Cancer Treatment Related Cardiovascular Toxicity: Comprehensive Myocardial and Vascular Phenotyping

Study Overview
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Brief Summary
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Observational prospective cohort study designed to assess the mechanisms of fluoropyrimidine induced cardiovascular toxicity.

Detailed Description
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Fluoropyrimidine (5-FU and Capecitabine) based chemotherapy regimens form the cornerstone of treatments for gastrointestinal (GI) cancers. Fluoropyrimidines however, are associated with the development of cardiovascular toxicity which can take on different forms including chest pain, myocardial infarction, arrhythmias, heart failure and sudden death. The underlying mechanisms of cardiovascular toxicity are not fully understood. The investigators will use quantitative cardiovascular magnetic resonance perfusion imaging, CT coronary angiography, extra-cardiac vascular assessments and serum cardiac biomarkers to improve insights into the pathophysiology of fluoropyrimidine cardiotoxicity. All enrolled participants in this two centre study will have GI cancers requiring treatment with fluoropyrimidine chemotherapy.

Official Title
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Cancer Treatment Related Cardiovascular Toxicity: Comprehensive Myocardial and Vascular Phenotyping

Conditions
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Cardiovascular Diseases, Cardiotoxicity, Fluorouracil Adverse Reaction, Malignancy, Colorectal Cancer, Oesophagus Cancer, Gastric Cancer, Pancreatic Cancer

Intervention / Treatment
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* Diagnostic Test: Cardiovascular magnetic resonance with stress perfusion
* Diagnostic Test: CT coronary angiography
* Diagnostic Test: Retinal OCT angiography
* Diagnostic Test: Sublingual microscopy (GlycoCheck)
* Diagnostic Test: Serum cardiac biomarkers (High sensitivity troponin, NT pro BNP)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age >18 years Gastrointestinal malignancy Receiving fluoropyrimidine chemotherapy Exclusion Criteria: Participants unable or unwilling to provide consent Participants that have a conventional contraindication for magnetic resonance imaging (MRI) including permanent implantable cardiac devices, ferromagnetic implants, pregnancy, large body size not fitting into the scanner bore and severe claustrophobia will be excluded Participants that have a conventional contraindication for adenosine stress perfusion including a history of trifascicular block or of second-degree heart block or higher on ECG, or uncontrolled asthma. Participants with significant renal impairment (eGFR<30ml/min) History of allergy to adenosine, gadolinium or iodinated contrast Patients with terminal illness (life expectancy <6 months) will be excluded.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Cohort 1<br>Stable patients with gastrointestinal malignancies will be recruited to this 3 timepoint study prior to initiation of fluoropyrimidine chemotherapy. All investigations will be performed at baseline, at the end of cycle 1 and 4-6 weeks post completion of treatment. | Diagnostic Test: Cardiovascular magnetic resonance with stress perfusion<br>* Cardiac MRI scan to assess changes in left ventricular function, parametric mapping, strain and myocardial blood flow. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>Diagnostic Test: CT coronary angiography<br>* CT coronary angiogram at baseline only in both cohorts to assess for coronary artery disease<br>Diagnostic Test: Retinal OCT angiography<br>* Retinal OCTa to assess changes in retinal vasculature. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>Diagnostic Test: Sublingual microscopy (GlycoCheck)<br>* To determine changes in sublingual microvascular health. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>Diagnostic Test: Serum cardiac biomarkers (High sensitivity troponin, NT pro BNP)<br>* Performed to assess for myocardial injury. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>|
| Cohort 2<br>Patients with gastrointestinal malignancies presenting to hospital with acute symptoms of fluoropyrimidine cardiotoxicity. All investigations will be performed during the acute presentation and the second visit will be performed 4-6 weeks post completion of treatment. | Diagnostic Test: Cardiovascular magnetic resonance with stress perfusion<br>* Cardiac MRI scan to assess changes in left ventricular function, parametric mapping, strain and myocardial blood flow. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>Diagnostic Test: CT coronary angiography<br>* CT coronary angiogram at baseline only in both cohorts to assess for coronary artery disease<br>Diagnostic Test: Retinal OCT angiography<br>* Retinal OCTa to assess changes in retinal vasculature. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>Diagnostic Test: Sublingual microscopy (GlycoCheck)<br>* To determine changes in sublingual microvascular health. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>Diagnostic Test: Serum cardiac biomarkers (High sensitivity troponin, NT pro BNP)<br>* Performed to assess for myocardial injury. In cohort 1 this will be performed pre, during and on completion of treatment. In cohort 2 this will be performed during the acute presentation and on completion of treatment.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in myocardial blood flow from baseline with adenosine stress assessed by quantitative perfusion cardiac MRI | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in left ventricular ejection fraction from baseline | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in left ventricular extracellular volume from baseline | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in left ventricular global longitudinal strain from baseline | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in N-terminal pro B-type natriuretic peptide (NT-pro BNP) | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in high sensitivity troponin T | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in sublingual perfused boundary region | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in sublingual capillary density | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 
| Change in retinal vessel density | Assessed at baseline, following cycle 1 and 4-6 weeks post completion of treatment | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Cardio-oncology, Cardiotoxicity, Fluoropyrimidine cardiotoxicity