Jan Walter Dhillon Shanmuganathan - PhD Scholarship 2022

Project summary:
Is the risk of heart attack greater with cancer treatment?

There have been major advances in the treatment of heart disease and cancer, which has meant elderly patients living with cancer and heart disease to a greater extent. Today the treatment of cancer patients with heart disease is therefore up to the individual doctor, as there are no guidelines to lean on. This leads to both over- and under-treatment of these seriously ill patients. Sometimes there are difficulties among heart and cancer doctors when a treatment must be organized. This is mainly based on a different assessment of the patient's remaining life and thus the word palliation. The goal is to form a better understanding that doctors can use in the meeting with the cancer patient with heart disease and thus strengthen the collaboration between heart and cancer doctors.

We know that every year 1300 patients die from colon cancer. Many times, surgery is performed depending on the spread and then medical treatment with 5-Fluorouracil which is given directly into the blood stream through a vein. As a side effect of the medical treatment, you can get heart attack. Research around this is extremely limited. We have recently published a paper that approximately 30,000 patients, of which 10,000 receive medical treatment with Fluoropyrimidines, showing a higher tendency for heart attack in the first 6 months of treatment, which decreases after 1 year. There are only limited options for treatment for patients who cannot tolerate medical treatment. Therefore, with our studies, we want to increase the collaboration between heart and cancer doctors so that we can provide the best possible treatment for the patient.

We want to look whether there is the same tendency for heart attack with the oral formula of 5-Fluorouracil as capecitabine.

Furthermore, inhibition of the growth factor system (angiogenesis) has been a treatment option in oncology for the treatment of patients with bowel cancer, kidney cancer, liver cancer, thyroid cancer and lung cancer. The treatment can be given over the years and as pills. There is a lack of knowledge about the tendency for heart attack, which we would like to clarify in more detail. We will comprehensively explore the risk of heart attack in relation to different cancer types.

Project title

Risk of myocardial infarction depending on cancer subtype and treatment


Cardiovascular disease and cancer are leading causes of mortality and morbidity worldwide. Cardiovascular events in patients with cancer is more frequent and associated with worse cardiovascular outcomes. Patients with cancer who present with acute coronary syndrome often have a set of risk factors that can influence the risk of invasive coronary treatment.


  • To examine risk of myocardial infarction in patients with colon- and rectal cancer treated with the oral formula of 5-Fluorouracil (capecitabine).
  • To examine whether Vascular endothelial growth factor receptor-Tyrosine kinase inhibitors VEGFR-TKI treatment is associated with increased myocardial infarction risk.
  • To explore the risk of myocardial infarction in relation to different cancer types.


Patients with gastrointestinal cancer with all stages treated with Capecitabine/VEGFR-TKI between 2004 and 2016 will be identified in the Danish National Patient Register and risk set matching will be used to find background population controls matched on age and sex as well as year and month equivalent to the Capecitabine/ VEGFR-TKI treatment. For gastro-intestinal cancer patients the time to event analysis will be defined as the time of receiving Capecitabine / VEGFR-TKI treatment and the controls will be matched to that time. Patients treated with Capecitabine/ VEGFR-TKI as well as
controls with preexisting ischemic heart disease will be excluded. Lastly, we aim to examine the risk of myocardial infarction dependent on different cancer types.

Jan Walter Dhillon Shanmuganathan

  • MD
  • Aalborg University & Aalborg University Hospital, Department of Cardiology

Main supervisor:

Associate Professor Phillip Freeman, MD, PhD, Department of Cardiology, Aalborg University Hospital


Associate Professor Laurids Østergaard Poulsen, Clinical Oncology, Aalborg University Hospital

Professor, Ursula Falkmer, senior consultant, Department of Oncology, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, and Head of the Clinical Cancer Research Centre, Aalborg Univeristy Hospital

Kristian Hay Kragholm, MD, PhD, Department of Cardiology, Aalborg University Hospital

Professor Peter Søgaard, MD, DMSc, Department of Cardiology, Aalborg University Hospital and Institute for Clinical Medicine, Aalborg University

Professor Mamas Mamas, MD, PhD, Director for the Centre Prognosis Research, Institute of Primary Care and Health Sciences.
Keele University, Department of Cardiology, Royal Stoke University Hospital, North Staffordshire, UK