What about colorectal cancer patients with combined cardiovascular disease?
Cardiovascular disease and tumor are two major chronic diseases that affect human health and quality of life. Colorectal cancer is very common among malignant tumors, ranking third among male malignant tumors and second among female. With the economic development, medical improvement and the aging of the population, the incidence of cardiovascular diseases is increasing year by year. Patients with colorectal cancer also have longer life expectancy due to more detection means, better treatment methods, and therefore there may be more colorectal cancer patients with concomitant cardiovascular disease. Cardiovascular disease and colorectal cancer share some common risk factors, such as age, obesity, lack of exercise, high-fat diet, etc. For patients with colorectal cancer, actively facing and treating cardiovascular disease not only helps control cardiovascular disease, but also helps improve the prognosis of colorectal cancer. So, how should patients with colorectal cancer face cardiovascular disease?
(a) What should be paid attention to in terms of diet?
Healthy diet is the foundation of cardiovascular disease prevention. Long-term adherence to a reasonable dietary structure can reduce the risk of cardiovascular disease by 30% or more. Fruits, vegetables, cereals, nuts, beans, fish, poultry, lean meats, low-fat and fat-free dairy products, and vegetable oils rich in essential trace elements and fiber, and moderate amounts of unsaturated fatty acids, can reduce the risk of cardiovascular disease.
A healthy diet should pay attention to the following aspects.
① Daily intake of salt <5 g, which is beneficial for blood pressure control.
(ii) A daily intake of 200 g of fruits and 200 g of vegetables; fruits and vegetables are rich in vitamin C and fiber and also help to prevent colorectal cancer.
(iii) 30-45 g of fiber per day through whole grain products, fruits and vegetables; various cereals contain vitamins, phytoestrogens, phenols, unsaturated fatty acids, durable starch, and minerals, which can reduce the risk of cardiovascular disease.
④ Nuts are a good source of monounsaturated fatty acids, fiber, minerals and flavonoids; walnuts are particularly high in polyunsaturated fatty acids, so an appropriate increase in the intake of beans, walnuts, almonds and other nuts can reduce the risk of cardiovascular disease.
⑤ Fish and fish oil can protect the heart from ischemia, anti-inflammatory, and lower plasma triglycerides because they are rich in omega-3 fatty acids, fish oil unsaturated fatty acids, etc. It is recommended to eat fish at least twice a week and one of them must be oil-rich fish.
(6) Moderate alcohol consumption can increase serum HDL concentration, improve fibrinogen activity, inhibit platelet aggregation and thus reduce the risk of cardiovascular disease. Moderate alcohol consumption can also increase insulin sensitivity and promote glucose utilization and thus play a role in regulating blood glucose, but excessive alcohol consumption increases the risk of hypertension, and alcoholic beverages should be limited to 2 drinks per day (20 g alcohol/day) for men and Half. Alcohol grams = volume of alcohol (ml) x degree of alcohol. 20 g of alcohol is equivalent to 250 ml (half a bottle) of beer with a degree of 8% and 25-30 ml (1/15 to 1/12 bottle) of white wine with a degree of 50-60%. The relationship between small amounts of alcohol consumption and colorectal cancer is inconclusive, but heavy alcohol consumption increases the risk of colorectal cancer. Given that alcohol consumption increases the risk of diseases such as alcoholic fatty liver and alcoholic hepatitis, moderate alcohol consumption also needs to be weighed against the pros and cons.
(ii) Adopt good lifestyle habits
Poor lifestyle habits are closely related to the development of cardiovascular disease and colorectal cancer. Some changes in lifestyle habits play a very important role in preventing the occurrence and development of diseases.
① Quit smoking, tobacco smoke contains a variety of cardiotoxic substances, the most important may be nicotine, a cigarette smoke can cause an increase in blood pressure and heart rate. Both smoking and passive smoking increase the risk of cardiovascular disease. Smoking doubles the incidence of coronary heart disease and increases mortality by 50%, and these risks increase with age and the amount smoked. The risk of coronary events decreases by 50% in the first or second year after quitting, and it takes 5-15 years after quitting for the risk to return to that of non-smokers. Smoking is also a risk factor for the development of colorectal cancer, and quitting smoking has an important role in preventing the progression of cardiovascular disease and colon cancer.
