Dr. Rhee is Assistant Professor, Division of Cardiology, Department of Medicine, City of Hope, Duarte, CA, and is assistant editor for JACC: CardioOncology and associate editor for Frontiers in Cardiovascular Medicine: Cardio-Oncology section. She is also a committee member of the ACC/AHA Joint Committee on Clinical Data Standards, cardio-oncology liaison; the AHA Cardio-oncology committee; and the AHA BCVS communications committee.

Dr. Rhee has dedicated her career to finding new ways to prevent or minimize cardiovascular complications from cancer treatment.

Welcome back to this month’s MedscapeLIVE! Cardiology E-News. This month I speak with Dr. June-Wha Rhee, Assistant Professor, Division of Cardiology, Department of Medicine, City of Hope, Duarte, CA. As a cardiologist with specialized clinical and research training in cardiovascular drug toxicity and pharmacogenomics, Dr. Rhee has very insightful perspectives on new research and treatment options. Her own current research employs clinical data, genomics, and patient-derived iPSCs models to study genetic determinants and mechanisms of drug-induced cardiovascular toxicities. We discussed:

• What established resources/guidelines are coming for clinicians and researchers in cardio-oncology.
• Takeaways from the update on ibrutinib-related arrhythmias that she recently co-authored.
• Is everybody doing as much as they can (industry, medical associations, hospitals, etc) to eradicate racial and ethnic disparities and improve the care of all patients?
• The new treatment modality that excites her in her area of cardiology?—not necessarily “treatment,” but a look at the concept of “permissive cardiotoxicity.”
• Her recent Frontiers in Cardiovascular Medicine article, Artificial intelligence applications in cardio-oncology: Leveraging high dimensional cardiovascular data.
• Critical insights and a status check on what has been accomplished since publication two years ago of her article, Racial and Ethnic Disparities in Cardio-Oncology: A Call to Action.

‍

Also check out this issue’s Pulse, with articles from the Journal of the American Heart Association, Circulation, European Heart Journal, Journal of the American College of Cardiology, Cardiology News, and New England Journal of Medicine. 

‍

Housekeeping: CME 2023—Add this to your calendar now and sign up for updates:

Going Back to the Heart of Cardiology Conference (4th Annual)

Saturday-Monday December 8-10, 2023; Anaheim, California

To register, click here! .

• Sessions 1-6: Cardiopulmonary Failure; Atherosclerosis and Thrombosis; and Cardiometabolic Disease; Electrical Failure; Valvular Disease: Special Topics in Cardiology
• View Faculty & Agenda: https://www.heartofcardio.com/agenda
• View 2022 HOC Recap—Click HERE! 

‍

Thank you to Dr. Rhee for her time and expertise as faculty and in this interview. Don’t forget to register here for Medscape’s 2023 Going Back to the Heart of Cardiology conference for the best 2023 CME opportunity available! Please contact me at colleen@cmhadvisors.com with any comments and/or suggestions! –Colleen Hutchinson

From Artificial Intelligence to Permissive Cardiotoxicity: Hot Topics with Dr. June-Wha Rhee

Dr. June-Wha Rhee, is Assistant Professor, Division of Cardiology, Department of Medicine, City of Hope, Duarte, CA. Dr. Rhee has specialized clinical and research training in cardiovascular drug toxicity and pharmacogenomics; her research employs clinical data, genomics, and patient-derived iPSCs models to study genetic determinants and mechanisms of drug-induced cardiovascular toxicities. Dr. Rhee is also assistant editor for JACC: CardioOncology and associate editor for Frontiers in Cardiovascular Medicine: Cardio-Oncology section. She serves as a committee member of the ACC/AHA Joint Committee on Clinical Data Standards, cardio-oncology liaison; the AHA Cardio-oncology committee; and the AHA BCVS communications committee.

Colleen: In Frontiers in Cardiovascular Medicine, you co-authored the article, Artificial intelligence applications in cardio-oncology: Leveraging high dimensional cardiovascular data. How would you characterize the current status of use of AI, and where do you see it in 10 years?

Dr. Rhee: AI is rapidly evolving everywhere. I don’t know what its limitations are, and its applications in healthcare can really change the way we practice medicine. This is not that it’d replace healthcare workers, but it can improve workflow efficiency, diagnostic accuracy, and even therapeutic discovery. 

I am working in the field of cardio-oncology, which is an emerging field that primarily deals with detection, diagnosis and monitoring, prevention, and treatment of cardiovascular complications associated with cancer therapy. The main issue within cardio-oncology has been related to difficulties with detecting early signs of cardiotoxicity. While cardiovascular imaging such as echocardiogram has been the main modality to monitor signs of cardiotoxicity, the conventional measures such as left ventricular ejection fraction have not been reliably predictive of early cardiotoxicity. I believe AI-guided analysis of unique imaging features associated with cardiotoxicity can not only improve our diagnostic yield, but can expedite time to diagnosis. Ultimately 10 years from now, I do believe that AI-guided or AI-assisted imaging analysis will become an integral part of our practice. 

Colleen: Coming up on two years since the publication of your article, Racial and Ethnic Disparities in Cardio-Oncology: A Call to Action, what has been accomplished since this publication? Has “a multidisciplinary approach to dismantle these disparities and include key stakeholders, including health care policy makers, patients, scientists, and clinicians” been developed?

Dr. Rhee: I wish! It was more for a call to action by raising awareness of the current state and problems. However, in small scales, I believe there has been positive changes across the board. While I can’t disclose too much, I have been actively involved in various research efforts to 1) identify cardiotoxicity biomarkers and 2) better characterize cardiovascular profiles in response to cancer therapies, specifically focused on underrepresented minority groups funded by various organizations and industries. I am also a part of the American Heart Association Cardio-oncology Committee and a select group of the members have been working tirelessly to come up with a more specific statement addressing racial and ethnic disparities related to cardio-oncology. As these clinical and research efforts and findings get disseminated to the broader clinical community, it can ultimately change the practice pattern and enable policy level changes to bring more equitable care forward. 

