Ponencia presentada por la Dra. Almudena Castro Conde en el sexto webinar del programa COH18 (Cardio-onco-hematología), titulado ‘Cardio-oncología en la práctica clínica’ y realizado en la SEC el 20 de junio de 2018.

1. cardiotoxicidad - rehabilitación cardiaca
Almudena Castro
Unidad de Rehabilitación Cardiaca
Servicio de Cardiología
Hospital Universitario La Paz

3. Integrative Cancer Therapies 2011 10(1) 47–57
SED TM WR
10 weeks exercise preconditioning period
DOX vs SAL

4. Integrative Cancer Therapies 2011 10(1) 47–57
P < .05 P < .05 P < .05- 21%
Echocardiographic parameters
* **
* P< .05
* * *
* P< .05 48%%
37% 47%
38%

5. SED 2 weeks EXE
DOX vs SAL
Muscles, Ligaments and Tendons Journal 2017;7 (3):418-425

6. Muscles, Ligaments and Tendons Journal 2017;7 (3):418-425
Myogenic Regulatory Factor Expression
Soleus (A) Extensor digitorum longus (B) Diaphragm (C)
† Main exercise effect (p<0.05)
‡ Main drug effect (p<0.05)
* Significantly greater than SED+DOX

7. Miotoxicity
Cardiotoxicity

8. Circulation Research. 2016;118:1008-1020

9. Antioxid Redox Signal. 15(9): 2543-2563

10. VO2 = Q x A-VO2 Dif
VO2 = Q x A-VO2 Dif
Hypothesis:
Exercise
could prevent
direct cardiotoxic effects
of cancer therapy
Exercise
May be protective against
the harmful effects of
chemotherapy

11. strongest
predictor
VO2 peak
and
risk of cancer-
related deathAll cause mortality Decreased mortality
VO2
peak
N Engl J Med. 2002;346:793–801
Med Sci Sports Exerc. 2009;41:742–8 JAMA. 1995;273:1093–8
Evidence of a relationshipVO2 peak Non-cancer populations

12. After treatment completionThe course of chemotherapy 12 to 24 weeks
J Clin Oncol. 2007;25:4396–404 Lancet Oncol. 2009;10:598–605 Circulation. 2001;104:1358–66
5–10 %
VO2
22 %
VO2
VO2
30 y of normal agingsedentary controlswomen breast cancer

13. Paciente de 45 años:
No hábitos tóxicos
Linfoma de Hodgkin 2002: 6 ciclos de ABVD en remisión
Eco 2015: FEVI normal
Consulta CardioTox:

14. Eco feb/2017: DSVI ( 28%)

15. Feb/2017: GF II- III NYHA
Optimización de tratamiento
NT-ProBNP 2557
Consulta CardioTox:
Abril/2017: Persisten síntomas
NT proBNP en descenso
Se remite a RhC

16. Rehabilitación Cardiaca
VT1
1’18’’
91 lpm
9,2 ml/min/kg
43% predicho
VT2
5’51’’
103 lpm
12 ml/min/kg
57% predicho

17. Pronóstico cpet según V02 en IC
WEBER
Gravedad VO2 max/kg/min Vo2/kg/min en UA Clase funcional Índice cardiaco
(l/min/m2)
Ninguna >20 >14 A >8
Leve 16-20 11-14 B 6-8
Moderada 10-16 8-11 C 4-6
Grave 6-10 5-8 D 2-4
Muy grave <6 <4 E <2
VT1

19. Rehabilitación Cardiaca
VT1
6’01’’
99 lpm
11,1 ml/min/kg
52% predicho
VT2 máx
10´01’’
117 lpm
18,2 ml/min/kg
68 % predicho

20. Pronóstico cpet según V02 en IC
WEBER
Gravedad VO2 max/kg/min Vo2/kg/min en UA Clase funcional Índice cardiaco
(l/min/m2)
Ninguna >20 >14 A >8
Leve 16-20 11-14 B 6-8
Moderada 10-16 8-11 C 4-6
Grave 6-10 5-8 D 2-4
Muy grave <6 <4 E <2
VT1

21. Eco mayo /2017: DMVI

24. JAMA Intern Med. doi:10.1001/jamainternmed.2016.1548

25. Ejercicio físico sí ….pero
¿ Cuándo? ¿Cuánto? ¿ Dónde?

26. ¿ Cuándo ?

27. J Clin Oncol 2015 (33):1918-1927
Cardiorespiratory
fitness
Upper muscle
strength
Lower muscle
strength
Fatigue
Primary outcome measures:
Randomly assigned
(n = 230)
OnTrack (n =
76)
Onco-Move (n = 77)
Usual care
(n = 77)

28. Cancer Epidemiol Biomarkers Prev 2005;14(7).

29. J Clin Oncol 2015 (33):1918-1927(P .002)
Rates of and Reasons for Chemotherapy Dose Reduction

30. Curr Oncol Rep (2016) 18: 12
Direct evidence of the benefit of exercise is currently
limited.
Improvements in:
• cardiorespiratory fitness
• muscle strength and lean mass
• body composition
• cardiovascular risk factors
• bone health

31. ¿ Cuánto ?

32. Summary of the ACSM Exercise Guidelines for Ca Survivors
J Support Oncol. 2012 Sep-Oct; 10(5): 171–177

33. Rating the evidence-base supporting the ACSM
Exercise Guidelines for Cancer Survivors.
J Support Oncol. 2012 Sep-Oct; 10(5): 171–177

34. ¿ Dónde ?

35. Leclerc et al. Archives of Public Health (2016) 74:50
Supportive care
interventions
Psychological and
behavioral
Physical
activity/rehabilitation
Physiotherapy
Diet

36. Supervised
Home- Based
Program
Psychological
and
behavioral

37. https://www.cancer.org/treatment/survivorship-during-and-after-
treatment/staying-active/physical-activity-and-the-cancer-patient.html

38. A supervised, moderate to high-intensity + resistance and aerobic
exercise program is most effective
A home-based, low-intensity physical activity program represents a
viable alternative
RCTs with long-term follow-up are required to confirm that the
beneficial effect of exercise
For patients with cancer undergoing
adjuvant Ctx and/or Rtx: