1
|
Hayek SS, Zaha VG, Bogle C, Deswal A, Langston A, Rotz S, Vasbinder A, Yang E, Okwuosa T. Cardiovascular Management of Patients Undergoing Hematopoietic Stem Cell Transplantation: From Pretransplantation to Survivorship: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1113-e1127. [PMID: 38465648 DOI: 10.1161/cir.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Hematopoietic stem cell transplantation can cure various disorders but poses cardiovascular risks, especially for elderly patients and those with cardiovascular diseases. Cardiovascular evaluations are crucial in pretransplantation assessments, but guidelines are lacking. This American Heart Association scientific statement summarizes the data on transplantation-related complications and provides guidance for the cardiovascular management throughout transplantation. Hematopoietic stem cell transplantation consists of 4 phases: pretransplantation workup, conditioning therapy and infusion, immediate posttransplantation period, and long-term survivorship. Complications can occur during each phase, with long-term survivors facing increased risks for late effects such as cardiovascular disease, secondary malignancies, and endocrinopathies. In adults, arrhythmias such as atrial fibrillation and flutter are the most frequent acute cardiovascular complication. Acute heart failure has an incidence ranging from 0.4% to 2.2%. In pediatric patients, left ventricular systolic dysfunction and pericardial effusion are the most common cardiovascular complications. Factors influencing the incidence and risk of complications include pretransplantation therapies, transplantation type (autologous versus allogeneic), conditioning regimen, comorbid conditions, and patient age. The pretransplantation cardiovascular evaluation consists of 4 steps: (1) initial risk stratification, (2) exclusion of high-risk cardiovascular disease, (3) assessment of cardiac reserve, and (4) optimization of cardiovascular reserve. Clinical risk scores could be useful tools for the risk stratification of adult patients. Long-term cardiovascular management of hematopoietic stem cell transplantation survivors includes optimizing risk factors, monitoring, and maintaining a low threshold for evaluating cardiovascular causes of symptoms. Future research should prioritize refining risk stratification and creating evidence-based guidelines and strategies to optimize outcomes in this growing patient population.
Collapse
|
2
|
Li W, Cheng X, Zhu G, Hu Y, Wang Y, Niu Y, Li H, Aierken A, Li J, Feng L, Liu G. A review of chemotherapeutic drugs-induced arrhythmia and potential intervention with traditional Chinese medicines. Front Pharmacol 2024; 15:1340855. [PMID: 38572424 PMCID: PMC10987752 DOI: 10.3389/fphar.2024.1340855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/05/2024] [Indexed: 04/05/2024] Open
Abstract
Significant advances in chemotherapy drugs have reduced mortality in patients with malignant tumors. However, chemotherapy-related cardiotoxicity increases the morbidity and mortality of patients, and has become the second leading cause of death after tumor recurrence, which has received more and more attention in recent years. Arrhythmia is one of the common types of chemotherapy-induced cardiotoxicity, and has become a new risk related to chemotherapy treatment, which seriously affects the therapeutic outcome in patients. Traditional Chinese medicine has experienced thousands of years of clinical practice in China, and has accumulated a wealth of medical theories and treatment formulas, which has unique advantages in the prevention and treatment of malignant diseases. Traditional Chinese medicine may reduce the arrhythmic toxicity caused by chemotherapy without affecting the anti-cancer effect. This paper mainly discussed the types and pathogenesis of secondary chemotherapeutic drug-induced arrhythmia (CDIA), and summarized the studies on Chinese medicine compounds, Chinese medicine Combination Formula and Chinese medicine injection that may be beneficial in intervention with secondary CDIA including atrial fibrillation, ventricular arrhythmia and sinus bradycardia, in order to provide reference for clinical prevention and treatment of chemotherapy-induced arrhythmias.
Collapse
Affiliation(s)
- Weina Li
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaozhen Cheng
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guanghui Zhu
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ying Hu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine (National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion), Tianjin, China
| | - Yunhan Wang
- Henan Province Hospital of Traditional Chinese Medicine (The Second Affiliated Hospital of Henan University of Traditional Chinese Medicine), Zhengzhou, Henan, China
| | - Yueyue Niu
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Hongping Li
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Aikeremu Aierken
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jie Li
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ling Feng
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guifang Liu
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| |
Collapse
|
3
|
Tamargo J, Villacastín J, Caballero R, Delpón E. Drug-induced atrial fibrillation. A narrative review of a forgotten adverse effect. Pharmacol Res 2024; 200:107077. [PMID: 38244650 DOI: 10.1016/j.phrs.2024.107077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 01/22/2024]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with an increased morbidity and mortality. There is clinical evidence that an increasing number of cardiovascular and non-cardiovascular drugs, mainly anticancer drugs, can induce AF either in patients with or without pre-existing cardiac disorders, but drug-induced AF (DIAF) has not received the attention that it might deserve. In many cases DIAF is asymptomatic and paroxysmal and patients recover sinus rhythm spontaneously, but sometimes, DIAF persists, and it is necessary to perform a cardioversion. Furthermore, DIAF is not mentioned in clinical guidelines on the treatment of AF. The risk of DIAF increases in elderly and in patients treated with polypharmacy and with risk factors and comorbidities that commonly coexist with AF. This is the case of cancer patients. Under these circumstances ascribing causality of DIAF to a given drug often represents a clinical challenge. We review the incidence, the pathophysiological mechanisms, risk factors, clinical relevance, and treatment of DIAF. Because of the limited information presently available, further research is needed to obtain a deeper insight into DIAF. Meanwhile, it is important that clinicians are aware of the problem that DIAF represents, recognize which drugs may cause DIAF, and consider the possibility that a drug may be responsible for a new-onset AF episode.