②Exercise. The benefits of exercise for cardiovascular disease and colorectal cancer are multiple. Exercise itself can lead to weight loss and contribute to lower blood pressure; physical activity has a positive effect on glucose metabolism and insulin sensitivity thus reducing the incidence of diabetes; exercise can also change the distribution of lipid components thus improving dyslipidemia; regular exercise can reduce the coagulation ability of platelets and reduce thrombosis. Regular physical activity and/or aerobic exercise training is associated with reduced mortality from cardiovascular disease. Patients with cardiovascular disease can choose a reasonable exercise regimen based on their exercise tolerance, such as walking, jogging, cycling, tai chi, swimming, etc.
Principles of the exercise program.
Exercise intensity: It is best to perform an exercise test before developing an exercise program. For most patients, the exercise intensity needs to be 65%-85% of the maximum heart rate determined during the exercise test. If an exercise test is not performed, a target exercise heart rate of 20 beats/min above the resting heart rate is sufficient. For symptomatic patients with ST-segment depression or arrhythmias, a target heart rate of 10 beats/min above the resting heart rate should be used.
Exercise frequency: This can be started from 3 times per week and gradually increased.
Exercise duration: Encourage aerobic exercise of at least up to 30 minutes per day, preferably all at once.
③ Relax and avoid excessive stress. Psychological factors such as social helplessness, stressful work and family life, depression and anxiety increase the risk of cardiovascular disease and worsen the prognosis. Negative emotions are inevitable during the course of the disease, and we can reduce stress and increase confidence in treatment by increasing contact with loved ones and friends, and communicating with other patients through exercise. It is also possible to resort to psychological interventions such as group psychotherapy, individual psychotherapy, behavioral counseling, relaxation or stress management sessions.
(iii) Control of risk factors for cardiovascular disease
Some chronic diseases increase the risk of cardiovascular diseases among themselves or indirectly. Active control of risk factors of cardiovascular diseases is of great significance for the prevention of cardiovascular and cerebrovascular events, so which diseases are in need of strict control and what are the requirements of the control targets?
① Hypertension: The diagnostic criteria for hypertension are systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Hypertension is an important risk factor for heart disease and stroke, and every 20 mmHg increase in systolic blood pressure or 10 mmHg increase in diastolic blood pressure can double the risk of cardiovascular disease. For general hypertensive patients, the goal of blood pressure lowering should be 140/90mmHg or less, while for patients with combined diabetes, blood pressure should be lowered to 130/80mmHg or less.
②Diabetes: Diabetes increases the risk of cardiovascular and microvascular disease, so all patients with diabetes should receive aggressive treatment. Treatment includes diet, exercise and medication. glycated hemoglobin (HbA1c) targets for prevention of cardiovascular disease are less than 7%, total cholesterol less than 175 mg/dl, triglycerides less than 150 mg/dl, and blood pressure less than 130/80 mmHg. for medication, metformin should be used as should be used as first choice.
③Lipid level: most patients with atherosclerosis have dyslipidemia, and the severity of atherosclerosis is aggravated by the increase of plasma cholesterol level, especially the continuous increase of plasma low-density lipoprotein (LDL) level and the decrease of high-density lipoprotein (HDL) level are positively correlated with the degree of atherosclerosis incidence. LDL, triglyceride and cholesterol have atherogenic effects HDL has a strong anti-atherosclerotic effect. Early intervention to control lipid levels can significantly reduce the risk of coronary events.
Lipid control targets: According to the 2011 European Society of Cardiology guidelines for the management of dyslipidemia abnormalities, control of low-density lipoprotein cholesterol (LDL-C) should be the primary target for lipid management, and HDL-C need not be used as an intervention target. The SCORE system was first used to classify patients as very high risk, high risk, intermediate risk or low risk for cardiovascular risk, with specific LDL-C control target values as follows.
