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Open access

Sadie Bennett, Duwarakan Satchithananda, and Gareth Law

Summary

A 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus.

Learning points:

  • Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus.

  • A large and mobile LV thrombus is associated with an increased risk of embolic events.

  • Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients.

  • NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults.

  • To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus.

  • Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.

Open access

Sadie Bennett, Arzu Cubukcu, Chun Wai Wong, Timothy Griffith, Cheryl Oxley, Diane Barker, Simon Duckett, Duwarakan Satchithananda, Ashish Patwala, Grant Heatlie, and Chun Shing Kwok

Background

Anthracycline agents are known to be effective in treating tumors and hematological malignancies. Although these agents improve survival, their use is associated with cardiotoxic effects, which most commonly manifests as left ventricular systolic dysfunction (LVSD). As such, guidelines recommend the periodic assessment of left ventricular ejection fraction (LVEF). However, as diastolic dysfunction likely proceeds systolic impairment in this setting, the role of Tei index may offer additional benefit in detecting subclinical LVSD.

Methods

We conducted a systematic review to investigate the evidence for the use of Tei index in assessing subclinical cardiotoxicity in patients receiving anticancer agents. A search of Medline and EMBASE was performed and relevant studies were reviewed and narratively synthesized.

Results

A total of 13 studies were included with a total of 800 patients (mean age range 46–62 years, percentage of male participants ranged from 0–86.9%). An increase in Tei index was observed in 11 studies, which suggested a decline in cardiac function following chemotherapy. Out of these, six studies indicated that the Tei index is a useful parameter in predicting cardiotoxic LVSD. Furthermore, five studies indicated Tei index to be superior to LVEF in detecting subclinical cardiotoxicity.

Conclusions

Though there are some studies that suggest that Tei index may be a useful indicator in assessing subclinical anthracycline-related cardiotoxicity, the findings are inconsistent and so more studies are needed before the evaluation of Tei index is performed routinely in patients receiving chemotherapy.