Acute Coronary Syndrome and Cancer　― Cardio-Oncology in the Super Aged Society in Japan ―

Japan’s super-aged society continues to grow older. Moreover, the number of patients with cancer is increasing. Based on 2019 data, approximately 66% of men and 51% of women in Japan are diagnosed with cancer during their lifetime.¹ In such circumstances, cardio-oncology, which combines cancer and cardiovascular disease, has developed into a new academic field.

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In the past, cancer prognosis was poor. However, with advances in surgery and therapeutic agents, such as immune checkpoint inhibitors, a combination of therapies is expected to either cure or provide long-term survival in an increasing number of patients with cancer. The number of patients who develop cardiovascular diseases during or after cancer treatment has also increased significantly, and cancer therapy-related cardiovascular toxicities have been reported.² Cardiac conditions may be exacerbated by cancer therapy, and the number of hospitalizations due to heart failure and thrombosis has been reported to be significantly greater in patients who experienced treatment for cancer. Moreover, it has been suggested that immune checkpoint inhibitors are associated with atherosclerotic plaque progression.³

In super-aged societies, cancer treatments are often performed in older patients. In addition to cancer, age is a risk factor for cardiovascular diseases, such as heart failure, coronary artery disease, and atrial fibrillation. Most anticancer agents and radiation therapy damage the heart and blood vessels and cause other injuries that result in the development of cardiovascular diseases in older people.² In addition, there is a causal relationship between cardiovascular disease and cancer, which can be explained by shared risk factors, including aging, diabetes, obesity, and smoking.⁴ These phenomena may contribute to the complexity of coronary arteries in patients with acute coronary syndrome (ACS) following a cancer diagnosis. We have to consider the fact that in patients with cancer, a typical clinical presentation can be missed due to the cancer itself or analgesics,⁵ as well as comorbidities such as diabetes and chronic kidney disease. In addition, distinguishing between type 1 and type 2 myocardial infarction (MI) is sometimes difficult in patients with ACS and a history of cancer.

The US National Inpatient Sample database, with over 6.5 million patients, has reported that approximately 10% of patients with acute MI have either a current or historical diagnosis of cancer.⁶ In Japan, a similar trend was observed in the study by Takeuchi et al.⁷ In that study, the authors assessed the impact of cancer history on future cardiovascular events in Japanese patients with MI undergoing coronary revascularization.⁷ The J-PCI OUTCOME study evaluated 20,042 patients with ACS who underwent percutaneous coronary intervention (PCI) in 2017.⁸ In that study, the overall 1-year incidence of all-cause mortality was 7.3% in patients with ST-elevation MI (STEMI), 7.1% in those with non-STEMI (NSTEMI), and 3.6% in those with unstable angina (UA).⁸ In addition, non-cardiac deaths occurred in 2.6%, 2.8%, and 2.0% of patients with STEMI, NSTEMI, and UA, respectively.⁸ Although the precise cause of deaths was unknown in the J-PCI OUTCOME study because of study limitations, a relatively large number of non-cardiac deaths could be due to cancer. From this perspective, the findings of the study by Takeuchi et al.⁷ provide us details on MI patients with a history of cancer. This finding is clinically significant.

Regarding the management of ACS in patients with cancer, both bleeding and ischemic risks are concerns after PCI (Figure). Patients with ACS and cancer often present with chronic kidney disease, frailty and poor nutritional status. These variables are well-known major factors for high bleeding risk in Japan.⁹ Therefore, it is essential for interventionalists to perform appropriate PCI for ACS to avoid thrombotic complications and to provide appropriate antithrombotic therapy.^2,9,10

Figure.

Acute coronary syndrome (ACS) and cancer: Various factors should be considered in ACS patients with a history of cancer. CKD, chronic kidney disease; PCI, percutaneous coronary intervention.

In Japan, the Cancer Control Act was enacted in April 2007. Based on this Act, various strategies have been implemented, resulting in a substantial decrease in cancer prevalence and mortality rates. Regarding cardiocerebrovascular diseases, the Cerebrovascular and Cardiovascular Act was enacted in December 2019. Based on that law, the Disease Control Act of the Japanese National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Diseases has been established.¹¹ There are many issues to be resolved in the cardio-oncology field. To prolong healthy life expectancy, it is important for experts in both fields to collaborate and take actions together. In addition, in the case of patients with cardiovascular disease and a history of cancer who have a relatively short life expectancy, palliative care and shared decision making should be considered in clinical practice.

Disclosures

H.I. has received lecture fees from AstraZeneca Inc., Bayer Pharmaceutical Co., Ltd., Boehringer Ingelheim Japan, Bristol-Myers Squibb Inc., Daiichi-Sankyo Pharma Inc., MSD K.K., Mitsubishi Tanabe Pharma Co., Ltd., Mochida Pharmaceutical Co., Ltd., Novartis Japan, and Pfizer Japan Inc. H.I. has also received scholarship funds or donations from Boehringer Ingelheim Japan, Bristol-Myers Squibb Inc. and Pfizer Japan Inc. H.I. is a member of Circulation Journal’s Editorial Team.

IRB Information

None.

References

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