3. Perform resistance exercise

• Perform moderate-to-high intensity, muscle-strengthening exercises (body weight, dumbbells, or resistance bands) that involve all the major muscle groups at least two days per week.

Your overall health before beginning your cancer treatment may affect your risk of developing problems from anti-angiogenic therapy. Although all the factors that increase risk of complications are not clear, studies suggest they include:

• History of high blood pressure
• Older age
• Obesity
• Diabetes
• History of protein in your urine (proteinuria)

Known risk factors for heart disease, which include smoking and high cholesterol (hypercholesterolemia), are also thought to be risk factors for anti-angiogenic-related problems. Some evidence also suggests that genetics and certain ethnicities play a role in risk, but research is ongoing.

Your doctor will screen for risk factors and work with you to lower your risk as much as possible.

Exams and Tests

Physical examination and tests ordered by your physician will be based on your health history and risk factors.

Common heart tests include echocardiograms, electrocardiograms, and stress tests.

If you develop symptoms of fatigue, shortness of breath, or swelling during anti-angiogenic therapy, your doctor may order an ultrasound of the heart to assess heart function.

Typically, your cardiologist also will assess your heart rhythm activity with an electrocardiogram.

If you develop symptoms of chest pain or new shortness of breath with physical activity, your doctor may also order a stress test of your heart. A heart stress test examines your heart function during physical activity, which can detect problems with blood flow and blockages in your heart.

For patients with physical limitations, a chemical stress test can simulate exercise and help detect any heart blockages. Often imaging with ultrasound, nuclear images, or MRI is used during a stress test to reveal possible heart blockages.

Preventing Heart Disease 

Know your numbers!

It is crucial to regularly check your blood pressure, cholesterol levels and, if you have diabetes, your blood sugar (glucose).

In addition, not smoking, weight loss (if needed to maintain a healthy weight), and cardiovascular exercise are important for your health during anti-angiogenic treatment.

Living With Cancer Treatment

While you are having anti-angiogenic therapy and after your treatment ends, regular health visits are important.

Follow-up visits with your oncologist and cardiologist are crucial to monitor your blood pressure, blood sugar, and cholesterol levels.

Tracking these numbers will help detect any side effects that may require further treatment.

To survive and grow, cancer tumors depend on blood vessels supplying oxygen and nutrition. The growth of blood vessels, which is called angiogenesis, also helps cancer tumors spread to other areas of the body.

That is why cancer treatment often includes therapies to block the growth of blood vessels. These agents are also known as anti-angiogenic therapies.

Targeted therapies to block growth of new blood vessels include: 

• Monoclonal antibodies (mAbs): These drugs attach and block those proteins that help blood vessels grow. 
• Tyrosine kinase inhibitors (TKIs): These drugs block the action of enzymes known as tyrosine kinases, which help cells grow, divide, and send and receive signals. 

Monoclonal antibodies and certain tyrosine kinase inhibitors that block the growth of blood vessels are called vascular endothelial growth factor inhibitors (VEGF inhibitors). 

VEGF inhibitors block the signals causing abnormal growth of blood vessels and to prevent oxygen and nutrients from reaching the cancer cells. At the same time, it is important to know that VEGF inhibitors also can affect healthy cells.

Use this condition center to learn how anti-angiogenic therapies can affect your heart and what you can do to prevent developing heart disease.

Cancer Types Treated 

Anti-angiogenic therapies have been approved by the U.S. Food and Drug Administration to treat several types of cancers. These therapies work well for solid tumors because solid tumors require blood vessels to bring oxygen and nutrients to the tumor.

Below is a list of some common cancers that may be treated with anti-angiogenic therapy:

• Renal cell carcinoma (kidney cancer)
• Glioblastoma
• Non-small cell lung cancers
• Colo-rectal cancer
• Liver (hepatocellular) carcinoma
• Gastro-intestinal carcinoma
• Neuroendocrine tumors
• Sarcoma
• Endocrine tumors
• Cervical Cancer
• Ovarian epithelial cancers.

Possible Heart Effects:

Treatment to block growth of blood vessels to cancer tumors can cause some side effects including high blood pressure, kidney injury, heart failure, heart attack or stroke, and bleeding or clotting problems.

In the following sections, learn how therapy can cause these complications and when to call the doctor.

High Blood Pressure:

High blood pressure is the most common side effect linked to VEGF inhibitor treatment. It can occur in 20%-60% of patients, depending on which therapy is used.

The normal range for blood pressure is less than 120/80 mm Hg. It is important to check your blood pressure regularly and to go over your results with your health care professional. That will help you detect whether the anti-angiogenic therapy is causing your blood pressure to go up. It doesn’t mean you need to stop the medication, just that your blood presume may need treatment.Before you start therapy
Your doctor will assess your risk of developing serious problems linked to high blood pressure. If your blood pressure is high, your doctor will treat it. High blood pressure should be well controlled before starting anti-angiogenic therapy.

Over time, high blood pressure increases your risk of developing heart disease and stroke. During anti-angiogenic therapy, your goal for blood pressure will depend on your overall health and other medical conditions.

For most people during treatment, this means their blood pressure should be under 140/90. But you should discuss your blood pressure target with your doctor.

Healthy eating and regular physical activity are also important. Your doctor may also prescribe medicine to keep your blood pressure within a normal range during treatment.

