BRIEF REPORT

Prevalence of Preexisting Cardiovascular Disease

in Patients With Different Types of Cancer: The
Unmet Need for Onco-Cardiology
Sadeer G. Al-Kindi, MD, and Guilherme H. Oliveira, MD

Abstract

Cancer and cardiovascular diseases (CVDs) share many of the same risk factors. Using a cloud-based
health care database, we identied patients with malignancies that often require cardiotoxic treat-
ments (leukemia/lymphoma and lung, breast, colon, renal, and head and neck cancers). We report
the prevalence of CVDs (coronary artery disease, carotid artery disease, peripheral vascular disease,
cerebrovascular disease, and heart failure) in those populations. Overall, CVD prevalences were 33%
for hematologic, 43% for lung, 17% for breast, 26% for colon, 35% for renal, and 26% for head and
neck cancers. Generally, patients with lung and hematologic malignancies had the highest preva-
lence of all types of CVDs. Of those with CVD, only half were referred to cardiologists and received
guideline-directed medical therapy. The prevalence of CVDs is unexpectedly high and suboptimally
managed in patients with cancer. There seems to be an opportunity for onco-cardiologists to
fulll this unmet need and help improve outcomes in patients with cancer and coexisting heart
disease.
2015 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2015;nn(n):1-3

From the Onco-

C
ancer and cardiovascular diseases hospitals between March 18, 2014, and March
Cardiology Program, and
(CVDs) share many of the same risk fac- 18, 2015. We then identied those diagnosed as Advanced Heart Failure
tors, geographically coexist, and are the having the most common types of cancer treated and Transplant Center,
leading causes of death in the United States.1 with potentially cardiotoxic interventions: Harrington Heart and
Vascular Institute,
Furthermore, patients with cancer and preexist- hematologic (leukemia and lymphoma), co- University Hospitals Case
ing CVD are at increased risk for cardiotoxicity lon, lung, breast, renal, and head and neck Medical Center,
when exposed to cardiotoxic agents, as well as cancers. We also identied lifetime diagnosis Cleveland, OH.

other cardiac events.2 Identication and treat-
ment of preexisting CVD may attenuate the
development of cardiotoxicity and other cardiac
events, thereby improving overall survival. We,
therefore, sought to investigate the prevalence
of preexisting CVD in patients with common
types of cancer.
We used a commercial electronic health
care database (Explorys, Explorys Inc), an
aggregate of electronic medical records
from outpatients and inpatients from 23 in-
tegrated health care systems in all 50 states
capturing data from 45 million patients.
This database uses Systematized Nomencla-
ture of MedicinedClinical Terms, which
have been validated previously. The details
of data capture and reporting are described
elsewhere.3 We selected patients aged 40
to 74 years who were seen by participating
of CVD (coronary artery disease, carotid
artery disease, peripheral vascular disease,
cerebrovascular disease, and heart failure),
visits to cardiologists, and prescriptions
written for antiplatelet therapy, statins,
b-blockers, and angiotensin-converting enzyme
inhibitors or angiotensin receptor blockers.
Of 6,989,240 patients aged 40 to 74 years
who had active medical records in the past
year, we identied 208,520 patients with com-
mon cancers that frequently require cardiotoxic
therapy: 93,850 (1.34%) had colon cancer,
32,060 of 3,988,310 (women) (0.80%) had
breast cancer, 48,910 (0.70%) had head and
neck cancer, 15,900 (0.23%) had lung cancer,
11,330 (0.16%) had hematologic cancer, and
6470 (0.09%) had renal cancer. The prevalence
of coronary artery disease ranged from 5.7%
(95% CI, 5.4%-5.9%) (breast) to 20.8% (95%

Mayo Clin Proc. n XXX 2015;nn(n):1-3 n http://dx.doi.org/10.1016/j.mayocp.2015.09.009 1

www.mayoclinicproceedings.org n 2015 Mayo Foundation for Medical Education and Research
 MAYO CLINIC PROCEEDINGS

43%

35%
33%

28%

26%
26%

21%
21%
20%

17%

17%

17%
16%

16%
13%

12%
12%

11%
11%

10%
9%

9%
9%

9%
7%
6%

6%

5%
5%
5%

4%
3%

3%
3%
3%
1%

Hematologic Lung Breast Colon Renal Head and neck

Coronary artery disease Carotid artery disease Peripheral vascular disease

Cerebrovascular disease Heart failure Any cardiovascular disease

FIGURE 1. Prevalence of cardiovascular diseases by type of malignancy.

