4 Cardiology Research and Practice RA (a) RV Ao Ao PA LV (b) (c) Ao LA Figure 2: 53-year-old male with metastatic melanoma underwent testing prior to Interleukin-2 (IL-2) therapy. Resting electrocardiogram and echocardiogram are normal. Dobutamine stress echocardiogram shows inferior wall inducible ischemia. IL-2 is held while coronary CT angiography is performed. Based on CT ﬁndings, IL-2 is started and given uneventfully. (a) Curved reformat view of the right coronary artery shows no atherosclerotic plaque. The conus branch (arrowhead) and sinoatrial nodal branch (arrow) are identiﬁed. (b) Curved reformat view of the left anterior descending artery shows no atherosclerotic plaque. The circumﬂex artery origin (black arrowhead) and ﬁrst diagonal artery (white arrowhead) are identiﬁed. (c) Curved reformat view of the circumﬂex coronary artery shows no atherosclerotic plaque. The ﬁrst obtuse marginal branch (arrowhead) is identiﬁed. LA = left atrium. LV = left ventricle. RA = right atrium. RV = right ventricle. Ao = Aortic root. PA = pulmonary artery root. Table 5: Cardiac treatment decisions based on cardiac computed tomographic angiography ﬁndings. Table 6: Impact of cardiac computed tomographic angiography on cancer-related treatment decisions. Cardiac treatment decisions ICA∗ only ICA followed by CABG† Medical management of nonobstructive CAD‡ CAD risk factors modiﬁcation Management of chemotherapy-induced cardiomyopathy ∗ICA: invasive coronary angiography. †CABG: coronary artery bypass grafting. ‡CAD: coronary artery disease. N (%) 8 (10) 4 (5) 30 (37.5) 20 (25) 18 (22.5) Coronary ﬁndings in CCTA are detailed in Table 4. Normal coronaries were found in 26.3% of patients, while mild to moderate CAD was found in 46% and severe CAD in 28%. Cardiac treatment decisions based on CCTA ﬁndings are outlined in Table 5. Due to concomitant advanced cancer or patient refusal, only 12 out of 22 patients with severe CAD by CCTA under- went ICA, including 4 patients who eventually underwent coronary artery bypass grafting (CABG). The majority of the patients were managed medically, with 38% of the patients treated medically for nonobstructive CAD and 23% of patients treated for chemotherapy-induced cardiomyopathy (Figure 1). In 25% of the cases the result of CCTA led to CAD risk factor modiﬁcations. A total of 41 pts (51.3%) had their cancer management altered based on CCTA ﬁndings (Table 6). In 24% of cases, these ﬁndings directly inﬂuenced the decision to restarting chemotherapy (Figure 2), while in 9% of cases, they led to Cancer treatment decisions Proceed with chemotherapy Proceed with stem cell transplant evaluation Proceed with cancer surgery Proceed with radiation therapy Change chemotherapy agents due to cardiomyopathy Hold chemotherapy for invasive coronary angiography N (%) 19 (23.8) 8 (10.0) 3 (3.8) 2 (2.5) 7 (8.8) 2 (2.5) a change in chemotherapy agents based on a diagnosis of chemotherapy-induced cardiomyopathy. In 2.5% of cases, chemotherapy was temporarily discontinued in order to proceed with invasive angiography (Figure 3). In 10% of cases, exclusion of signiﬁcant CAD by CCTA allowed for stem cell transplant evaluation to proceed. In 4% of cases, cancer surgery was performed without further cardiac testing, and 2.5% of cases subsequently started radiation therapy. 4. Discussion The present study shows that CCTA can have important consequences in evaluating cancer patients with suspected coronary disease, often leading to important decision in the care of both cancer and heart disease. For more than half the patients in our study, CCTA had a signiﬁcant impact on their cancer care. Coexistence of CAD and malignancy often creates a therapeutic and diagnostic challenge: faced with two potentially life-threatening conditions, prioritization of care is paramount. This is because cancer, its treatment, and complications may render commonly used cardiac tests and