Those at intermediate risk should be less than 3.0 mmol/L (115 mg/dl).
High-risk individuals should be less than 2.5 mmol/L (100 mg/dl)
Very high-risk individuals should be below 1.8 mmol/L (70 mg/dl), or at least 50% lower if the target cannot be met.
In addition, non-HDL-C and apolipoprotein B are also lipid modulation targets that should be considered, especially in patients with combined type 2 diabetes and metabolic syndrome. The target value for non-HDL-C is more than 0.8 mmol/L (30 mg/dl) higher than LDL-C, and Apo B should be less than 80 mg/dl (very high risk) or 100 mg/dl (high risk). Patients with atherosclerotic dyslipidemia (high triglycerides, low HDL-C) are at higher cardiovascular risk regardless of LDL-C levels, and non-HDL-C and Apo B should be secondary targets for this group of patients.
Treatment principles: Except for low-risk patients (SCORE score <1%) with LDL-C <100 mg/dl (2.5 mmol/L), patients with dyslipidemia should actively try lifestyle interventions such as diet modification and exercise; low-risk patients with LDL-C >190 mg/dl (4.9 mmol/L) and intermediate-risk patients with LDL-C >100 mg/dl ( 2.5 mmol/L), and drug therapy was initiated if lifestyle interventions failed. However, in patients with ACS, statin therapy was initiated regardless of their baseline LDL-C levels; in patients with stable coronary artery disease, T2DM, and stroke, drug therapy was considered and initiated immediately if LDL-C was ≥70 mg/dl (1.8 mmol/L).
Relationship between blood lipids and tumors: Numerous studies have shown that many tumor patients have significantly lower blood lipid levels, which may be related to the significantly enhanced cholesterol uptake and anabolic metabolism of malignant tumor cells in order to meet the needs of continuous proliferation. However, many tumor patients have low blood lipids for a long time before tumor development, and some studies have shown that lower serum cholesterol levels increase the risk of tumor development. Therefore, too low or too high blood lipids are not good for human health.
④Overweight and obesity: overweight and obesity are associated with the risk of cardiovascular disease death, with the lowest mortality rate when the body mass index (BMI) is 20-25 kg/m2; excessive weight loss, however, is not beneficial to the prevention of cardiovascular disease.
⑤ Other effective pharmacological interventions to prevent CVD: Aspirin, applied to patients with CVD can reduce secondary events by 25% and should be used in most known CVD. For patients who are allergic or intolerant to aspirin, consider applying other effective antiplatelet agents such as clobigrel. β-blockers (e.g., betalactam) are indicated in post-myocardial infarction patients. ACE inhibitors are indicated for patients with low ejection fraction, other cardiovascular diseases and diabetes mellitus.
(iv) Are chemotherapeutic drugs harmful to the heart?
Some commonly used chemotherapy drugs such as anthracycline antibiotics, trastuzumab, 5-fluorouracil, cyclophosphamide and paclitaxel have different degrees of cardiotoxicity. So, what should I be aware of during the use of the above drugs?
Anthracycline antibiotics such as adriamycin, toxicity may manifest as arrhythmia, myocardial dysfunction and pericardial effusion, and cardiomyopathy due to anthracyclines may develop more than ten years after the drug application. Prevention: limiting the cumulative dose of adriamycin to less than 450 mg/m2 is the primary line of defense against cardiotoxicity; in addition, split dosing or small weekly dosing regimens can achieve effective antitumor doses with low peak concentrations, which can also reduce cardiac damage.
Cardiotoxicity of trastuzumab: Trastuzumab affects cardiac function by inhibiting the conduction of myocardial protective signaling pathways, which can manifest as asymptomatic reduced left ventricular ejection fraction, tachycardia, palpitations, etc., and can progress to congestive heart failure. It should be noted that trastuzumab can increase the toxicity of anthracyclines in cardiomyocytes, and the incidence of cardiac dysfunction is 28% when combined with anthracyclines, so the combination with anthracyclines should be avoided as much as possible.