Collapse
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| | - Julián Villacastín
- Hospital Clínico San Carlos, CardioRed1, Universidad Complutense de Madrid, CIBERCV, 28040 Madrid, Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain.
| | - Eva Delpón
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, 28040 Madrid, Spain
| |
Collapse
|
4
|
Krishan S, Munir MB, Khan MZ, Al-Juhaishi T, Nipp R, DeSimone CV, Deshmukh A, Stavrakis S, Barac A, Asad ZUA. Association of atrial fibrillation and outcomes in patients undergoing bone marrow transplantation. Europace 2023; 25:euad129. [PMID: 37208304 PMCID: PMC10198774 DOI: 10.1093/europace/euad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/14/2023] [Indexed: 05/21/2023] Open
Abstract
AIMS Haematopoietic stem cell transplantation (HSCT) is a potentially curative therapy for several malignant and non-malignant haematologic conditions. Patients undergoing HSCT are at an increased risk of developing atrial fibrillation (AF). We hypothesized that a diagnosis of AF would be associated with poor outcomes in patients undergoing HSCT. METHODS AND RESULTS The National Inpatient Sample (2016-19) was queried with ICD-10 codes to identify patients aged >50 years undergoing HSCT. Clinical outcomes were compared between patients with and without AF. A multivariable regression model adjusting for demographics and comorbidities was used to calculate the adjusted odds ratio (aOR) and regression coefficients with corresponding 95% confidence intervals and P-values. A total of 50 570 weighted hospitalizations for HSCT were identified, out of which 5820 (11.5%) had AF. Atrial fibrillation was found to be independently associated with higher inpatient mortality (aOR 2.75; 1.9-3.98; P < 0.001), cardiac arrest (aOR 2.86; 1.55-5.26; P = 0.001), acute kidney injury (aOR 1.89; 1.6-2.23; P < 0.001), acute heart failure exacerbation (aOR 5.01; 3.54-7.1; P < 0.001), cardiogenic shock (aOR 7.73; 3.17-18.8; P < 0.001), and acute respiratory failure (aOR 3.24; 2.56-4.1; P < 0.001) as well as higher mean length of stay (LOS) (+2.67; 1.79-3.55; P < 0.001) and cost of care (+67 529; 36 630-98 427; P < 0.001). CONCLUSION Among patients undergoing HSCT, AF was independently associated with poor in-hospital outcomes, higher LOS, and cost of care.
Collapse
Affiliation(s)
- Satyam Krishan
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Muhammad Bilal Munir
- Department of Cardiovascular Medicine, Electrophysiology Section, University of California Davis, Davis, CA, USA
| | - Muhammad Zia Khan
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Taha Al-Juhaishi
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Ryan Nipp
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Ana Barac
- Cardio Oncology Program, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| |
Collapse
|
5
|
Slatter M, Lum SH. Personalized hematopoietic stem cell transplantation for inborn errors of immunity. Front Immunol 2023; 14:1162605. [PMID: 37090739 PMCID: PMC10113466 DOI: 10.3389/fimmu.2023.1162605] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023] Open
Abstract
Patients with inborn errors of immunity (IEI) have been transplanted for more than 50 years. Many long-term survivors have ongoing medical issues showing the need for further improvements in how hematopoietic stem cell transplantation (HSCT) is performed if patients in the future are to have a normal quality of life. Precise genetic diagnosis enables early treatment before recurrent infection, autoimmunity and organ impairment occur. Newborn screening for severe combined immunodeficiency (SCID) is established in many countries. For newly described disorders the decision to transplant is not straight-forward. Specific biologic therapies are effective for some diseases and can be used as a bridge to HSCT to improve outcome. Developments in reduced toxicity conditioning and methods of T-cell depletion for mismatched donors have made transplant an option for all eligible patients. Further refinements in conditioning plus precise graft composition and additional cellular therapy are emerging as techniques to personalize the approach to HSCT for each patient.
