Dipti Gupta, MD, MPH: Fast-forward to 2016—there was a clinical update in the American Heart Association’s journal called Circulation. They outlined this very useful and practical schema for the baseline evaluation of patients being considered for ADT. What they show you is the ABCDE algorithm for prostate cancer survivors, which I think is worth its weight in gold. It emphasizes awareness for using 81 mg of aspirin for primary and secondary prevention here. I would emphasize that there are actually data that demonstrate that aspirin works not only for cardiovascular health but may also have antitumor properties. In fact, there was a study not too long ago that said that this was beneficial for prostate cancer-specific mortality. So, this is definitely something to consider.

The B stands for blood pressure control. The goal blood pressure in this document was less than 140/90. I would argue that today, in the day and age of the SPRINT trial and everything that we know since then, we need to go even lower—to a targeted blood pressure of 130/90.

Again, high-intensity statins for patients with hyperlipidemia or a high ASCVD (atherosclerotic cardiovascular disease) risk score or pre-existing cardiovascular disease or diabetes—very, very important. We know that statins work not only by cholesterol lowering but they also have pleomorphic effects. Cigarette smoking absolutely needs to be discouraged. You need complete abstinence. We know that it is an independent and negative prognostic factor for prostate cancer—specific mortality, as well as all-cause mortality in patients with prostate cancer.

Diabetes mellitus—we talked a little bit about what to do for screening of these patients. Metformin—it’s beneficial for patients with metabolic syndrome, so that’s definitely an option for patients with pre-existing cardiovascular disease. Now there are multiple new classes of medications for diabetes. Those can be opted for. They have a positive effect not only on diabetes control but also have shown a beneficial effect on cardiovascular disease—specific mortality. So, those are the newer generations of medications that should be preferred.

And then, I cannot overemphasize the importance of regular, regimented exercise programs. It turns out there is a wealth of data showing that regular, regimented exercise can mitigate some of the side effects of androgen deprivation therapy. It can also help mitigate some of the cardiometabolic aberrations that we are seeing. So, that definitely has to be counseled to patients.

Susan Slovin, MD, PhD: Dr. Gupta, what happens if somebody is not on aspirin? They’re on Pradaxa (dabigatran) or Eliquis (apixaban). We have patients who have stents. They’re challenging enough, from that cardiac risk standpoint.

Dipti Gupta, MD, MPH: Putting patients on anticoagulation, as well as antiplatelet therapy, should be done in collaboration with primary care providers, cardiologists, interventional cardiologists. We often balance the thrombotic risk against the risk of bleeding, and so I would say that is a decision that has to be made on a case-by-case basis, in a multidisciplinary environment.

Referring back to the real-world patient with prostate cancer, we’ve talked a lot about what we should do—how we manage these patients at our institution. This is a patient who came through our doors. Just to recapitulate, this is a 72-year-old obese male with diabetes, hypertension, dyslipidemia, and coronary artery disease, who had an inferior myocardial infarction 1 year ago, with prostate cancer, who is going on ADT—definitely a high-risk patient. His blood pressure is 160/90. He has a heart rate of 70 and a high BMI. He was on aspirin, Toprol (metoprolol), lisinopril, pravastatin, with an LDL of 120, and glipizide, 10 mg, with a hemoglobin A1C of 7.4. Further testing was all unremarkable.

We engaged in an extensive risk-benefit discussion. We clearly outlined that he was going to be a high-risk patient. We went through the ABCDE model that we talked about, and in terms of lifestyle modification etc, we reviewed the diet and exercise goals with the patient. We changed the statin therapy to a high-potency statin. Because this patient does have known coronary artery disease, he would benefit from that. We substituted metformin for glipizide. We increased the lisinopril because he clearly was not at goal blood pressure. We advised that he keep ambulatory blood pressure logs at home and bring them to his appointments so that we could continue titration of his antihypertensives. And then, very importantly, we went over the symptoms that would necessitate immediate medical attention if he were to have acute coronary syndrome or other complications.

So, to summarize, androgen deprivation therapy is associated with increased cardiovascular risk. GnRH antagonists may be safer than GnRH agonists. The short-term cardiovascular risk is highest in patients who have had cardiovascular adverse events in the year prior to starting androgen deprivation therapy. And, appropriate referral to primary care providers and cardiology for primary and secondary prevention and multidisciplinary collaboration is really the key to successfully managing these patients and ensuring an optimal outcome.

Transcript Edited for Clarity