CI, 20.2%-21.5%) (lung), of carotid artery dis-
ease ranged from 1.50% (95% CI, 1.4%-1.6%)
(breast) to 4.7% (95% CI, 4.3%-5.0%) (lung),
of peripheral artery disease ranged from 11.3%
(95% CI, 10.9%-11.6%) (breast) to 28.5%
(95% CI, 27.8%-29.2) (lung), of cerebrovascular
disease ranged from 4.8% (95% CI, 4.6%-5.0%)
(breast) to 12.9% (95% CI, 12.4%-13.4%)
(lung), and of heart failure ranged from 3.5%
(95% CI, 3.3%-3.7%) (breast) to 11.8% (95%
CI, 11.3%-12.3%) (lung) (Figure 1). Overall,
antiplatelet therapy, statins, b-blockers, and
angiotensin-converting enzyme inhibitors/
angiotensin receptor blockers were prescribed
to just less than half of all patients with CVD
(Figure 2). Also, only approximately half of
the patients with cancer and CVD were referred
to cardiology: breast cancer, 43%; hematologic
malignancies, 52%; lung cancer, 50%; colon
cancer, 50%; renal cancer, 54%; and head and
neck cancer, 48%. Last, the overall prevalence
of CVD in the present cohort was 26.6% (95%
CI, 26.4%-26.8%) vs 17.3% (95% CI, 17.2%-
17.3%) in 6,198,950 age-matched cancer-free
controls in Explorys (P<.001).
In this big data analysis, we found for
the rst time that patients diagnosed with
n n
2 Mayo Clin Proc.
common cancers have an unexpectedly higher
prevalence of CVD than the general population.
In addition, we found that the type and preva-
lence of CVD varies signicantly by cancer etiol-
ogy, providing data that serve to guide specic
CVD investigation in patients with different types
of cancer. Last, these ndings indicate that only
half of the patients with cancer and CVD are
treated with guideline-directed medical therapy
or are referred for cardiology consultation at the
time of cancer diagnosis.
Cardiovascular comorbidities not only nega-
tively impact outcomes of antineoplastic therapy
but also decrease long-term cancer survivor-
ship.4 In addition, patients with preexisting
CVD may be more susceptible to cardiotoxicity
and other cardiac events, either becoming
ineligible for treatment with certain agents5 or
requiring dose reductions and premature discon-
tinuation.6 The development of cardiotoxicity
has been reported to adversely affect outcomes
of patients with cancer,7 and its prevention
may be benecial to overall patient survival.
This analysis has limitations. First,
because we report only CVD that has been
diagnosed, therefore missing undiagnosed
CVD, the prevalence may be underestimated.
XXX 2015;nn(n):1-3 http://dx.doi.org/10.1016/j.mayocp.2015.09.009
www.mayoclinicproceedings.org
CARDIOVASCULAR DISEASE IN PATIENTS WITH CANCER

61%
55%
55%

55%

54%

54%
54%

54%

53%
52%
52%

52%
51%

51%
50%
50%

49%

49%
48%
48%
47%

45%

45%

44%

43%
41%

41%

40%
38%

38%
Hematologic Lung Breast Colon Renal Head and neck

Antiplatelet Statin -Blocker ACE/ARB Cardiologist

FIGURE 2. Management strategies in patients with cardiovascular disease by type of malignancy. ACE angiotensin-converting
enzyme inhibitor; ARB angiotensin receptor blocker.

Also, because this database has no information REFERENCES

on diagnostic criteria for CVD (eg, angiograms,
stress tests, ankle-brachial index, etc), the accu-
racy of this diagnosis cannot be ascertained.
Nevertheless, the large-scale nature of this anal-
ysis provides insights and raises questions that
need to be further investigated.
In conclusion, the prevalence of CVD in
patients diagnosed with cancer is high and
varies according to cancer etiology. There
seems to be an unmet need for better CVD
investigation and treatment that can be sup-
plied by onco-cardiologists.
Abbreviations and Acronyms: CVD = cardiovascular disease
Correspondence: Address to Guilherme H. Oliveira, MD,
Section of Heart Failure, Onco-Cardiology Program, and
Advanced Heart Failure and Transplantation Center,
Seidman Cancer Center and Harrington Heart and Vascular
Institute, University Hospitals and Case Western Reserve
University School of Medicine, 11100 Euclid Ave, Cleveland,
OH 44106 (guilherme.oliveira@uhhospitals.org).
1. Herrmann J, Lerman A, Sandhu NP, Villarraga HR, Mulvagh SL,
Kohli M. Evaluation and management of patients with heart dis-
ease and cancer: cardio-oncology. Mayo Clin Proc. 2014;89(9):
1287-1306.
2. Jensen S, Srensen J. Risk factors and prevention of cardiotoxicity
induced by 5-uorouracil or capecitabine. Cancer Chemother
Pharmacol. 2006;58(4):487-493.
3. Kaelber DC, Foster W, Gilder J, Love TE, Jain AK. Patient char-
acteristics associated with venous thromboembolic events: a
cohort study using pooled electronic health record data. J Am
Med Inform Assoc. 2012;19(6):965-972.
4. Kravchenko J, Berry M, Arbeev K, Kim Lyerly H, Yashin A,
Akushevich I. Cardiovascular comorbidities and survival of lung
cancer patients: Medicare data based analysis. Lung Cancer.
2015;88(1):85-93.
5. Hershman DL, McBride RB, Eisenberger A, Tsai WY,
Grann VR, Jacobson JS. Doxorubicin, cardiac risk factors,
and cardiac toxicity in elderly patients with diffuse B-cell
non-Hodgkins lymphoma. J Clin Oncol. 2008;26(19):3159-
3165.
6. Wang SY, Long JB, Hurria A, et al. Cardiovascular events, early
discontinuation of trastuzumab, and their impact on survival.
Breast Cancer Res Treat. 2014;146(2):411-419.
7. Oliveira GH, Mukerji S, Hernandez AV, et al. Incidence, predic-
tors, and impact on survival of left ventricular systolic dysfunction
and recovery in advanced cancer patients. Am J Cardiol. 2014;
113(11):1893-1898.

Mayo Clin Proc. n XXX 2015;nn(n):1-3 n http://dx.doi.org/10.1016/j.mayocp.2015.09.009 3

www.mayoclinicproceedings.org