 Hi, my name is Nancy Moldauer and I am a kidney cancer research nurse at Cedars-Sanay Medical Center and I'm going to be speaking to you about the cardiovascular side effects associated with many of the drugs that we use to treat kidney cancer. I'm going to start by talking about what needs to take place prior to starting these new medications. It is very important that any risk factors you might have pertaining to your heart be reviewed with your physician prior to starting the therapy. This means reviewing your blood pressure and any current medications that you are taking. Do you have a history of coronary artery disease? Again, an example of this could be high blood pressure. And if so, you need to begin coordinating your medical care with your primary care physician and your oncologist. You will also need to know how to monitor for signs and symptoms of any types of problems with your heart. That could be shortness of breath, a feeling of overwhelming fatigue, any weight gain, swollen ankles, or perhaps even a cough. Let's take a minute and talk about why these targeted therapies cause an increase in your blood pressure. Well, blood vessels relax or dilate in response to a substance called nitric oxide. But when targeted therapies are given, the production of nitrous oxide is decreased. Thus, blood vessels are not able to relax. And this can result in the walls of the blood vessel to stiffen, causing an increase in blood pressure. So when your heart is pumping and the blood leaves the heart and actually goes out into the vessels, the vessels are not as elastic. So therefore, there's an increase in pressure as the blood is released from the heart and then hits the walls of the blood vessel. Well how often does hypertension actually occur when these targeted therapies are given? And we know that the incidence of high blood pressure ranges from 9 up to 40%. And again, this can depend on several factors, some of which we spoke about, and that is what particular anti-cancer agent is used, do you have a history of high blood pressure, and also any other medical conditions that might contribute to high blood pressure? Do you have a history of diabetes, cigarette smoking, high cholesterol, high triglycerides, and being overweight? There are many drugs known today that are known to cause increase in blood pressure. They are a very common side effect with the drug synitinib, seraphonib, bevacivamid, vasopinib, and exitinib. Why is it important to lower your blood pressure? We want to decrease the incidence of having a stroke, we also want to decrease the incidence of heart attack, and also the incidence of heart failure. So it is very important while you are on these targeted therapies that we maintain a good healthy heart for you. Some of the considerations that we look at when we start these medications is, number one, getting a very accurate baseline blood pressure. So we really know what your blood pressure is prior to starting on the medications. Once we know what that is, we will then tell you how to monitor your blood pressure. And we can do this by the use of diaries where you would actually write down your blood pressure at home, and the use of taking your blood pressure at home with a cuff. And what we would look for is an increased trend in your blood pressure. So we would look to see if the number increased by 20 milligrams in the bottom number, or an increase overall if your blood pressure just jumped to something that was greater than 150 over 100. Both of those numbers would mean that you would need to call your physician and tell him about the changes in your blood pressure. And it is very common to prescribe a medication during the course of your treatment within one of these oral targeted therapies. The other thing that's very important is to look at what medications you are currently taking because some of the medications may actually interfere with some of the targeted therapies. A key person who could be very helpful in this could perhaps be your pharmacy because as we deliver these medications through your local pharmacy, they will also have access to what other medications you are taking. Are you on blood thinner, a common medication is warfarin, any vitamins and complementary therapies could also interact with some of the drugs that we use for hypertension and also the drugs that we are using to treat your cancer. So a very careful review of the medications that you are currently on is necessary and also careful monitoring of your blood pressure at home. And when you stop the targeted therapy, what often happens is your blood pressure will normalize. So you need to let your physician know or ask the question, do I continue on my medications for my high blood pressure if indeed I need to stop the medication to treat my cancer. Some signs and symptoms of hypertension, many people with high blood pressure will have no signs or symptoms. However, some people may complain of a dull headache, dizzy spells or more frequent nosebleeds than normal. Sometimes these signs and symptoms typically don't occur until high blood pressure has reached a severe or even a life-threatening stage. Why is it important to measure your blood pressure at home? It's important to measure your blood pressure at home because that will give us some information on indeed whether or not your targeted therapy or the medication that's used to treat the cancer is indeed being taken. It could also measure a response to the high blood pressure medication. So if we're giving you medication to treat the high blood pressure, we certainly want to know if it is working. Sometimes patients will come to see us and as soon as they come into the clinic and they start seeing nurses and physicians, their blood pressure jumps up a little bit just being in the clinic area. So we call that the white coat influence. So sometimes a patient will tell us that my blood pressure is only elevated when I come to see us. You must check the home device on a regular basis so that we know that it is giving us accurate readings. If the blood pressure at home, for example, is 135 over 85, for some people that could be considered an elevated blood pressure, but generally what we like to see is blood pressure in the range of 120 over 70 to 130 over 80. That is the range that we like to see patients' blood pressure. But most importantly, review your blood pressures that you take at home with your physician and they can best judge whether or not medication needs to be prescribed to help control blood pressure. This slide just talks about how we define blood pressure classification, what is normal, what we call systolic, and normal diastolic, systolic being the top number, diastolic being the lower number. And then the range is for what might be considered prehypertension and then stage one of hypertension and stage two. Again, this is just background information so that you will have knowledge about how we define high blood pressure. An interesting piece of information that we know about the development of high blood pressure and these oral medications is that hypertension, should it develop, may actually be what we call a biomarker of efficacy in patients treated with synitinib. In other words, for those patients that are actually on synitinib and develop high blood pressure, it has been associated with a response to treatment and that it actually helps the patients being treated with this drug and their cancer. Now I'm going to switch and talk a little bit about bleeding associated with some of these oral agents. Again, at the beginning of your treatment, you must tell your physician, do you have a history of a GI ulcer and again, high blood pressure? Do you take blood thinners and are you on low dose aspirin? Do you have a history of nosebleeds, bleeding gums? And also let them know if you develop any red or black stools or vomiting blood, again telling them the history of what drugs that you are currently taking or if you have a history of frequent nosebleeds, letting them know what your baseline is so that when you report something, we will then have something to judge it from. The other side effect would be the development of a blood clot because this is sometimes associated with these oral agents. So it is important to report sudden chest pain, difficulty breathing, a swollen or pain in your lower extremity immediately to your health care team. In summary then, the management of side effects is critical to maintaining your treatment. It is important that you know that prolonged administration of targeted therapy may affect your heart. These medications do require chronic administration so it is important that we keep your blood pressure and your heart healthy. Hypertension is a frequent side effect associated with these medications but it can be treated under medical guidelines. Remember, hypertension may mean the drug is working and to be proactive in your care and ask questions and bring medical issues to the attention of your physician and make sure you know when to contact your physician. Thank you very much and good luck with your treatment.