Collapse
Affiliation(s)
- Mary Slatter
- Paediatric Immunology and HSCT, Newcastle University, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
| | - Su Han Lum
- Paediatric Immunology and HSCT, Newcastle University, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
6
|
Al-Yafeai Z, Ghoweba M, Ananthaneni A, Abduljabar H, Aziz D. Cardiovascular complications of modern multiple myeloma therapy: A pharmacovigilance study. Br J Clin Pharmacol 2023; 89:641-648. [PMID: 35996166 DOI: 10.1111/bcp.15499] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Multiple myeloma accounts for over 10-15% of haematological malignancies. Continued molecular advances have resulted in the development of new drugs for treatment of multiple myeloma. Four drugs were approved by the Food and Drug Administration (FDA) in 2015, but their safety is not well defined. The aim of this study is to delineate the cardiovascular adverse events of these drugs. METHODS We reviewed the adverse cardiac events of newly approved FDA drugs since 2015 using the US FDA Adverse Events Reporting System (FAERS) database. We calculated the reporting odds ratio (ROR) with 95% confidence interval (CIs) for the drugs that have the highest incidence of cardiovascular adverse events. RESULTS Among the medications that have approved for multiple myeloma between 2015 and 2020, 4 novel drugs showed the highest incidence of cardiotoxicity. ROR (95% CI) for atrial fibrillation due to elotuzumab, ixazomib, daratumumab and panobinostat compared to other FAERS drugs was 5.8 (4.4-7.7), 1.9 (1.5-2.3), 4.8 (4.2-5.6) and 5.7 (4.1-8.1), respectively. The ROR (95% CI) for cardiac failure was 8.2 (6.4-10.5), 4.7 (4.1-5.4), 5.8 (4.9-6.7) and 5.6 (3.8-8.1) and ROR (95% CI) for coronary disease was 2.7 (1.9-3.9), 2.7 (2.3-3.2), 2.3 (1.9-2.8) and 4.6 (3.2-6.6) due to elotuzumab, ixazomib, daratumumab and panobinostat compared to all other drugs in FAERS. CONCLUSION Our results demonstrated that certain newly approved antimyeloma therapies are significantly associated with previously unknown cardiotoxicity. These results warrant further studies and highlight the importance of considering the cardiac history of patients with multiple myeloma when utilizing these novel agents.
Collapse
Affiliation(s)
- Zaki Al-Yafeai
- Department of Internal Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Mohamed Ghoweba
- Department of Internal Medicine, CHRISTUS Good Shepherd/Texas A&M College of Medicine, Longview, TX, USA
| | - Anil Ananthaneni
- Department of Internal Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Hamzah Abduljabar
- Department of Internal Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - David Aziz
- Department of Internal Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| |
Collapse
|
7
|
Leiva O, Bohart I, Ahuja T, Park D. Off-Target Effects of Cancer Therapy on Development of Therapy-Induced Arrhythmia: A Review. Cardiology 2023; 148:324-334. [PMID: 36702116 PMCID: PMC10614257 DOI: 10.1159/000529260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Advances in cancer therapeutics have improved overall survival and prognosis in this patient population; however, this has come at the expense of cardiotoxicity including arrhythmia. SUMMARY Cancer and its therapies are associated with cardiotoxicity via several mechanisms including inflammation, cardiomyopathy, and off-target effects. Among cancer therapies, anthracyclines and tyrosine kinase inhibitors (TKIs) are particularly known for their pro-arrhythmia effects. In addition to cardiomyopathy, anthracyclines may be pro-arrhythmogenic via reactive oxygen species (ROS) generation and altered calcium handling. TKIs may mediate their cardiotoxicity via inhibition of off-target tyrosine kinases. Ibrutinib-mediated inhibition of CSK may be responsible for the increased prevalence of atrial fibrillation. Further investigation is warranted to further elucidate the mechanisms behind arrhythmias in cancer therapies. KEY MESSAGES Arrhythmias are a common cardiotoxicity of cancer therapies. Cancer therapies may induce arrhythmias via off-target effects. Understanding the mechanisms underlying arrhythmogenesis associated with cancer therapies may help design cancer therapies that can avoid these toxicities.