In general, if your blood pressure is ≥140/90 mm Hg, treatment includes lifestyle changes along with medications

Your doctor will check your blood pressure during your office visits. He or she likely will ask you to take your blood pressure at home, too. If you develop high blood pressure, medications—along with lifestyle changes such as following a heart-healthy diet and lowering your salt intake—can help you manage the condition.

When to Call the Doctor: If your blood pressure is above 140/90 mm Hg often or your diastolic blood pressure (lower number) has increased a lot, you should talk to your doctor. If your blood pressure is elevated and you are also having a headache, chest pain, shortness of breath, swelling, vision changes, or clouded thinking, you should seek emergency help.  

Kidney Injury:

Anti-angiogenic therapy can affect how your kidney functions and lead to a loss of protein in the urine. Protein in the urine occurs in about 20% of patients. In severe cases, losing protein in the urine can sometimes lead to swelling, cholesterol problems, nutritional deficiencies, or increase your risk for blood clots. Kidney injury may be more common in patients who have high blood pressure. 

Your doctor will check your kidney function with blood and urine tests before starting treatment. He or she will regularly monitor your kidney function during your treatment as well. 

When to Call the Doctor: Kidney injury can cause fluid buildup and the loss of protein in the urine. If you develop kidney problems, you may be urinating less and notice swelling particularly in your feet and legs or that your urine appears foamy. If you notice these symptoms, be sure to talk to your doctor. 

Kidney injury is usually treated based on the underlying cause of stress on the kidneys, such as high blood pressure or poor management of blood sugar (glucose). If you develop kidney problems from anti-angiogenic treatment, blood pressure medications can help improve kidney function. In some cases, specific medicines can cause kidney injury. Your doctor may have you stop taking certain medications and prescribe others. 

Heart Failure and Cardiomyopathy:

Anti-angiogenic therapies can cause weakening of the heart muscle (cardiomyopathy), which means your heart muscle can’t pump well enough to meet your body’s needs for oxygen and blood. About 10%-15% of patients who receive anti-angiogenic therapy may develop weakening of the heart muscle, and a proportion of these patients may develop symptoms of shortness of breath and related symptoms consistent with heart failure. A history of coronary artery disease, high blood pressure, or heart failure can increase your risk of developing heart failure during treatment. 

Signs of heart failure include swelling  especially in your feet and legs, increased fatigue, shortness of breath, or difficulty breathing when lying down. For patients at an increased risk of developing heart failure, your doctor may order cardiac testing before starting therapy. He or she likely also will monitor your heart function during therapy. 

When to Call the Doctor: You should also talk to your doctor if you have shortness of breath, fatigue, poor exercise tolerance, swelling on the legs, trouble sleeping at night because of shortness of breath, or unexplained weight gain of 3 pounds or more in two to three days. 

Treatment for heart failure may include changes in lifestyle, medications, exercise and, in some cases, surgical placement of cardiac devices. 

Heart Attack:

Patients are also at an increased risk of a heart attack (myocardial infarction or acute coronary syndrome) with anti-angiogenic therapy.  A heart attack occurs when the heart is deprived of enough blood, usually due to a blockage in a blood vessel that supplies the heart.

Aspirin or blood thinners may help to reduce the risk of heart attack in patients who are receiving anti-angiogenic therapy, but more research is ongoing.

When to Call the Doctor: Chest pain, shortness of breath and sweating can be warning signs of a heart attack. If you experience these symptoms, call 911 and seek emergency help.

An urgent heart attack is treated with both medications and surgical procedures to help restore blood flow to the heart. Both medications and cardiac rehabilitation are important for patients who are recovering from heart attacks.

Stroke and blood clots:

Anti-angiogenic treatment also increases your risk of stroke. A stroke occurs when a blood vessel that supplies nutrients and oxygen to the brain ruptures or is blocked by a clot. It is important for patients and family members to know the signs and symptoms of a stroke. They include

• Sudden loss of vision
• Weakness
• Paralysis of one side of the body
• Slurred speech

A “mini-stroke,” also called a transient ischemic attack (TIA), can be a warning of an impending stroke. A mini-stroke occurs when blood flow to part of the brain is temporarily reduced or blocked, usually by a blood clot. Mini-strokes last only a short time and don’t cause permanent damage. However, if you think you are having a mini-stroke, call 911 and seek emergency help. 

Blood clots can develop in various parts of the body during anti-angiogenic therapy. Symptoms may include leg pain and swelling. Blood clots also may cause a stroke. 

When to Call a Doctor: If you have symptoms of a stroke such as numbness or weakness in a limb, slurred speech, or clouded thinking, call 911. 

Appropriate treatment for stroke depends on early identification of symptoms by patients or family members. If symptoms are identified within three hours of the start of a stroke, blood flow can be restored to the brain, usually through treatment with a medication to dissolve the blood clot. Other medicines may also be prescribed to help prevent a stroke in the future.

If you have prostate cancer, hormone therapy may be part of your treatment. Stopping some hormones can prevent the growth of cancer cells. Androgen deprivation therapy (ADT) includes surgery or medicines that aim to block the effects of male hormones such as testosterone—called androgens—that can cause cancer cells to grow and spread.  

This therapy can make developing cardiovascular disease (heart and blood vessel problems) more likely. It also can make existing heart disease worse.

Possible Heart Effects

How does androgen deprivation therapy, or ADT, affect your heart?

