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Screening for Coronary Artery Disease After Mediastinal Irradiation for Hodgkin's Disease

Paul A. Heidenreich, Ingela Schnittger, H. William Strauss, Randall H. Vagelos, Byron K. Lee, Carol S. Mariscal, David J. Tate, Sandra J. Horning, Richard T. Hoppe, Steven L. Hancock

From the Department of Medicine, Division of Cardiology; Division of Medical Oncology; Department of Radiology, Division of Nuclear Medicine; and Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA

Address reprint requests to Paul A. Heidenreich, MD, 111C Cardiology, Palo Alto VAMC, 3801 Miranda Avenue, Palo Alto, CA 94034; e-mail: heiden{at}stanford.edu

Purpose Incidental cardiac irradiation during treatment of thoracic neoplasms has increased risks for subsequent acute myocardial infarction or sudden cardiac death. Identifying patients who have a high risk for a coronary event may decrease morbidity and mortality. The objective of this study was to evaluate whether stress imaging can identify severe, unsuspected coronary stenoses in patients who had prior mediastinal irradiation for Hodgkin's disease.

Patients and Methods We enrolled 294 outpatients observed at a tertiary care cancer treatment center after mediastinal irradiation doses 35 Gy for Hodgkin's disease who had no known ischemic cardiac disease. Patients underwent stress echocardiography and radionuclide perfusion imaging at one stress session. Coronary angiography was performed at the discretion of the physician.

Results Among the 294 participants, 63 (21.4%) had abnormal ventricular images at rest, suggesting prior myocardial injury. During stress testing, 42 patients (14%) developed perfusion defects (n = 26), impaired wall motion (n = 8), or both abnormalities (n = 8). Coronary angiography showed stenosis 50% in 22 patients (55%), less than 50% in nine patients (22.5%), and no stenosis in nine patients (22.5%). Screening led to bypass graft surgery in seven patients. Twenty-three patients developed coronary events during a median of 6.5 years of follow-up, with 10 acute myocardial infarctions (two fatal).

Conclusion Stress-induced signs of ischemia and significant coronary artery disease are highly prevalent after mediastinal irradiation in young patients. Stress testing identifies asymptomatic individuals at high risk for acute myocardial infarction or sudden cardiac death.

Supported by Grant No. 1 RO1 CA63001 from the National Cancer Institute, National Institutes of Health. P.A.H. was supported by a Career Development Award from the Veterans' Affairs Health Services Research Development Office.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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