Collapse
Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Isaac Bohart
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Tania Ahuja
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - David Park
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| |
Collapse
|
8
|
Chen Y, Zeng Q, Chu B, Liu Z, Wei X, Chen M, Yang P, Tang M, Niu T, Jia Y, Qu Y, Qian Z. Melphalan-loaded methoxy poly(ethylene glycol)-poly(D,L-lactide) copolymer nanomicelles in the treatment of multiple myeloma. CHINESE CHEM LETT 2023. [DOI: 10.1016/j.cclet.2023.108133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
9
|
Tufano A. Optimizing antithrombotic therapy for atrial fibrillation in cancer. Thromb Res 2022; 213 Suppl 1:S103-S106. [DOI: 10.1016/j.thromres.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/03/2022] [Accepted: 01/03/2022] [Indexed: 10/18/2022]
|
10
|
Ostroumova OD, Chernyaeva MS, Kochetkov AI, Vorobieva AE, Bakhteeva DI, Korchagina SP, Bondarets OV, Boyko ND, Sychev DA. Drug-Induced Atrial Fibrillation / Atrial Flutter. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2021-12-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Drug-induced atrial fibrillation / flutter (DIAF) is a serious and potentially life-threatening complication of pharmacotherapy. Purpose of the work: systematization and analysis of scientific literature data on drugs, the use of which can cause the development of DIAF, as well as on epidemiology, pathophysiological mechanisms, risk factors, clinical picture, diagnosis and differential diagnosis, treatment and prevention of DIAF. Analysis of the literature has shown that many groups of drugs can cause the development of DIAF, with a greater frequency while taking anticancer drugs, drugs for the treatment of the cardiovascular, bronchopulmonary and central nervous systems. The mechanisms and main risk factors for the development of DIAF have not been finally established and are known only for certain drugs, therefore, this section requires further study. The main symptoms of DIAF are due to the severity of tachycardia and their influence on the parameters of central hemodynamics. For diagnosis, it is necessary to conduct an electrocardiogram (ECG) and Holter monitoring of an ECG and echocardiography. Differential diagnosis should be made with AF, which may be caused by other causes, as well as other rhythm and conduction disturbances. Successful treatment of DIAF is based on the principle of rapid recognition and immediate discontinuation of drugs (if possible), the use of which potentially caused the development of adverse drug reactions (ADR). The choice of management strategy: heart rate control or rhythm control, as well as the method of achievement (medication or non-medication), depends on the specific clinical situation. For the prevention of DIAF, it is necessary to instruct patients about possible symptoms and recommend self-monitoring of the pulse. It is important for practitioners to be wary of the risk of DIAF due to the variety of drugs that can potentially cause this ADR.
Collapse
Affiliation(s)
- O. D Ostroumova
- Russian Medical Academy of Continuing Professional Education
| | - M. S. Chernyaeva
- Central State Medical Academy of the Administrative Department of the President; Hospital for War Veterans No. 2
| | - A. I. Kochetkov
- Russian Medical Academy of Continuing Professional Education
| | - A. E. Vorobieva
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimova
| | | | | | - O. V. Bondarets
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimova
| | | | - D. A. Sychev
- Russian Medical Academy of Continuing Professional Education
| |
Collapse
|
11
|
Essa H, Wright DJ, Dobson R, Lip GYH. Chemotherapy-Induced Arrhythmia - Underrecognized and Undertreated. Am J Med 2021; 134:1224-1231.e1. [PMID: 34216562 DOI: 10.1016/j.amjmed.2021.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
Cancer is one of the leading causes of death worldwide. Chemotherapy-induced arrhythmia is a potential complication of treatment that confers increased morbidity and mortality. The relationship between chemotherapeutic agents and arrhythmias is poorly established. Atrial fibrillation, ventricular ectopic beats, and prolonged QTc are the most common arrhythmias suffered by cancer patients undergoing chemotherapy. The treatment of atrial fibrillation in cancer is complicated by complex drug-drug interactions and a lack of evidence guiding practice. Furthermore, the normal risk assessment scores utilized in the decision-making for anticoagulation in the normal population are not validated in the cancer population. Multiple agents are implicated in prolonging the QTc, and this can often have adverse consequences for both the patient and the treatment of their cancer. This can manifest as torsades de pointes and sudden cardiac death. It is advised that, during treatment, oncologists should have close liaison with cardio-oncologists to ensure optimum patient management.
Collapse
Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, UK.
| | - David J Wright
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, UK
| | - Rebecca Dobson
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
| |
Collapse
|
12
|
Rotz SJ, Ryan TD, Hayek SS. Cardiovascular disease and its management in children and adults undergoing hematopoietic stem cell transplantation. J Thromb Thrombolysis 2021; 51:854-869. [PMID: 33230704 PMCID: PMC8085022 DOI: 10.1007/s11239-020-02344-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 02/07/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for many malignancies, hemoglobinopathies, metabolic diseases, bone marrow failure syndromes, and primary immune deficiencies. Despite the significant improvement in survival afforded by HSCT, the therapy is associated with major short and long-term morbidity and mortality. Cardiovascular complications such as cardiomyopathy, arrhythmias, pulmonary hypertension, and pericardial effusions are increasingly recognized as potential outcomes following HSCT. The incidence of cardiac complications is related to various factors such as age, co-morbid medical conditions, whether patients received cardiotoxic chemotherapy prior to HSCT, the type of HSCT (autologous versus allogeneic), and the specific conditioning regimen. Thus, the cardiovascular evaluation has become a core component of the pre-transplant assessment, however, the practice differs from center to center as national guidelines and contemporary high-quality studies are lacking. We review the incidence of cardiotoxicity in pediatric and adult HSCT, potential mechanisms of injury, and effects on long-term outcomes. We also discuss the possible therapeutic approaches when disease arises, as well as the indications and need for surveillance before, during, and after transplantation.