Research has not shown that androgen deprivation therapy definitively causes cardiovascular disease. However, we do know that men who receive hormone therapy have a higher likelihood of developing conditions that increase their chance of cardiovascular disease.

For example, ADT has been shown to:

• Raise cholesterol levels
• Raise blood sugar levels
• Reduce the body’s ability to process sugar
• Increase body fat
• Reduce muscle mass
• Increase the thickness of the walls of blood vessels

Having higher levels of blood sugar and difficulty processing blood sugar can cause diabetes. If you have diabetes, you are more likely to develop heart disease or have a stroke.

In men with prostate cancer who already have a buildup of plaque—made up of cholesterol, fatty substances and calcium—in their arteries (atherosclerosis), ADT might increase the chance that patients may suffer from a heart attack.

ADT also can make you have low counts of red blood cells, a condition called anemia, which may stress your heart. If you have anemia, less oxygen goes to your heart muscle.

Reducing testosterone to very low levels also may increase the chance of blood clots forming in your blood vessels, known as deep venous thrombosis.

Symptoms of Heart Disease

Cardiovascular disease can cause many different symptoms including:

• Chest pain (including pressure, tightness, heaviness)
• Shortness of breath
• Tiredness
• Dizziness or lightheadedness
• Passing out
• Swelling in the legs
• Pain or cramping of the legs with walking

Cardiovascular disease can also result in a stroke or mini-stroke (also called transient ischemic attack). Symptoms include: trouble speaking, loss of vision, weakness or inability to move part of the body, or abnormal feeling (sensation) in part of the body.

Treatment With ADT

Although the link between ADT and cardiovascular disease has not been proved, if you are on ADT, it’s important to take steps to protect your heart. Adopt healthy habits and try to control conditions that are major risk factors for developing cardiovascular disease:

• Blood pressure
• Cholesterol
• Diabetes
• Weight
• Tobacco use
• Physical inactivity

If you already have cardiovascular disease and need androgen deprivation therapy, it is important to continue your treatment and, if needed, take medicines proven to help lower the chances the disease gets worse.

What Increases Your Risk?

Unhealthy habits can make it more likely for you to have harmful effects from androgen deprivation therapy, for example:

• Poor diet (including too much salt, saturated fat, cholesterol, and sugar)
• Lack of exercise
• Smoking

Also, if you have high blood pressure, high cholesterol, or diabetes, not treating those conditions could increase your risk for cardiovascular problems from ADT.

If you have known heart problems, such as coronary artery disease, plaque and blockage of heart arteries, or if you have had a heart attack, you may have a higher risk of a cardiac event in the first year undergoing ADT. Also, in some cases certain types of ADT may be better for your heart, so it is very important to talk with your cancer doctor (oncologist) about your heart health before starting ADT.

When to Call a Doctor

It is important to talk to your doctor if you are experiencing symptoms such as:

• Chest pain or discomfort
• Shortness of breath at rest or with activity
• Fatigue or tiredness limiting your ability to exercise
• Dizziness or lightheadedness
• Passing out
• Swelling in the legs
• Pain or cramping of the legs at rest or with walking

You should seek emergency medical care for severe symptoms.

If you notice signs of stroke—someone having sudden loss of movement in face, leg or arm, or trouble speaking—call 911 at once. It’s important to act fast to avoid permanent brain damage or even death.

Exams and Tests

To help minimize harm from androgen deprivation therapy, your physician will conduct a thorough history and physical exam to assess your heart risk factors or evaluate any existing cardiovascular disease you may have.

Talk about the risks and benefits of the treatment with your doctor. It’s also good to go over the plan for future treatment and follow-up visits.

Tests to evaluate your risk may include blood tests such as:

• Fasting cholesterol (lipid panel)
• Fasting blood sugar
• Kidney function and blood electrolytes (potassium, sodium, calcium)
• Complete blood count, including hemoglobin, to assess for anemia
• Brain natriuretic peptide, a test evaluating for signs of heart failure

Other tests include:

• Electrocardiogram, ECG, a test to evaluate electrical activity of the heart
• Echocardiography, an ultrasound examination of the heart to assess size, thickness of the muscle, pumping function and relaxation of the heart, and valve function
• Stress testing, exercise testing while monitoring of the heart to look for signs that might suggest blocked coronary arteries.

Preventing Heart Problems

If you have prostate cancer and are receiving androgen deprivation therapy, the best way to prevent developing heart problems is to control your risk factors and manage existing heart disease.

Regular exercise, attention to a healthy diet, and a healthy body weight are important for everyone—especially if you are being treated with ADT.

Eat Better

Try to follow a diet rich in fruits, vegetables, and whole grains, while limiting saturated fats and refined sugars. Weight gain and increased body fat often accompany ADT, so limiting the calories you consume through portion control is important. You may find it helpful to talk to a dietitian to learn about healthy ways to eat.

Stop Smoking

Avoid tobacco in any form (for example, smoking or chewing) and nicotine in e-cigarettes. Tobacco use is a leading cause of heart disease. Prostate cancer patients who use tobacco have a higher rate of death than prostate cancer patients who do not use tobacco.

Exercise

After talking to your health care professional, you should start or continue to exercise regularly with a goal of building up to at least 150 minutes of moderate-intensity activity every week. Examples of moderate-intensity activity include walking briskly, swimming, water aerobics, and tennis.