Cyclophosphamide: It can cause acute pericarditis, which is related to the peak dose, and its risk can be reduced by splitting the dose. With high dose, myocardial lesions can occur after an average of 10 days.
Paclitaxel: sinus bradycardia, transient atrioventricular conduction delay and ventricular tachycardia. Doxorubicin (Tysodi) also has arrhythmogenic effects.
In general, chemotherapy drugs should be used under close monitoring in a hospital, under the guidance of a medical professional, and when using drugs with cardiotoxic effects, care should be taken to assess cardiac function regularly.
(E) Can heart patients have surgery?
Early surgical treatment is important to prolong the life of colon cancer patients, but many patients with combined cardiovascular disease have great concerns about surgical treatment. Indeed, the incidence of cardiovascular complications and the resulting mortality rate increase significantly when patients with cardiovascular disease or patients with high-risk factors for cardiovascular disease are operated. However, with the exception of a few cases where surgery is contraindicated, most patients can be treated surgically when their cardiovascular disease is stable and under control. Prior to surgery, all patients need to undergo an evaluation of the cardiovascular system. The patient’s general status and activity tolerance need to be understood, and the patient’s hematocrit level, liver and kidney function, and electrolyte levels need to be known. An electrocardiogram should be routinely performed before the procedure. For patients with a history of organic heart disease or risk factors, a cardiac ultrasound should be performed to understand the structure and function of the patient’s heart and the condition of the valves. Preoperative coronary artery examination (including coronary CTA or coronary angiography) is not necessary in patients with definite or suspected coronary artery disease. These tests are only required in patients who are clinically unstable or have very little activity tolerance and are at high risk for perioperative disease.
The patient’s cardiac function can also be assessed preoperatively by a number of non-invasive methods, mainly
Exercise stress tests, such as the plank exercise test and the 6-minute walk test. If the patient has not recently undergone an exercise test, then an assessment of his or her functional status can be obtained from daily activity status. The Duke Activity Status Index contains questions to assess the patient’s ventricular functional reserve status. Functional reserve status can be classified as excellent (greater than 10 METs), good (7 to 10 METs), moderate (4 to 7 METs), and poor (less than 4 METs). The odds of having myocardial or neurological problems during major non-cardiac surgical procedures were significantly lower in patients with good exercise tolerance than in those with poor tolerance. (MET: refers to energy metabolic equivalent, a common index expressing relative energy metabolic levels during various activities based on energy expenditure in a quiet, seated position).
SPECT myocardial perfusion imaging: used to assess physiological and pathological changes in myocardial blood flow, myocardial metabolism and ventricular function. Pre-operative pre-determination of the presence of myocardial ischemia.
Cardiovascular magnetic resonance imaging: used to assess myocardial and coronary structure and function, which is highly complementary to echocardiography.
Acute coronary syndrome (e.g., unstable angina) or decompensated heart failure are high-risk factors for further deterioration of cardiac function, myocardial infarction, or even death during surgery, and patients in both categories should be withheld from surgery and receive further evaluation and related pharmacological management. The period within 6 weeks after myocardial infarction is a high-risk period for recurrent infarction and is also not suitable for surgical treatment. For patients undergoing surgical treatment, attention should be paid to enhancing postoperative analgesia and avoiding stress.
Summary
Cardiovascular disease and cancer are both very common diseases, and many patients with cardiovascular disease also have cancer at the same time. Risk factors for both intersect, such as obesity and smoking. A proper diet, healthy lifestyle habits, and active control of risk factors for cardiovascular disease play an important role in controlling both cardiovascular disease and colon cancer progression. Many chemotherapy drugs are cardiotoxic and should be applied with caution under the guidance of a medical professional. Patients with cardiovascular diseases are not inoperable; they should do preoperative evaluation carefully and grasp the timing of surgery.