Collapse
Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
13
|
Baker JK, Shank-Coviello J, Zhou B, Dixon J, McCorkle R, Sarpong D, Medoff E, Cooper D, Seropian S, Dai F. Cardiotoxicity in Hematopoietic Stem Cell Transplant: Keeping the Beat. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:244-251.e4. [PMID: 32067953 DOI: 10.1016/j.clml.2019.12.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/21/2019] [Accepted: 12/28/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The number of hematopoietic stem cell transplants (HSCTs) performed in the United States and worldwide is increasing. Cardiac events have been well described in HSCT, and the incidence and type of cardiac events have not changed over recent decades. PATIENTS AND METHODS This study adds to the body of evidence in describing the incidence and type of cardiac events experienced by an allogeneic and autologous HSCT population at a single institution from 2012 to 2017. RESULTS Sixty-five (9.8%) patients experienced cardiac events, including atrial arrhythmia (N = 39), acute heart failure (N = 9), acute coronary syndrome (N = 7), and new onset hypertension (N = 9), with a few instances of bradycardia, ventricular arrhythmia, pericardial effusion, and pericarditis. Our multivariable regression analysis identified age (older), creatinine (higher), and history of coronary artery disease to significantly correlate with risk of cardiac event (P = .005, P = .039, and P = .038, respectively). A subgroup analysis of those patients experiencing a cardiac event found pre-transplant atrial dilation by trans-thoracic echocardiogram to correlate with increased risk of atrial arrhythmia (33.8% vs. 9.7%; P = .03). Patients developing a CE had an increased risk of death within 1 year (11% vs. 32%; P < .001). CONCLUSION We review our results in context of other important HSCT cardiac studies to illuminate the most relevant factors of medical history, laboratory data, and cardiac measurements that will identify patients at higher risk, allowing for intervention to improve HSCT outcomes.
Collapse
Affiliation(s)
| | | | - Bin Zhou
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| | - Jane Dixon
- School of Nursing, Yale University, Orange, CT
| | | | - Daniel Sarpong
- Center for Minority Health and Health Disparities Research and Education, Xavier University, New Orleans, LA
| | - Erin Medoff
- Department of Medicine, Yale University, New Haven, CT
| | - Dennis Cooper
- Department of Medicine, Stem Cell Transplantation, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Stuart Seropian
- Department of Medicine, Blood and Marrow Transplantation, Smilow Cancer Institute at Yale University, New Haven, CT
| | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT
| |
Collapse
|
14
|
Chiengthong K, Lertjitbanjong P, Thongprayoon C, Bathini T, Sharma K, Prasitlumkum N, Mao MA, Cheungpasitporn W, Chokesuwattanaskul R. Arrhythmias in hematopoietic stem cell transplantation: A systematic review and meta-analysis. Eur J Haematol 2019; 103:564-572. [PMID: 31478231 DOI: 10.1111/ejh.13322] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/24/2019] [Accepted: 08/26/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND There are controversial data regarding the relationship between hematopoietic stem cell transplantation and arrhythmias. This meta-analysis was performed to evaluate the incidence of arrhythmias in patients following hematopoietic stem cell transplantation (HSCT). METHODS A literature search was conducted utilizing MEDLINE, EMBASE, and Cochrane Databases from inception through April 2019. Pooled incidence with 95% confidence interval (CI) were calculated using random-effects meta-analysis. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019131833). RESULTS Thirteen studies consisting of 10,587 patients undergoing HSCT were enrolled in this systematic review. Overall, the pooled estimated incidence of all types of arrhythmias following HSCT was 7.2% (95% CI: 4.9%-10.5%). With respect to the most common type of arrhythmia, the pooled estimated incidence of atrial fibrillation/atrial flutter (AF/AFL) within 30 days following HSCT was 4.2% (95% CI: 1.7%-9.6%). Egger's regression test demonstrated no significant publication bias in this meta-analysis of post-HSCT arrhythmia incidence. CONCLUSION The overall estimated incidence of arrhythmias following HSCT was 7.2%. Future large scale studies are needed to further elucidate the significance and clinical impact of arrhythmias in post-HSCT patients.
