A novel tool may help predict the risk of complications following hematopoietic stem cell transplantation and guide the pretransplant process, according to new Scientific Statement published by Hayek et al in Circulation. The findings may also illuminate the contemporary prevalence of cardiovascular complications following the procedures.
Background
Hematopoietic stem cell transplantation offers the potential to cure thousands of U.S. patients with leukemias, lymphomas, and immune deficiency disorders per year. However, the procedure can affect various organs, including the cardiovascular system. With advancements in medical science and improvements in protocols, more hematopoietic stem cell transplants are being performed in older patients who may be at greater risk of cardiovascular disease.
“In the early era of [hematopoietic stem cell] transplant, patients with [cardiovascular] disease were often excluded due to the cardiotoxicity of the conditioning regimens used at the time,” explained lead statement author Salim Hayek, MD, Adjunct Professor of Internal Medicine–Cardiology at the University of Michigan Medical School. “Understanding the cardiovascular risks of modern [hematopoietic stem cell] transplantation is crucial for selecting the right patients and to ensure that none are excluded unnecessarily. This is the first contemporary evidence that shows the risks associated with [hematopoietic stem cell] transplantation and how to assess a patient’s risk for cardiovascular complications—which, taken together, can guide clinicians to ensure better outcomes for this procedure,” he continued.
Findings on Cardiovascular Complications
In a recent study published by Vasbinder et al in JACC: Cardio-Oncology, Dr. Hayek and his colleagues developed the Cardiovascular Registry in Bone Marrow Transplantation (CARE-BMT), which was designed to compile the data of patients who underwent transplant from both the University of Michigan Health and Rush University. Investigators revealed that among 3,300 patients who underwent hematopoietic stem cell transplantation between 2008 and 2019, 4.1% and 13.9% of them experienced adverse cardiovascular events within 100 days and 5 years of the procedure, respectively.
Overall, cardiovascular complications during hospitalization for hematopoietic stem cell transplant were rare, the most common of which was atrial fibrillation diagnosed after 5 years (6.8%) followed by heart failure (5.4%). Severe cardiovascular complications such as heart attacks and strokes were uncommon. Additionally, the investigators found that 16.4% of allogeneic transplant recipients experienced long-term adverse cardiovascular events after 5 years compared with 12.1% of autologous recipients.
“The landscape of [hematopoietic stem cell] transplants has rapidly evolved over the last 20 years, with many improvements in the way patients are selected for and treated during [the procedure]. Our cohort allowed us to reevaluate the incidence of cardiovascular complications in patients who received more modern treatment,” Dr. Hayek highlighted.
Patients with preexisting cardiovascular conditions like diabetes and coronary artery disease were more likely to experience long-term cardiovascular complications but not during the transplant process.
“Determining who is at high and low risk of cardiovascular outcomes is crucial to help guide both the pretransplant evaluation as well as the posttransplant management—which is why we invested so much in creating a simple risk score that health-care providers can use to identify these patients,” emphasized lead study author Alexi Vasbinder, PhD, RN, a postdoctoral fellow at the University of Michigan Frankel Cardiovascular Center at the time the research was conducted.
Findings on the Novel Risk Score
In a second recent study published by Vasbinder in the Journal of the American Heart Association, researchers used easily accessible clinical data from the CARE-BMT cohort—including age, race, history of coronary artery disease or heart failure, and prior doses of cardiotoxic chemotherapy—to create a novel points-based risk score.
In an analysis of over 2,400 adult patients, the final CARE-BMT risk score identified a high-risk group accounting for over 30% of the patients. The 5-year and 10-year cardiovascular complication rates were a respective 31.9% and 55%.
The researchers discovered that the novel risk score performed equally well in allogeneic and autologous hematopoietic stem cell transplant recipients, as well as in a separate cohort of over 900 patients from Rush University.
“It’s a very simple score that can be easily calculated and implemented in any health-care record,” Dr. Hayek suggested. “This will be easy to replicate and use during evaluations before [hematopoietic stem cell] transplantation to guide referrals of high-risk patients to cardiovascular specialists who can then optimize medical and lifestyle management of their conditions,” he added.
Conclusions
The two recent studies formed the basis of a new Scientific Statement regarding the cardiovascular management of patients undergoing hematopoietic stem cell transplantation. The statement authors focused on considerations during the four steps of hematopoietic stem cell transplantation: evaluation prior to transplant, conditioning therapy and transplant, the immediate posttransplant period, and long-term survivorship.
“This innovative cardiac risk assessment tool significantly improves our ability to provide a safer path throughout treatment to our cell therapy recipients possessing cardiovascular comorbidities, which in turn will have a positive effect on long-term recovery and quality of life,” concluded co–study author John Maciejewski, MD, PhD, Clinical Assistant Professor of Internal Medicine at the University of Michigan Medical School and a bone marrow transplant physician at the University of Michigan Health.
Disclosure: For full disclosures of the statement authors, visit ahajournals.org, jacc.org, and ahajournals.org.