Because of the potential for increased body fat and reduced muscle mass, you should also engage in two sessions of strength training every week. Examples of strength training include light weightlifting, use of resistance bands, pushups, yoga and Pilates.

Control Other Conditions

Control high blood pressure by eating a low-salt (sodium) diet, exercising, and taking medicine if needed. If you need medicine to lower your blood pressure, angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI and ARBs) may be good options because some research suggests they offer better outcomes for patients with cancer, including those with prostate cancer.

Manage your cholesterol, including total-, LDL- (bad), HDL- (good) cholesterol, and triglycerides by adopting healthy habits: healthy diet, regular exercise, and weight control. If cholesterol levels are abnormal and do not improve despite lifestyle changes, you may have to start medication. Statin drugs are the most commonly used and proven agents.

If you have diabetes, it’s very important to keep the condition under control and treat it aggressively, according to the American Diabetes Association guidelines. Androgen deprivation therapy can be associated with high blood sugars. As exercise and weight loss help control blood sugars, it is essential to follow a healthy diet and get regular exercise when undergoing ADT.

What About Aspirin?

In general, aspirin may be beneficial in some men as a preventive measure of cardiovascular disease, although more research is needed to better identify which men would benefit from its use.

If you already have cardiovascular disease, continue your treatment and practice healthy habits. This may include aspirin, medicine to lower cholesterol or blood pressure, or both.

Talk to your health care professional if you have any questions. Also, never start or stop taking medicine without talking to your care team.

Living With Your Condition

With any complex medical problem, good communication and a strong partnership between you and your health care team will improve your chances of having the best possible outcome.

Be proactive and talk about your heart health and what matters to you with your care team.

Although androgen deprivation therapy carries some cardiovascular risk, it can be very effective in treating prostate cancer. Being aware of your heart health and adopting healthy habits can help you minimize your cardiovascular risk during cancer treatment.

Finding out that you have breast cancer can be overwhelming. As a person newly diagnosed with the condition, you may have several questions. A common concern relates to cancer treatments and their side effects: How will they impact your life over the following days, months and years?

Breast cancer treatment depends on the type of breast cancer you have as well as the stage, or progression, of the disease. Often, breast cancer treatment will involve a combination of different therapies:

• Surgery
• Radiation therapy
• Chemotherapy
• Hormonal therapy
• Targeted therapies

About 20% of patients diagnosed with breast cancer will have a specific type of tumor called HER2-positive breast cancer (breast tumors with high levels of a protein called human epidermal growth factor 2, or HER2). Treatment of HER2-positive breast cancer involves medications that target HER2, also called HER2-targeted therapies.

Ask your provider about the HER2 status of your tumor and whether HER2-targeted therapy is an option for you. Use this condition center to learn more about targeted therapy for breast cancer and how it can affect your heart.

Overview

What is HER2-positive breast cancer? HER2-positive breast cancers are breast tumors with high levels of a protein called human epidermal growth factor 2 (HER2). HER2 is a protein that functions as a receptor outside of breast cancer cells. When HER2 receives an activating signal from the body, it promotes cell growth and multiplication. As such, HER2-positive breast cancers may grow quickly and have a high chance of spreading to other parts of the body (metastasis).

The good news is that the outlook for patients with HER2-positive breast cancers has improved greatly over the past decade with new therapies that target HER2.

In many ways, treatment of HER2-positive breast cancer is similar to treatment of HER2-negative breast cancer. It often involves a combination of surgery, chemotherapy and radiation therapy, but with the addition of HER2-targeted therapy.

Most HER2-targeted therapies block HER2 receptors from receiving signals that tell the cells to grow and multiply. These targeted therapies can be given before, during or after chemotherapy. They generally don’t cause the side effects common with chemotherapy such as nausea, vomiting or hair loss. However, HER2-targeted therapies have unique side effects. A possible side effect involves the heart and is called cardiotoxicity. If you are prescribed a HER2-targeted therapy, ask your provider about its potential side effects.

What is Cardiotoxicity?

Cardiotoxicity is the term used for heart damage caused by medications. The form cardiotoxicity takes can range from temporary changes in heart function that you might not notice to more serious conditions such as heart failure. It also can be life threatening.

Most cases of cardiotoxicity from HER2-targeted therapies are without symptoms and last for a short time. However, more serious reactions can occur.

Why do HER2-Targeted Therapies Cause Cardiotoxicity?

HER2-targeted therapies block HER2 receptors from receiving signals that tell the cells to grow and multiply. Blocking HER2 on cancer cells is good because it stops the message telling tumor cells to grow and spread. However, HER2 receptors are also on healthy cells, such as heart muscle cells. In the heart, HER2 activation is important for cell survival, particularly during stressful situations, and thus blocking HER2 may cause heart damage.

What Increases Your Risk of Harm to Your Heart

The rate of cardiotoxicity from HER2-targeted therapy varies according to the agent used, other treatments given and some characteristics unique to the patient. The most important factors that make patients receiving HER2-targeted therapy more likely to experience cardiotoxicity are the following:

• Cancer treatments given at the same time that also can affect the heart, including anthracyclines or radiation.
• Older age. The risk of cardiotoxicity rises with increasing age, especially if you are 60 or older.
• Existing heart disease or risk factors for heart disease.