Collapse
Affiliation(s)
- Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | | | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ, USA
| | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Narut Prasitlumkum
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | - Michael A Mao
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Ronpichai Chokesuwattanaskul
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| |
Collapse
|
15
|
Yang X, Li X, Yuan M, Tian C, Yang Y, Wang X, Zhang X, Sun Y, He T, Han S, Chen G, Liu N, Gao Y, Hu D, Xing Y, Shang H. Anticancer Therapy-Induced Atrial Fibrillation: Electrophysiology and Related Mechanisms. Front Pharmacol 2018; 9:1058. [PMID: 30386232 PMCID: PMC6198283 DOI: 10.3389/fphar.2018.01058] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/03/2018] [Indexed: 12/19/2022] Open
Abstract
Some well-established immunotherapy, radiotherapy, postoperation, anticancer drugs such as anthracyclines, antimetabolites, human epidermal growth factor receptor 2 blockers, tyrosine kinase inhibitors, alkylating agents, checkpoint inhibitors, and angiogenesis inhibitors, are significantly linked to cardiotoxicity. Cardiotoxicity is a common complication of several cancer treatments. Some studies observed complications of cardiac arrhythmia associated with the treatment of cancer, including atrial fibrillation (AF), supraventricular arrhythmias, and cardiac repolarization abnormalities. AF increases the risk of cardiovascular morbidity and mortality; it is associated with an almost doubled risk of mortality and a nearly 5-fold increase in the risk of stroke. The occurrence of AF is also usually researched in patients with advanced cancer and those undergoing active cancer treatments. During cancer treatments, the incidence rate of AF affects the prognosis of tumor treatment and challenges the treatment strategy. The present article is mainly focused on the cardiotoxicity of cancer treatments. In our review, we discuss these anticancer therapies and how they induce AF and consequently provide information on the precaution of AF during cancer treatment.
Collapse
Affiliation(s)
- Xinyu Yang
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China.,Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xinye Li
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Mengchen Yuan
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Chao Tian
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yihan Yang
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China.,Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xiaofeng Wang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yang Sun
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Tianmai He
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Songjie Han
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Guang Chen
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Nian Liu
- Department of Cardiology, Beijing An Zhen Hospital of the Capital University of Medical Sciences, Beijing, China
| | - Yonghong Gao
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Dan Hu
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Yanwei Xing
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China.,Institute of Integration of Traditional and Western Medicine of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
16
|
Hari P, Reece DE, Randhawa J, Flomenberg N, Howard DS, Badros AZ, Rapoport AP, Meisenberg BR, Filicko-Ohara J, Phillips GL, Vesole DH. Final outcomes of escalated melphalan 280 mg/m2 with amifostine cytoprotection followed autologous hematopoietic stem cell transplantation for multiple myeloma: high CR and VGPR rates do not translate into improved survival. Bone Marrow Transplant 2018; 54:293-299. [DOI: 10.1038/s41409-018-0261-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/12/2018] [Accepted: 05/22/2018] [Indexed: 12/18/2022]
|
17
|
Alexandre J, Moslehi JJ, Bersell KR, Funck-Brentano C, Roden DM, Salem JE. Anticancer drug-induced cardiac rhythm disorders: Current knowledge and basic underlying mechanisms. Pharmacol Ther 2018; 189:89-103. [PMID: 29698683 DOI: 10.1016/j.pharmthera.2018.04.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Significant advances in cancer treatment have resulted in decreased cancer related mortality for many malignancies with some cancer types now considered chronic diseases. Despite these improvements, there is increasing recognition that many cancer patients or cancer survivors can develop cardiovascular diseases, either due to the cancer itself or as a result of anticancer therapy. Much attention has focused on heart failure; however, other cardiotoxicities, notably cardiac rhythm disorders, can occur without underlying cardiomyopathy. Supraventricular tachycardias occur in cancer patients treated with cytotoxic chemotherapy (anthracyclines, gemcitabine, cisplatin and alkylating-agents) or kinase-inhibitors (KIs) such as ibrutinib. Ventricular arrhythmias, with a subset of them being torsades-de-pointes (TdP) favored by QTc prolongation have been reported: this may be the result of direct hERG-channel inhibition or a more recently-described mechanism of phosphoinositide-3-kinase inhibition. The major anticancer drugs responsible for QTc prolongation in this context are KIs, arsenic trioxide, anthracyclines, histone deacetylase inhibitors, and selective estrogen receptor modulators. Anticancer drug-induced cardiac rhythm disorders remain an underappreciated complication even by experienced clinicians. Moreover, the causal relationship of a particular anticancer drug with cardiac arrhythmia occurrence remains challenging due in part to patient comorbidities and complex treatment regimens. For example, any cancer patient may also be diagnosed with common diseases such as hypertension, diabetes or heart failure which increase an individual's arrhythmia susceptibility. Further, anticancer drugs are generally usually used in combination, increasing the challenge around establishing causation. Thus, arrhythmias appear to be an underappreciated adverse effect of anticancer agents and the incidence, significance and underlying mechanisms are now being investigated.
