Cardiovascular Disease (CVD)

Hodgkin Lymphoma often appears in the lymph nodes in the neck and in the chest, or “mantle” area. Therefore, this part of the body is more likely to sustain damage when treated with radiation. The kind of radiation that was used years ago, such as cobalt radiation, was given in much larger doses than what is common today, and was not as precise in scope- meaning that any organs that were nearby, like the heart and lungs, were especially vulnerable. Radiation treatments to the neck also increases the risk of having a stroke, as the blood vessels in the neck that supply blood and oxygen to the brain may have been damaged.

Cardiac Disease is one of the more serious Late Effects for Hodgkin’s survivors. They are about seven times more likely to develop heart disease than the general population. Both radiation and chemotherapy can damage the heart, which means that survivors who received a combination of these therapies may be at even greater risk.

Risk factors for CVD in Hodgkin’s survivors:

Heart and vascular issues that are a result of radiation are often referred to as “Cardiotoxicity” and can develop within weeks or months after radiation but often not until years later. Hodgkin’s survivors might exhibit few if any symptoms of cardiac disease for quite a while, and yet still be at risk. The overall risk of cardiotoxicity for Hodgkin’s survivors depends on how much radiation they received (overall dose, given in “Grays,” or “GY’s”), where it was given (i.e. neck, chest area, etc.), the age at treatment, and whether or not shielding techniques were used (procedures to limit exposure to adjacent tissue, such as the use of lead shielding). In general, survivors who were treated with radiation in their teens and early 20’s are at greater risk for cardiotoxicity. Survivors who received radiation doses of 30 Gy’s or more are also at greater risk.

In addition to radiation treatment, certain chemotherapy drugs, in particular “anthracyclines,” are also known to produce heart damage. As many long-term Hodgkin’s survivors may have had a combination of these therapies (chemotherapy and radiation), their risk of heart disease could be increased.

The chances of having heart disease after cancer treatment may be significant for those who have other risk factors, such as diabetes, high blood pressure, high cholesterol, a history of smoking, being overweight, or having a history of heart disease in the family.

These are some of the specific cardiac problems that Hodgkin’s survivors may have:

Congestive Heart Failure (CHF)

Congestive Heart Failure, commonly referred as “heart failure,” occurs when the heart muscles don’t pump blood as well as they should. As a result, fluids build up in the heart, forcing the heart to pump less efficiently.

Symptoms of CHF include shortness of breath (dyspnea), weakness and fatigue, swelling in the legs, ankles and feet, irregular heartbeat, weight gain from fluid retention, lack of appetite and nausea, and chest pain

Heart Valve Disease – Heart Valve Disease occurs when one or more of the four heart valves (aortic, mitral, tricuspid, and pulmonary valves) are not working properly. In Hodgkin’s survivors, the most common cause of this is damage from radiation treatments, chemotherapy treatments, or both. The heart valves may become scarred, stiff, or “sclerotic.” This is referred to as “Valvular stenosis.” The result of stenosis is that the valves do not open and close properly. This can cause “leaky” valves or “regurgitation”, where blood actually flows back into the heart chamber instead of out of it.

Symptoms of Heart Valve Disease include shortness of breath, weakness and dizziness, a feeling of pressure or discomfort in your chest, rapid or irregular heartbeat, swelling of ankles, feet, or abdomen, and weight gain.

Arrhythmia (Heart rhythm changes) -Arrhythmia refers to a disturbance in the rhythm of the heart. It means that the electrical impulses that coordinate the heartbeat aren’t working properly. Radiation to the chest area can damage this electrical (“conduction”) system. There are two types of arrhythmias, “Tachycardia,” which is a fast heartbeat (a resting heart rate greater than 100 beats per minute, and “Bradycardia,” which is a slow heartbeat (a resting heart rate of less than 60 beats per minute).

Symptoms of Arrhythmia include a “fluttering” in your chest, a feeling of a “racing ” heart, chest pain, shortness of breath, lightheadedness, sweating, fatigue, and anxiety.

Pericarditis and Pericardial Effusion:

Pericarditis occurs when the pericardium, the thin membrane surrounding the heart, becomes swollen or inflamed. This in turn causes the layers of the pericardium to rub against each other, resulting in sharp chest pains. “Myopericarditis” is a condition where the inflammation becomes significant and spreads to the heart muscle itself.