If you already have some form of heart disease, you are more prone to have heart damage from cardiotoxic medications. For example if you have:

• Heart failure
• Abnormal heart function (low ejection fraction)
• Coronary heart disease
• Atrial fibrillation
• High blood pressure
• High cholesterol
• Diabetes
• Abnormal kidney function
• Obesity (BMI of 30 or greater)

You are at higher risk for cardiotoxicity likely because your heart’s ability to tolerate stress is lower. Occasionally, providers may choose not to give HER2-targeted therapies if the risk of heart damage is too great. This might occur for patients with an abnormal heart function or who have heart failure. In these circumstances and for most patients with heart disease, talking to a cardio-oncologist or cardiologist might be recommended.

Patients and providers are encouraged to engage in a discussion about risks and benefits and decide together which is the right treatment plan for you, the patient. In some cases, the HER2-targeted therapies may be given with careful monitoring if the benefits are seen to outweigh the risks. They may also be given with heart medications, which may act to protect the heart from damage.

Risks Linked With Specific Treatments

This section covers the different types of HER2-targeted therapies and concerns associated with them.

Trastuzumab (Herceptin®): The oldest and most widely studied HER2-targeted therapy is trastuzumab. Trastuzumab was first approved for use in patients with metastatic HER2-positive breast cancer in 1998 and is used to treat various stages of HER2-positive breast cancer. Trastuzumab may reduce the risk of death or slow the progress of breast cancer by up to 50%. Cardiotoxicity from trastuzumab is uncommon when it is used in young and healthy patients, without other heart risk factors (for example, high blood pressure, high cholesterol or diabetes), and who are not receiving other cardiotoxic drugs. However, cardiotoxicity from trastuzumab may occur at much higher rates (20% to 40% of patients) when used in combination with cardiotoxic chemotherapy (especially those containing agents called anthracyclines), in patients who are older, have several heart risk factors or already have heart disease.

Pertuzumab (Perjeta®): The combination of pertuzumab and trastuzumab with chemotherapy is most often used in patients with metastatic HER2-positive disease, or before surgery for patients with earlier stages of HER2-positive breast cancer. The addition of pertuzumab to trastuzumab does not appear to increase the risk of cardiotoxicity beyond that linked with trastuzumab alone.

Lapatinib (Tykerb®): Lapatinib is an oral HER2-targeted therapy sometimes used in patients with metastatic HER2-positive breast cancer that continues to grow and spread despite treatment with therapies including trastuzumab. In this setting, adding lapatinib may prevent the cancer from spreading. The impact of lapatinib on the heart has been studied less than trastuzumab; however, the available data suggest lapatinib has a low risk of cardiotoxicity.

Ado-trastuzumab emtansine (Kadcyla®): Ado-trastuzumab emtansine is a combination of trastuzumab and a chemotherapy called emtansine. It is approved for use in patients with metastatic breast cancer who have had tumor growth despite treatment with therapies including trastuzumab. As is the case for lapatinib, ado-trastuzumab emtansine appears to cause less cardiotoxicity than trastuzumab. However, its effects on the heart have been less studied than trastuzumab.

Neratinib (Nerlynx®): Neratinib is a recently approved oral HER2-targeted treatment that can be used in patients with early breast cancer who have completed one year of trastuzumab. It helps lower the chance the cancer will return. Neratinib does not appear to be cardiotoxic.

Other Cardiotoxic Medications

The risk of cardiotoxicity from HER2-targeted therapies is greatest when it is used with anthracyclines. Two major drugs are in this class: doxorubicin and epirubicin. Anthracyclines are effective in treating breast cancer. Unfortunately, they also can cause cardiotoxicity. The risk is greater when high doses are given (>250 mg/m2 of doxorubicin or >600 mg/m2 of epirubicin). The use of trastuzumab at the same time or after anthracyclines increases the risk of poor heart function or development of heart failure.

Today, anthracyclines usually are given in low doses or aren’t given at the same time as HER2-targeted therapy to reduce the risk of heart damage. Radiotherapy may also be linked with heart damage, although more research is needed to find out how much risk is added when used with HER2-targeted therapy.

Signs and Symptoms

In most cases of cardiotoxicity from HER2-targeted therapies, a decline in heart function will be found during routine monitoring with the patient having no symptoms or vague symptoms, such as fatigue. In some cases, however, the decrease in heart function will be accompanied by symptoms of heart failure.

In heart failure, the heart isn’t pumping as well as it should, which leads to fluid buildup in the lungs and eventually in the legs. Patients may experience:

• Shortness of breath, especially with exertion.
• Swelling of the ankles, legs and sometimes abdomen.
• Chest pressure or shortness of breath when lying flat.
• Waking up with severe shortness of breath.
• Rapid changes in weight.
• Heart palpitations.
• Extreme fatigue.
• Decreased appetite.
• Nausea.

If you develop any of these symptoms, talk to your doctor at once.

Exams and Tests

Most cancer centers perform routine monitoring of heart function during treatment with HER2-targeted therapies. The method used for monitoring and the frequency of tests depends on each case.

Imaging of the heart will take place before therapy begins to ensure a normal heart function and will be repeated every three months after the HER2-targeted agent is started. Over time, you may have the test done less often, and no monitoring is required after therapy is completed. That is because the risk of cardiotoxicity is greatest during HER2-targeted therapies and lower once these cancer treatments are stopped. More testing may be done if you develop symptoms that suggest heart failure.

