Radiation heart disease is commonly overlooked in patients who have a remote history of radiation therapy. Cardiologists should work to uncover radiation treatment history from patients during clinical encounters. The following case illustrates the importance of uncovering this important history and knowing the time course and different manifestations of radiation-induced cardiovascular disease.
A 49-year-old Caucasian woman presented to our heart failure clinic for a follow-up visit to discuss chest pain. Her history included nonischemic cardiomyopathy presumed secondary to remote chemotherapy, heart failure with reduced ejection fraction (ejection fraction 20-25%), Hodgkin’s lymphoma in remission (20 years ago) after treatment with chemotherapy and chest radiation, and breast cancer (5 years ago) managed with double mastectomy and chemotherapy.
The patient stated that her chest discomfort started 1 year ago. It was substernal and intermittently radiating to her left shoulder, with pain intensity and frequency waxing and waning. The discomfort worsened with exertion and improved with rest. She had a recent acute congestive heart failure exacerbation with significantly worsened chest pain that improved with oral diuretics.
No record was available of the exact chemotherapy and radiation dosages given for her Hodgkin’s lymphoma or breast cancer. A coronary computed tomography angiography (CCTA) done about 8 months prior showed moderate coronary atherosclerosis with moderate stenosis of the left main coronary artery, which was not deemed clinically responsible for her angina.
We proceeded with selective coronary angiography due to her typical symptoms for coronary atherosclerotic vascular disease, which demonstrated a severe (95%) ostial left main disease.
What would you do next?
Due to the low Syntax score, the interventionalist performed left main stenting guided by intravascular ultrasound (Figure 1).
On follow-up, the patient reported markedly improved chest pain and exercise capacity.
Dr. Bhimaraj is a speaker for Abbott Laboratories, Abiomed, and AstraZeneca. He serves as an advisor to Maquet and CareDx. The other authors have no competing interests to declare.
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