Symptoms of Pericarditis: chest pain, usually occurring behind the breastbone or in the left side of the chest- it often gets worse when you cough, lie down, or take a deep breath; abdominal or leg swelling, cough, fatigue, low-grade fever, racing heartbeat

Pericardial effusion is the buildup of excess fluid in the pericardium. This can put pressure on the heart, affecting the ability of the heart to work properly.

Symptoms of Pericardial Effusion are similar to those of Pericarditis and may also include a feeling of “fullness” in the chest.

Cardiomyopathy: -Cardiomyopathy is a disease of the heart muscle, or “myocardium.” It is a progressive disease, where the heart becomes abnormally enlarged, thickened, and/or stiffened. It makes the heart muscle’s ability to pump blood less efficient, causing the heart to work harder than it should. Cardiomyopathy can also cause abnormal heart rhythms (Arrhythmia).

Symptoms of Cardiomyopathy include shortness of breath, especially after physical exertion, fatigue, and swelling in the abdomen, legs, feet, ankles, and veins in the neck

Coronary Artery Disease and Atherosclerosis: -Coronary Artery Disease (CAD) is a condition where the heart is unable to get enough blood. It occurs when the blood vessels that carry blood to the heart muscles, the coronary arteries, become narrowed and hardened due to the build up of plaque (fatty deposits in the artery walls).

The process of these blood vessels becoming narrow and less elastic is called “atherosclerosis.” If the arteries or vessels develop a significant blockage, serious damage to the heart may occur, resulting in a heart attack or “myocardial infarction”.

Symptoms of Coronary Artery Disease: Coronary artery disease often develops slowly, even over a period of years or decades. Symptoms may not be noticed for some time, if at all. It is possible to be unaware that you have CAD until you have developed a serious blockage. Symptoms of CAD include chest pain (angina), often occurring on the middle or left side of the chest. The chest pain may also feel like an intense pressure or tightness.

These symptoms are often triggered by physical or emotional stress. Other symptoms of CAD include shortness of breath and fatigue, especially after extreme activity.

Many of the heart conditions described above have similar symptoms, namely:

Shortness of Breath

“Fainting” feeling or light-headedness, dizziness

Fatigue

Racing heartbeat, irregular heartbeat, or a “floppy” feeling in the chest

Chest pain, Chest pressure

Sweating

Swelling in abdomen, legs, feet, and ankles

As we mentioned earlier, cardiac disease in Hodgkin’s survivors can develop at any time. It is not unusual, however, for signs of cardiac disease to go undetected. Survivors may be having symptoms of heart disease and not realize it, or they mistake certain symptoms for other conditions. It is therefore critical for Hodgkin’s survivors to have close follow up care.

In addition to their routine check ups, Hodgkin’s survivors should be monitored for possible signs of heart disease.

Additional tests, such as an echocardiogram may be suggested. Survivors may want to consult with a “Cardio-Oncologist” for closer evaluation. “Cardio-Oncology” is a relative new field of medicine, created out of the need to provide special, collaborative care for cancer survivors who have cardiac risks due to their treatment. Cardio-Oncology brings together cardiologists, oncologists, hematologists and others to bring a “team approach” in dealing with this serious Late Effect of cancer treatment.

There are several ways to treat cardiac disease. For some survivors, changes in diet and exercise can make an enormous difference. Others may need medication. When there is significant damage to the heart, there may be a need for additional intervention, including surgery. Fortunately, there are now “minimally invasive” surgeries, such as the “Transcatheter Aortic Valve Replacement”, or “TAVR” procedure, which is used to replace a damaged aortic valve. Minimally invasive procedures are less traumatic on the body and easier to recover from. They are not, however, an appropriate solution for ALL cardiac injuries or diseases. Some Hodgkin’s survivors may not be eligible for these techniques and may need to undergo more invasive procedures, such as open-heart surgery. This involves opening the rib cage to access the heart. It means a much longer recovery time and does present additional risk, but it may also be the best overall solution for certain survivors.

The good news is that new techniques in cardiac care are developing all the time. New medications, new procedures, new surgical techniques are always on the horizon. Additionally, more hospitals and treatment care facilities are now including Cardio-Oncology as part of their follow-up programs, offering the opportunity for cancer survivors to receive more specialized cardiac care.

For more information about Cardiac Disease in Hodgkin’s survivors, please visit our “Resources “page on this website.