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Clinical Decision Making Based on Radionuclide Determined Ejection Fraction in Oncology Patients

Department of Nuclear Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
Division of Nuclear Medicine, Departments of Oncology and Radiology, Stanford University Medical Center, Stanford, California

Correspondence: For correspondence or reprints contact: H. William Strauss, MD, Division of Nuclear Medicine, Dept. of Radiology, Stanford University Medical Center, Rm. H10101, Stanford, CA 94035-5281.

ABSTRACT

Decreased left ventricular ejection fraction (LVEF) is a ralative contraindication for the use of potentially cardiotoxic chemotherapy. A resting LVEF of 50% is usually used as the lower limit of normal values. The decision to change chemotherapy, however, is complex and is affected by many factors, including ejection fraction. Methods: To determine how LVEF data were used by clinical oncologists in clinical decision making, we performed a retrospective analysis of patients referred for ejection fraction measurements from the hematology/oncology divisions of Stanford University from March 1992 through March 1995. The records of 565 patients treated with potentially cardiotoxic chemotherapy were evaluated. Results: LVEFs <50% were found in 153 patients. The charts of patients with reduced ejection fractions were reviewed to determine if the radionuclide measurement resulted in either discontinuation of the cardiotoxic agent or substitution of a less cardiotoxic drug or mode of administration. These specific changes in therapy occurred in only 43 of the 153 (28%) patients with ejection fractions below 50%; 24 of the 43 (57%) had ejection fractions 40%. Patients with lower ejection fraction values were more likely to have their therapy changed than those with LVEFs close to normal. Patients with ejection fractions 30 generally had cardiotoxic agents discontinued. Of patients who had a resting LVEF <50% and whose therapy was not changed, 81% had a normal increase in LVEF with exercise. Conclusion: In clinical practice at our institution, ejection fraction <50% is not used as an absolute contraindication to cardiotoxic chemotherapy. When the LVEF is less than 40%, potentially cardiotoxic therapy is most often discontinued or omitted. Radionuclide evidence of cardiac reserve may account for decisions to continue cardiotoxic agents despite ejection fractions <50% in the majority of patients. Further study will be needed to establish standard criteria Reserve function, as measured by the change in ejection fraction from rest to stress may be an important parameter used by oncologists to help select patients for continued therapy in spite of a reduced ejection fraction. Our results argue that use of fixed criteria may be too restrictive.

Key Words: cardiotoxicity • left ventricle ejection fraction • equilibrium gated radionuclide angiography