Collapse
Affiliation(s)
- Joachim Alexandre
- CHU Caen, PICARO Cardio-oncology Program, Department of Pharmacology, F-14033 Caen, France; Normandie Univ, UNICAEN, CHU Caen, EA 4650, Signalisation, Électrophysiologie et Imagerie des Lésions d'Ischémie-Reperfusion Myocardique, 14000 Caen, France
| | - Javid J Moslehi
- Vanderbilt University Medical Center, Cardio-oncology Program, Department of Medicine, Nashville, Tennessee, USA
| | - Kevin R Bersell
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christian Funck-Brentano
- Sorbonne Université, INSERM CIC Paris-Est, AP-HP, ICAN, Pitié-Salpêtrière Hospital, Department of Pharmacology, F-75013 Paris, France
| | - Dan M Roden
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joe-Elie Salem
- Vanderbilt University Medical Center, Cardio-oncology Program, Department of Medicine, Nashville, Tennessee, USA; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA; Sorbonne Université, INSERM CIC Paris-Est, AP-HP, ICAN, Pitié-Salpêtrière Hospital, Department of Pharmacology, F-75013 Paris, France.
| |
Collapse
|
18
|
Poręba M, Gać P, Usnarska-Zubkiewicz L, Pilecki W, Kuliczkowski K, Mazur G, Sobieszczańska M, Poręba R. The analysis of the parameters of 24-hr ECG Holter monitoring in patients with blood neoplasms undergoing high-dose chemotherapy and stem cell transplantation. Ann Noninvasive Electrocardiol 2018; 23:e12534. [PMID: 29363852 DOI: 10.1111/anec.12534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/08/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is a widely used procedure in the treatment of malignant diseases, including blood neoplasms and has increased survival in hematological diseases. The aim of the study was to analyze parameters of 24-hr ECG monitoring in patients with selected blood neoplasms in whom the procedure of hematopoietic stem cell transplantation was performed. METHODS The study group consisted of 64 adults diagnosed with hematologic cancer qualified for HSCT with the previous high dose chemotherapy (HDC). In all patients 24-hr Holter monitoring was carried out twice. First examination took place prior to the HSCT procedure, and the second after finishing the procedure of HSCT. RESULTS The minimal and mean heart rate (HR min and HR max) from 24-hr ECG recording was statistically significantly higher after the transplantation in comparison with the first test. The number of premature ventricular complexes (PVCs) was higher in the test after HSCT. In the second examination there was significantly higher percentage of premature ventricular complexes, incidents of tachycardia, and Mobitz type 1 second degree atrioventricular block. In regression analysis, in a group of patients with blood neoplasms after HSCT and HDC, administration of cyclophosphamide, fludarabine and total body irradiation were independent risk factors for electrocardiographic abnormalities in 24-hr Holter monitoring, that is, the increase in HR min, HR mean and PVCs. CONCLUSION In patients with blood neoplasms undergoing HSCT more electrocardiographic abnormalities may be found after this procedure in comparison with the 24-hr Holter monitoring before transplantation.
Collapse
Affiliation(s)
- Małgorzata Poręba
- Department of Pathophysiology, Wroclaw Medical University, Wroclaw, Poland
| | - Paweł Gać
- Department of Hygiene, Wroclaw Medical University, Wroclaw, Poland
| | - Lidia Usnarska-Zubkiewicz
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Witold Pilecki
- Department of Pathophysiology, Wroclaw Medical University, Wroclaw, Poland
| | - Kazimierz Kuliczkowski
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Grzegorz Mazur
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Wroclaw, Poland
| | | | - Rafał Poręba
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Wroclaw, Poland
| |
Collapse
|
19
|
TACHYARRHYTHMIAS IN PATIENTS WITH CANCER. КЛИНИЧЕСКАЯ ПРАКТИКА 2017. [DOI: 10.17816/clinpract8476-89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Arrhythmia is often detected in cancer patient, from single ventricular premature contractions to sustained ventricular tachycardia, life threatening ventricular fibrillation and sudden cardiac death. Oncology per se, aggressive anticancer treatment, both chemotherapy and radiation and basic cardiac conditions are main causative factors for tachyarrhythmia. In this review we summarize evidence of arrhythmia and emphasize the importance of cardiac monitoring for the early diagnosis, intervention and surveillance of those patients more susceptible to develop proarrhythmia. Oncologists should be fully aware of arrhythmia and the close collaboration between cardiologists and oncologists would result in a better cardiovascular assessment, risk stratification, cardiac monitoring and treatment.