Here are the tests most commonly used to monitor heart function and cardiotoxicity:

• Echocardiogram: An ultrasound of the heart is used to calculate ejection fraction, a measure of how well your heart is pumping. Also, echocardiograms provide information on heart size, the relaxation of the heart, and the function of heart valves. The test is widely available and does not involve any radiation exposure.
• Multigated acquisition (MUGA) scan: This test involves your receiving a radioactive solution through a vein and then having an X-ray. A MUGA is commonly used to assess ejection fraction.
• Cardiac Magnetic Resonance Imaging (MRI): Cardiac MRI provides detailed information on heart size and function. It is usually reserved for cases when the images from the echocardiogram are not good enough or more information is needed.
• Blood tests: Some providers also may monitor markers present in your blood to measure heart injury. This is not done routinely and is more likely to occur in patients with increased risk of cardiotoxicity from HER2-targeted therapies and may help to detect heart damage early. Commonly measured blood markers are cardiac troponin (TnI, TnT) or natriuretic peptides (BNP, NT-proBNP).

Prevention

You can take several steps to help lower your risk of developing heart damage during treatment with cardiotoxic medications.

Be Heart-Healthy

Anything you can do to keep your heart as healthy as possible will reduce your risk of cardiotoxicity. Studies suggest that people who are overweight or obese are at increased risk of developing heart damage during cancer treatment. Similarly, data show that most patients decrease their levels of physical activity and gain weight after being diagnosed with cancer, both of which are associated with higher risk of heart disease. To find out whether you are above your ideal weight, calculate your body mass index (BMI). A BMI between 25 and 29.9 indicates you are overweight, and BMI of 30 or greater means that you have obesity.

If you are overweight or obese, try to lose weight. Try to eat a heart-healthy diet that is low in salt and saturated fats and rich in whole grains, fruits and vegetables. The DASH diet is a good one to try.

Similarly, it is important to stay active. Current guidelines recommend engaging in no less than 75 minutes per week of intense exercise or 150 minutes per week of moderate or intense exercise. But any physical activity is better than nothing.

Smoking increases the risk of heart attacks and heart damage. If you smoke, work with your provider on strategies to quit. If you don’t smoke, don’t start!

Know Your Numbers!

Most studies suggest that having an elevated blood pressure, diabetes or high cholesterol increases the risk of cardiotoxicity. These also are risk factors for heart disease and put stress on your heart. The more stress on your heart, the higher your chance of developing heart damage. Follow up with either your primary care provider or cardiologist to ensure these conditions are well controlled.

What if You Have Heart Disease

If you have a history of poor heart function (low ejection fraction), heart failure, coronary artery disease (if you had a heart attack or received a stent), or an abnormal heart rhythm, you should see a cardiologist or cardio-oncologist to manage these conditions.

A few studies have suggested certain medications may help prevent cardiotoxicity from HER2-targeted therapies. These include angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs) and beta blockers. Most providers will not routinely start these medications for this purpose if there is no history of heart disease or heart risk factors. More research is needed and currently in progress.

Living With Cardiotoxicity

What should you expect if you develop cardiotoxicity? Here is the good news: Cardiotoxicity from HER2-targeted therapies tends to be temporary and reversible. For most patients, their heart function will return to normal.

If you have a significant decline in your heart function detected by routine tests or because of symptoms, your provider may recommend you stop HER2-targeted therapies for a short time. Typically, therapy is put on hold for about four weeks and then tests are repeated. In most cases, the heart function returns to normal, and HER2-targeted therapy can start again with close monitoring.

If the heart function does not return to normal, your provider may recommend you stop the medication completely. However, this type of decision is made on an individual basis and in close consultation with your team of health providers, including your oncologist and cardiologist or cardio-oncologist, paired with a careful discussion of what you prefer and value.

However, if you already have heart disease, you may benefit from being on one or more of these medicines when you receive HER2-targeted therapy.

Treatment with 5-fluorouracil (5FU) or capecitabine

Treatment using drugs to kill cancer cells is called chemotherapy. More than 100 chemotherapy drugs are used in cancer treatments.

If you have cancer, your treatment will depend on the type of cancer you have and how far it has progressed. While your treatment will target the cancer cells, sometimes it also may cause heart problems. Although these heart side effects are rare, it’s important to understand and be aware of them.

Chemotherapy with fluoropyrimidine, which includes 5-fluorouracil (5FU) and capecitabine, may be used to treat solid tumors such as those involving your stomach and intestine (gastrointestinal), breast, or head and neck.

These medicines belong to a type of chemotherapy called antineoplastic or antimetabolite, which describes how they work on cancer cells. The drugs stop cancer cells from forming DNA—which contains genetic information—and growing.

This chemotherapy is often well tolerated, but you can have side effects depending on other medications you are taking. Your health history including age, risk factors for heart disease, and other chemotherapy treatments can also play a role in whether you develop complications.

The most common side effects with this chemotherapy are fatigue, nausea, diarrhea and lab abnormalities. It also can cause heart side effects including chest pain, spasm of the heart arteries or irregular heart rhythms, which can be felt as palpitations.

Use this condition center to learn more about damage to your heart, also called cardiotoxicity, from chemotherapy using 5-fluorouracil or capecitabine. 

