ADT and the Risk of Major Adverse Cardiovascular Events - Episode 9

Optimizing Prevention of MACEs in Prostate Cancer


Dipti Gupta, MD, MPH: Our group and others have been big proponents of optimizing primary and secondary prevention and making patients and providers aware of the cardiotoxic risk associated with androgen deprivation. To the same effect, there has been a scientific advisory that was published in the AHA [American Heart Association] journal called Circulation in 2010, which covered the risk, which highlighted the inconsistencies of the data and outlined some important primary and secondary prevention approaches. In 2016, there was again a good publication in Circulation. This was led mainly by cardiologists, and they outlined what we referred to as the ABCDE algorithm, which has been extremely important in trying to simplify what we need to do for these patients, both from a provider standpoint and a patient standpoint. So let’s go over that one by one.

So the A here stands for awareness, just making sure that the patient as well as the providers are aware of this relationship that we’ve been speaking about of the cardiovascular risk of metabolic aberrations. A also stands for aspirin therapy. Now, just a side note. In 2014, there was a publication that showed there might be a beneficial effect of aspirin, a post-diagnosis aspirin after patients were diagnosed with prostate cancer in actually lowering prostate cancer specific mortality. Not only beneficial for cardiovascular health but possibly also for prostate cancer specific mortality. So just to keep in mind, patients that actually qualify for aspirin therapy should be on an aspirin.

Coming to the B of the ABCDE algorithm, the B stands for blood pressure control. Now, we have extensive data from SPRINT and other trials, lower is indeed better. For drug management, we tend to prefer ACE [angiotensin-converting enzyme] inhibitors in patients who qualify for them. The reason being not only is there a cardiovascular benefit in diabetics and those with established cardiovascular disease, but again there was a study that had a signal toward beneficial effects in prostate cancer or delayed PSA [prostate-specific antigen] failure.

The C here stands for cholesterol lowering with statin therapy. The statins, as we know, don’t only have cholesterol lowering properties but have pleiotropic effects, anti-inflammatory properties, properties to stabilize plaque. So, again, patients who qualify for statin therapy should be on a statin therapy. The C also stands for cigarettes or smoking cessation. I cannot emphasize enough how important that is. Not only is it a strong and independent negative prognostic indicator for prostate mortality but also all-cause mortality. So tobacco abstinence is absolutely paramount for these patients.

The D stands for diabetes control, blood sugar control, follow ADA [American Diabetes Association] guidelines. I would be particularly aggressive in monitoring, and lifestyle modification, and in drug therapy for those who meet criteria for drug therapy. Especially within the first 3 to 6 months of starting ADT [androgen deprivation therapy], it’s really important to pay attention to blood glucose levels.

Lastly, exercise. There is now a growing body of literature about exercise, its beneficial effects not only to attenuate [adverse] effects of ADT, which include quality of life, body composition, fatigue. But also now there are studies showing us improved cardiometabolic panels and cardiometabolic effects of exercise regimens, both strength training as well as aerobic exercise 3 to 4 times a week, 30 to 40 minutes. If a patient is completely sedentary, have them start below the target and then work their way up to the target. In a recent meta-analysis, it was shown that patients on ADT with prostate cancer who were exercising regularly improved upper and lower muscle strength. They lowered their BMI [body mass index] and lowered their cholesterol level. So only beneficial effects. A lot of them are easy to do, and so patients must be encouraged to do this.

Transcript Edited for Clarity