放射性心脏损伤指南发布

欧洲心脏病学会(ESC)和美国超声心动学会(ASE)建议，应当对接受放疗的癌症患者进行基线心脏功能检查和心脏疾病常规筛查。该指南7月16日发表在《欧洲心脏杂志-心血管影像》上(Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40)。

这两个专业团体建议，患者接受放疗前应进行基线超声心动图、心脏检查和风险因素筛查，每年应进行心脏病史和身体检查，以及早发现新发心脏疾病。

比利时列日大学医院心脏病学教授、推荐指南工作组组长Patrizio Lancellotti博士在在声明中指出，10%~30%的放疗患者在放疗后10年内出现放射性心脏损伤(RIHD)，包括慢性心包炎、心肌纤维化、冠心病、主动脉钙化以及瓣膜关闭不全或狭窄。希望通过筛查能够早期发现RIHD，但目前筛查尚未常规化。“我们撰写专家共识，旨在提醒大家不应忽视RIHD，因为RIHD发病率正随着癌症患者生存率的提高而不断增加。”

Lancellotti博士称，虽然放疗的靶向性日益提高，且剂量也比以前有所降低，但患者的RIHD风险仍在增加，特别是心脏位于照射野之内的患者。这种情况见于淋巴瘤、乳腺癌以及食管癌放疗患者。颈癌放疗患者也有风险，因为病变部位可能在颈动脉，从而增加卒中风险。

工作组认为，避免和保护心脏照射的靶向放疗和照射野轮换，仍是心脏并发症最重要的干预保护措施。

工作组建议，病史和身体检查确认无心脏病证据的高危患者，应当每5年接受1次超声心动图筛查，每5~10年接受1次无创心脏负荷测试；低危患者应当每10年接受1次超声心动图筛查。一旦发现心脏损伤，应视具体情况进行超声心动图、心脏磁共振成像或颈动脉超声等常规监测。

高危患者包括接受放疗的年轻患者，具有心血管危险因素或已有心脏疾病的患者，以及接受大剂量放疗(＞30 Gy)、同时接受化疗、放疗时未采取防护措施、接受前胸或左胸放疗的患者。

工作组成员是在综述分析大量文献后提出上述推荐意见的。

作者报告无利益冲突，该工作也无外部经费资助。

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By: M. ALEXANDER OTTO, Cardiology News Digital Network

Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.