Cancer Types Treated

Many cancer types are treated with chemotherapy using fluoropyrimidine including:

• Gastrointestinal cancers, including colorectal cancer, anal cancer, some stomach cancers
• Breast cancer
• Lung cancer
• Esophageal cancer
• Head and neck cancer

Other cancers also receive this treatment:

• Hepatobiliary cancers (liver or gallbladder)
• Ovarian, fallopian tube, or peritoneal cancers
• Neuroendocrine (islet cell tumors)
• Pancreatic cancer

Chemotherapy may be given through a tube placed in a vein as an intravenous (IV) medication or with a pill taken by mouth. The IV form, 5-flourouracil, is given either continuously over hours or as one dose over minutes. The pill, capecitabine, may be taken twice a day.

Heart Conditions Linked

Although rare, some people may have side effects linked to 5FU or capecitabine chemotherapies that affect their hearts. Up to 6 people out of 100 patients receiving this treatment have cardiac side effects.

While some people have no symptoms, others might feel a chest pressure or pain. If you feel this or other side effects, your doctor may do an electrocardiogram (ECG) that measures the electrical activity of your heart. The test can detect a possible heart attack.

Why Does Chemotherapy Cause Chest Pain?

Chest pain may happen because 5FU can affect the coronary arteries. These arteries sometimes spasm (coronary vasospasm) causing blood flow to decrease. When that happens, your heart muscle may not get enough oxygen and nutrients to function well.

If you feel chest pain after having chemotherapy, call 911 and seek emergency care.

Chest Pain (Angina)

The most common heart symptom due to 5FU chemotherapy is chest pain or pressure that lasts a short time and feels like you are having a heart attack. You may feel like your chest is being squeezed, or have a feeling of heaviness, pressure, weight, or tightness in your chest. You also may feel a burning in your chest. The pain can radiate to the shoulder, neck, jaw, arm or back. The chest pain may lessen when the chemotherapy is stopped. If you experience chest pain, call 911 or go to the emergency room.

Irregular Heart Rhythms (Arrhythmias)

Normal heart function relies on a series of electrical events inside the heart that occur at the right time and in the right order. Chemotherapy with 5FU can damage the heart’s electrical system and disturb your heart rhythm. An irregular heart rhythm is called an arrhythmia. An arrhythmia can mean your heart rhythm is too fast or too slow. Your cancer doctor or treatment team may monitor your heart rhythm with an ECG.

Some patients may have palpitations — your heart beating rapidly and loudly in your chest — irregular heartbeat, skipped beats or other uncomfortable chest sensations. If you have these symptoms, feel lightheaded or dizzy, or if you faint while getting your chemotherapy, seek medical attention at once.

Heart Failure

Other less common complications from 5FU chemotherapy can include damage to the heart muscle causing the heart to weaken and not be able to pump blood well. This is known as a cardiomyopathy or heart failure and can result in fluid building up in your body causing:

• Swelling in the feet or legs
• Stomach or abdominal distension
• Difficulty breathing with exertion (such as going up a flight of stairs)
• Inability to lie flat on your back
• Waking up in the middle of the night feeling short of breath
• Sudden weight gain

If you experience any of these symptoms, talk to your doctor.

When Do Heart Side Effects Occur?

The timing of chest pain symptoms from 5FU chemotherapy depends on the type of chemotherapy (if it is given as an IV or as a pill) and how it is given (in one dose or continuous infusion).

IV infusion (5FU): When given in one dose (as a bolus), chest pain can occur during the infusion or a few hours afterward.

The continuous IV infusion is given over two to four days with a pump that you may take home. When given this way, the chemotherapy may reach certain parts of the body more slowly. Symptoms can occur between 12-72 hours after starting the infusion. With more cycles of continuous infusions, symptoms may begin earlier in the cycle, become more intense, and last longer.

Oral pill (capecitabine): The pill version, capecitabine, is processed by the body more slowly. As a result, the symptoms are like those experienced with continuous infusion. Side effects may be less intense and start 12-72 hours after starting the medicine.

How Will I Know If I Have Cardiotoxicity?

People who get heart symptoms or other problems from 5FU chemotherapy usually feel the side effects during the first or second cycles of treatment. Most people go through these chemotherapy regimens without heart complications.

If you don’t have symptoms during your first or second cycles, then it is unlikely you will have heart side effects later.

What Increases Your Risk of Cardiotoxicity?

5FU Risks

The way you receive the medicine can increase your likelihood of developing heart symptoms.

Other Risk Factors

Your personal risk factors may increase your likelihood of developing heart problems from 5FU chemotherapy.

History of Heart Disease: If you have coronary artery disease or blockages in your heart, you have a higher likelihood of developing cardiac symptoms from 5FU chemotherapy. They can even be life-threatening. Talk to your cancer doctor and your cardiologist (heart doctor) about the potential heart side effects of these medications.

A history of coronary artery disease does not mean that you can’t be treated with the 5FU chemotherapy. It is important that all heart risk factors — including your blood pressure and cholesterol — are addressed before chemotherapy begins.

Heart Disease Risk Factors: If you don’t have coronary artery disease, other factors may increase your chance of developing cardiac complications. It is important to talk with your care team about what increases your risk including whether you have:

• Diabetes (type 1 or type 2)
• High blood pressure
• High cholesterol
• Obesity
• Family history of heart disease

If you smoke or use nicotine, it’s important to stop. Nicotine and tobacco can increase your risk of developing spasm of the heart arteries (coronary vasospasm).