Colleen: Where do we stand on racial and ethnic disparities and improving the care of patients? Do you feel everybody is doing as much as they can be (industry, medical associations, hospitals, etc)?  

Dr. Rhee: I believe that over the past several years, there has been a significant emphasis on improving racial and ethnic disparities, resulting in new grant mechanisms as well as statement/guidelines by the medical societies and industries. However, I don’t know how much there has been an improvement microscopically (i.e. changing one’s practice pattern to make it more equitable care) or macroscopically (i.e. implementing policy-level changes to ensure equitable care). Healthcare workers are busy, often overworked/burnout, and therefore it is extremely hard to change our practice pattern unless there is an intentional effort to do it as well as policy-level changes. I think there is definitely room for improvement and better and equitable care. 

You recently published an article, Arrhythmia Patterns in Patients on Ibrutinib, in Frontiers in Cardiovascular Medicine. Serving as an update on ibrutinib-related arrhythmias, what was its main takeaway?

Dr. Rhee: Ibrutinib is a Bruton’s tyrosine kinase targeting small molecular inhibitors, effective in treating B-cell related malignancies such as chronic lymphocytic leukemia. It has, however, been associated with significant cardiovascular complications such as hypertension, arrhythmia, and heart failure. Notably, the arrhythmic complications of ibrutinib have been quite remarkable. First, ibrutinib increases the incidence of atrial fibrillation, with its rate ranging anywhere from about 15% in a randomized trial to more than 40% incidence rate if one has a prior history of atrial fibrillation. More recently, increasing data also suggest that it can lead to increased rates of ventricular arrhythmia. Therefore, we decided to comprehensively characterize arrhythmia patterns among patients on ibrutinib by analyzing data on the wearable event recorders. We found that ibrutinib indeed has resulted in a high prevalence of atrial and ventricular arrhythmias, with a high incidence of treatment interruption secondary to arrhythmias and related symptoms. We certainly need more research to optimize strategies to diagnose, monitor, and manage ibrutinib-related arrhythmias and also how ibrutinib compares to newer generation Bruton’s tyrosine kinase inhibitors in causing cardiac complications. 

What is a new treatment modality that excites you in your area of cardiology?

Dr. Rhee: This is not necessarily “treatment,” but I want to highlight the concept of “permissive cardiotoxicity.” Traditionally, if one has any pre-existing cardiovascular disease or any evidence of cancer therapy-related cardiotoxicity, the immediate response was to stop the life-saving cancer therapies which can compromise patients’ oncologic and cardiovascular outcomes. People have come up with an idea of permissive cardiotoxicity – even with some ongoing cardiotoxicity or cardiac dysfunction, with supportive care, cardioprotective strategies, and careful monitoring and surveillance, we may not need to stop the cancer therapies but rather continue on so that we can adequately treat patients for their underlying cancer. This certainly requires multi-disciplinary collaboration to ensure the patient can be safely treated. 

What resources are out there for cardio-oncology? Are there any established guidelines within cardio-oncology to guide and support healthcare providers?

Dr. Rhee: Currently there is only one guideline by the European Society of Cardiology published in 2022 and it certainly has been a great resource for everyone! The challenge is that the field of cardio-oncology is rapidly evolving, with many new cancer medications being tried and used every day, so it is difficult to keep up with clinical data and evidence to back up the guideline. Thus, in reality many of the recommendations remain rather expert consensus than true evidence-based. That being said, I am a part of ACC/AHA Joint Committee on Clinical Data Standards (serving as a cardio-oncology liaison) as well as a member of the AHA cardio-oncology subcommittee. We are also working to put together data standardization guidelines for cardio-oncology, which hopefully can serve as valuable references and tools for clinicians and researchers in cardio-oncology.
The Pulse

European Heart Journal Article: The link among heart failure, chronic kidney disease, and cancer: new light shed on the complex patient

https://academic.oup.com/eurheartj/article/44/13/1099/7099678

Circulation: Cardiovascular Intervention: Commissural and Coronary Alignment After Transcatheter Aortic Valve Replacement Using the New Supra-Annular, Self-Expanding Evolut FX System

https://www.ahajournals.org/doi/abs/10.1161/CIRCINTERVENTIONS.122.012657

JAMA Cardiology: Assessing Heart Failure vs Lymphoma Treatment Risks and Benefits—It Takes Two to Tango

https://jamanetwork.com/journals/jamacardiology/article-abstract/2803105

Cardiology News: New AHA statement on pediatric primary hypertension issued

https://www.mdedge.com/cardiology/article/262207/hypertension/new-aha-statement-pediatric-primary-hypertension-issued

The 2023 4th Annual Going Back to the Heart of Cardiology: 

https://www.heartofcardio.com/

‍

JACC Editorial: The EHR Has Exposed an Urgent Moral Imperative to Improve Heart Failure Care

https://www.sciencedirect.com/science/article/abs/pii/S0735109723045266

‍

NEJM Review Article: Right Ventricular Failure

https://www.nejm.org/doi/full/10.1056/NEJMra2207410?query=featured_cardiology

‍

Medical Intelligence Quiz: Opioid use after cardiac surgery

https://www.mdedge.com/cardiology/quiz/9569/interventional-cardiology-surgery/opioid-use-after-cardiac-surgery?channel=236

‍

Circulation: Heart Failure Article: Transforming Growth Factor-β Analysis of the VANISH Trial Cohort

https://www.ahajournals.org/doi/abs/10.1161/CIRCHEARTFAILURE.122.010314

‍