ONS Connect - December 2008 - (Page 19) heart failure. Ifosphamide is structurally related to cyclophosphamide and can cause arrhythmias and death in some patients. Taxanes: Of the taxanes, the highest incidence of cardiotoxicity is associated with paclitaxel, which has been reported to cause sinus bradycardia, heart block, and premature ventricular contractions. Researchers have found less evidence for docetaxel-induced cardiotoxicity. Trastuzumab: Trastuzumab cardiotoxicity usually occurs as type II chemotherapy-related cardiac dysfunction, which is mostly reversible with discontinuation of treatment. Trastuzumab also increases the cardiotoxic effects of other drugs, such as paclitaxel, and it is not recommended for use in combination with anthracyclines. Trastuzumab’s black box warning calls for evaluation of cardiac function throughout treatment and discontinuation of therapy if cardiomyopathy or decreased left ventricular ejection fraction (LVEF) are observed. Lapatinib: The lapatinib package insert warns that decreases in LVEF have been reported with use of the drug and that normal LVEF should be confirmed prior to the start of treatment. LVEF should be monitored throughout therapy. Imatinib mesylate: Approximately 2%–6% of patients receiving imatinib for chronic myelogenous leukemia develop peripheral edema, pleural effusion, pericardial effusion, pulmonary edema, or ascites. The current warning for imatinib indicates that patients with known heart disease or risk factors for heart failure should be monitored closely. Bevacizumab: Several cardiovascular effects have been noted with bevacizumab, including hypertension, congestive heart failure, and arterial thromboembolic events. The U.S. Food and Drug Administration warns that the risk of stroke, myocardial infarction, angina, reversible posterior leukoencephelopathy, and fatal heart disease is increased in patients receiving bevacizumab. For a full list of chemotherapy and targeted agents associated with cardiotoxicity, see Figure 1. Nursing Management and implications Nurses should watch for symptoms of cardiotoxicity in patients receiving chemotherapy, especially if they have a history of cardiovascular disease. Patients with heart failure may present with dyspnea, orthopnea, activity intolerance, rapid weight gain, fatigue, or edema. Nurses should take a complete medical history, focusing on the following health conditions. • Pulmonary, renal, thyroid, liver, and cardiovascular disease • Uncontrolled hypertension • Cardiac arrhythmias • Anemia • Exposure to radiation therapy • Prior chemotherapy or targeted therapy use • Alcohol use • Diabetes • Compliance with medications and diet A diagnosis of heart failure can be confirmed with laboratory tests, such as an electrolyte panel, complete blood count, thyroid and liver function, chest x-ray, electrocardiogram, B-type natriuretic peptide assay, and echocardiogram or radionuclide ventriculography. When monitoring patients with heart failure, nurses should watch for changes in patients’ functional status or fluid volume status and check patient weights at least three times per week. Treatment for heart failure includes lifestyle changes (e.g., quitting smok- figure 1. Chemotherapy and Targeted Agents That May increase Risk of Cardiotoxicity Chemotherapy • Anthracyclines • 5-fluorouracil/capecitbine • Cyclophosphamide/ifosphamide • Paclitaxel/docetaxel • Cisplatin • Mitomycin C • Busulfan • Bleomycin • Mitoxantrone • Etoposide • Vinca alkaloids Targeted Therapies • Trastuzumab • Lapatinib • Sunitinib • Sorafenib • Rituximab • Imatinib mesylate • Bevacizumab • Interferons/interleukins • Arsenic trioxide Note. Based on information from Viale & Yamamoto, 2008. ing and alcohol use, maintaining optimal blood pressure and weight, making dietary changes, increasing exercise), diuretic therapy, and initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. For more information on cardiovascular toxicity associated with cancer treatment, refer to the full article by Viale and Yamamoto (2008). ✱ Viale, P.H., & Yamamoto, D.S. (2008). Cardiovascular toxicity associated with cancer treatment. Clinical Journal of Oncology Nursing, 12(4), 627–638. December 2008 ONS CONNECT 19
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