Meet The Professors: Acute Myeloid Leukemia Edition, 2017 (Video Program) - Video 23Approach to patients with a low LVEF or history of heart failure
1:57 minutes.
TRANSCRIPTION:
DR LOVE: Rich, how do you approach, let’s say, the younger older patient, like — DR STONE: Like me? My age? DR LOVE: — 60, 65, 70, with a low ejection fraction or a history of heart failure? DR STONE: Sure. Obviously, individualization is really required in that kind of a patient. Again, it comes back to a combination of fitness for chemo and disease biology. So if the disease biology is favorable, I would give them standard chemo or something or if EF wasn’t, like, 10%. Even if it’s compromised, I would call a cardiologist, try to get them through, because the biggest risk in that patient is not heart failure but death from leukemia. And they can still be cured. So I’d want to be aggressive. DR COLE: What level are you comfortable at, 30%, 20% where you push on? DR STONE: I don’t know if there’s an absolute level. I mean, as you know, some people with EFs of 20% can play softball, and other people with EFs of 30% are bedridden. So it really depends on the patient and other features. I would ask my cardiologist. They’d probably get a cardiac MRI and all kinds of fancy stuff that might help me decide. But in general, I would look at the disease biology again and say, “If this patient’s a person that has a chemoresponsive disease, I’m going to tend to give the chemo.” If they have a chemo-unresponsive disease, like unfortunately most older adults do, I would tend to use hypomethylating agents for that patient. DR LOVE: How do you approach it yourself in your own practice? Suzanne, how often do you see this? DR COLE: So I don’t have a ton of patients who come in with even borderline ejection fractions. I do have to say, being in the community, not being at an academic center where I have, like, more protection from cardiologists that will swoop in and validate borderline decisions, I think that I would be a little less likely to treat someone with an anthracycline if they’re not meeting standard criteria just because of the litigious society that we live in. Granted, they’re probably going to die of their leukemia more likely than of heart failure issues, but that plays a role into how I think about these things. |