title: Screening for coronary artery disease after mediastinal irradiation for Hodgkin's disease.
abstract: OBJECTIVE
  Incidental cardiac irradiation during treatment of thoracic neoplasms has increased risks for subsequent acute myocardial infarction or sudden cardiac death. Identifying patients who have a high risk for a coronary event may decrease morbidity and mortality. The objective of this study was to evaluate whether stress imaging can identify severe, unsuspected coronary stenoses in patients who had prior mediastinal irradiation for Hodgkin's disease.
  
  
  METHODS
  We enrolled 294 outpatients observed at a tertiary care cancer treatment center after mediastinal irradiation doses 35 Gy for Hodgkin's disease who had no known ischemic cardiac disease. Patients underwent stress echocardiography and radionuclide perfusion imaging at one stress session. Coronary angiography was performed at the discretion of the physician.
  
  
  RESULTS
  Among the 294 participants, 63 (21.4%) had abnormal ventricular images at rest, suggesting prior myocardial injury. During stress testing, 42 patients (14%) developed perfusion defects (n = 26), impaired wall motion (n = 8), or both abnormalities (n = 8). Coronary angiography showed stenosis 50% in 22 patients (55%), less than 50% in nine patients (22.5%), and no stenosis in nine patients (22.5%). Screening led to bypass graft surgery in seven patients. Twenty-three patients developed coronary events during a median of 6.5 years of follow-up, with 10 acute myocardial infarctions (two fatal).
  
  
  CONCLUSIONS
  Stress-induced signs of ischemia and significant coronary artery disease are highly prevalent after mediastinal irradiation in young patients. Stress testing identifies asymptomatic individuals at high risk for acute myocardial infarction or sudden cardiac death.
authors.affiliation: Department of Medicine, Division of Cardiology, Stanford University Medical Center, Stanford, CA, USA. heiden@stanford.edu
authors.forename: Paul A
authors.initials: PA
authors.lastname: Heidenreich
authors.forename: Ingela
authors.initials: I
authors.lastname: Schnittger
authors.forename: H William
authors.initials: HW
authors.lastname: Strauss
authors.forename: Randall H
authors.initials: RH
authors.lastname: Vagelos
authors.forename: Byron K
authors.initials: BK
authors.lastname: Lee
authors.forename: Carol S
authors.initials: CS
authors.lastname: Mariscal
authors.forename: David J
authors.initials: DJ
authors.lastname: Tate
authors.forename: Sandra J
authors.initials: SJ
authors.lastname: Horning
authors.forename: Richard T
authors.initials: RT
authors.lastname: Hoppe
authors.forename: Steven L
authors.initials: SL
authors.lastname: Hancock
mesh_terms: D000328:Adult; D015331:Cohort Studies; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000175:diagnosis*; D023921:Coronary Stenosis / Q000175:diagnosis; D004452:Echocardiography; D005260:Female; D006689:Hodgkin Disease / Q000532:radiotherapy*; D006801:Humans; D008297:Male; D008482:Mediastinum / Q000528:radiation effects*; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis; D011878:Radiotherapy / Q000009:adverse effects*; D012306:Risk; D013997:Time Factors