When to Call a Doctor

If you have chest pain with the 5FU chemotherapy, you should stop the drug at once and seek medical care. If you are in the hospital or a chemotherapy suite, tell your care team right away. If you are at home, go to the nearest emergency room.

As always, if you are having severe chest pain at any time, call 911 seek and emergency care.

It also is important to seek medical attention if you experience palpitations, lightheadedness, dizziness, or feel like you are going to faint.

During chemotherapy, you will see your cancer doctor, oncology nurses, and other health professionals often. Be sure to talk to them about any symptoms you notice.

Exams and Tests

What types of heart tests might I need before starting cancer treatment?

You likely will get a baseline ECG before starting chemotherapy. Be sure to talk with your oncologist or cardiologist about your heart history. You also will discuss what other tests, if any, are needed.

What types of heart tests might I have to detect fluoropyrimidine cardiotoxicity?

If you have chest pain, you may get tests to check for heart muscle damage. Knowing when the symptoms started and what type of chest pain you are feeling will be important. Tests you may have:

• Lab tests (blood work) to look for heart muscle damage
• ECG
• Ultrasound of the heart called an echocardiogram
• Chest X-ray
• Computed tomography (CT) scan or the coronary arteries (coronary CT angiogram)
• Stress testing
• Cardiac catheterization

These tests help assess the overall health of your heart arteries. You may need more testing or procedures if the tests show that you have blockages in your heart because of pre-existing coronary artery disease or your cardiac risk factors. To learn more, go to What Increases Your Risk.

Prevention

What steps can I take to help reduce my risk of developing cardiotoxicity?

There is no way to know for sure who might develop heart problems from 5FU chemotherapy. However, people who already have heart risk factors or coronary artery disease — or both — have a higher likelihood of cardiotoxicity. During cancer treatment and for your overall health, it’s a good idea to follow heart-healthy behaviors.

CardioSmart has more resources about how to eat better, move more, or stop smoking.

Blood Pressure

Blood pressure control is important during your cancer treatment and for your overall health. Your goal for blood pressure depends on your age and other health problems. Your blood pressure will be checked at every visit during your treatment.

If you are concerned that your blood pressure is too high or too low, you may want to check your blood pressure at home and bring those readings to your health visits.

The medications to treat 5FU or capecitabine cardiotoxicity are also ones that can affect your blood pressure. These medications (anti-anginals) work to stop coronary vasospasm. If you have chest pain, your doctor may give you one or more of these medications.

What steps can you take to help reduce your risk of developing cardiotoxicity before, during and after radiation therapy? It’s important to take care of your heart:

• Make lifestyle changes to improve your heart health
• Stop smoking
• Control your blood pressure and cholesterol levels

Well-controlled blood pressure is important during cancer treatment, and the goal blood pressure depends on your age and other medical problems. Due to some of the changes that cancer treatment may have on your diet, or other medications such as steroids that may be administered with chemotherapy or radiation treatment, your blood pressure may run higher or lower than usual during treatment. Therefore, it is not uncommon for people to require blood pressure medicine in lower or higher amounts during their cancer treatment.

Your blood pressure will be checked at every appointment during your treatment. If you are concerned that it is too high or too low, you can check your blood pressure at home and bring those readings with you to your appointments.

Radiation can cause atherosclerosis—the buildup of plaque in the arteries of the heart—to occur at a faster rate than would be expected naturally. We know that cholesterol also contributes to the development of atherosclerosis. Your primary health care professional or oncologist can check a fasting cholesterol panel, a type of blood test, and help you decide whether treatment of cholesterol will be helpful to you.

Medicines

Currently, no medications have been shown to protect the heart from side effects of radiation treatment. However, with modern-day techniques aiming to limit cardiac exposure, it is expected that only a small fraction of patients will have long-term side effects of radiation.

Also, medications that treat underlying heart disease (coronary disease, heart failure) and risk factors (high blood pressure, high cholesterol) should be given to patients who also have those conditions.

Limit Exposure

Remember that newer radiation techniques appear to reduce the risk of radiation-induced cardiotoxicity.

History of Heart Disease

Patients with underlying medical issues that are risk factors for heart disease, such as diabetes, high blood pressure, smoking, obesity, and high cholesterol, have an increased risk of developing heart disease after receiving radiation. Visit CardioSmart’s resources to learn more about these health conditions and find out what you can do to improve your heart health.

Studies in cancer patients also suggest that increased physical activity decreases the risk of developing heart disease. Visit CardioSmart’s Move More section to learn about exercise and heart disease.

Learn more about common risk factors:

• Smoking
• Diabetes
• High Blood Pressure
• High Cholesterol
• Obesity
• Family history

When to Call a Doctor

During radiation treatment, you will see your radiation oncologist at least once a week to watch for any concerning symptoms. Typically, a radiation follow-up will occur between one to three months after completion of your treatment and then may rotate with other health care professionals.

Your radiation oncologist may want to follow up with you every three to six months for the first few years after your treatment ends, or he/she may have you follow up with your other oncologists. The schedule for follow-up appointments depends on your doctor and your type of cancer. Make sure to discuss long-term care before completing your radiation so you understand when you will need to see your doctor.

As always, if you are having severe chest pain at any time, you should seek emergency care and call 911.