Collapse
|
20
|
Mathur P, Thanendrarajan S, Paydak H, Vallurupalli S, Jambhekar K, Bhatti S, Schinke CD, Davies FE, Mehta JL. Cardiovascular complications of multiple myeloma in the elderly. Expert Rev Cardiovasc Ther 2017; 15:933-943. [PMID: 29164945 DOI: 10.1080/14779072.2017.1409114] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Multiple myeloma is a malignant neoplasm characterized by plasma cell proliferation in blood and bone marrow. Approximately two-thirds of the patients with multiple myeloma are >65 years at the time of diagnosis. Patients in this age group often have co-existing cardiovascular diseases. Areas covered: The presence of multiple myeloma adds to the malady by direct deposition of amyloid protein in the heart or via toxicity of chemotherapeutic agents. Cardiac contractile dysfunction, arrhythmias and thromboembolic disorders are the main issues in the management of elderly patients with multiple myeloma. Expert commentary: Assessment of cardiac risk and functional status requires careful evaluation by history, physical examination and imaging studies such as echocardiography and magnetic resonance imaging. The management of cardiovascular disorders in the presence of multiple myeloma is difficult and poses a challenge for the internist, the oncologist, and the cardiologist alike. This review is an overview of the problem of cardiovascular risk in and management of elderly patients with multiple myeloma.
Collapse
Affiliation(s)
- Pankaj Mathur
- a Myeloma Institute, Department of Medicine , University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Sharmilan Thanendrarajan
- a Myeloma Institute, Department of Medicine , University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Hakan Paydak
- b Department of Cardiovascular Medicine , Department of Medicine University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Srikanth Vallurupalli
- b Department of Cardiovascular Medicine , Department of Medicine University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Kedar Jambhekar
- b Department of Cardiovascular Medicine , Department of Medicine University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Sabha Bhatti
- c Department of Radiology , University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Carolina D Schinke
- a Myeloma Institute, Department of Medicine , University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Faith E Davies
- a Myeloma Institute, Department of Medicine , University of Arkansas Medical Sciences , Little Rock , AR , USA
| | - Jawahar L Mehta
- b Department of Cardiovascular Medicine , Department of Medicine University of Arkansas Medical Sciences , Little Rock , AR , USA
| |
Collapse
|
21
|
Buza V, Rajagopalan B, Curtis AB. Cancer Treatment–Induced Arrhythmias. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005443. [DOI: 10.1161/circep.117.005443] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 07/07/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Vitaly Buza
- From the Department of Medicine, University at Buffalo, NY
| | | | - Anne B. Curtis
- From the Department of Medicine, University at Buffalo, NY
| |
Collapse
|
22
|
Cheng WL, Kao YH, Chen SA, Chen YJ. Pathophysiology of cancer therapy-provoked atrial fibrillation. Int J Cardiol 2016; 219:186-94. [PMID: 27327505 DOI: 10.1016/j.ijcard.2016.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) occurs with increased frequency in cancer patients, especially in patients who undergo surgery or chemotherapy. AF disturbs the prognosis of cancer patients and challenges therapeutic outcomes of cancer treatment. Elucidating the mechanisms of cancer-induced AF would help identify specific strategies for preventing AF occurrence. In addition to concurrent risk factors of cancer and AF, cancer surgery, side effects of anticancer agents, and cancer-associated immune responses play critical roles in the genesis of AF. In this review, we provide succinct potential mechanisms of AF genesis in cancer patients.
Collapse
Affiliation(s)
- Wan-Li Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-Ann Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiology and Cardiovascular Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
23
|
Blaes A, Konety S, Hurley P. Cardiovascular Complications of Hematopoietic Stem Cell Transplantation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:25. [PMID: 26909819 PMCID: PMC4766226 DOI: 10.1007/s11936-016-0447-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OPINION STATEMENT Survivors of hematopoietic stem cell transplant (HSCT) are at significant risk for cardiac disease and cardiac complications. While there may be cardiac complications during the acute period of HSCT, long-term survivors remain at risk for cardiovascular disease at a rate at least fourfold higher than the general population. Aggressive screening for cardiac risk factors such as diabetes, hypertension, and arrhythmias is warranted pretransplant. For those with risk factors, particularly a history of cardiovascular disease or atrial fibrillation, cardiology consultation is warranted in the pretransplantation period. Aggressive screening for cardiac risk factors such as diabetes, hypertension, and hyperlipidemia is warranted in HSCT survivors as well; early and aggressive treatment of left ventricular dysfunction is warranted. Collaboration between hematology/oncology and cardiology through a cardio-oncology clinic is an optimal way to help manage these patients.
Collapse
Affiliation(s)
- Anne Blaes
- Division of Hematology/Oncology/Transplantion, University of Minnesota, 420 Delaware Street, S.E., MMC 480, Minneapolis, MN, 55455, USA.
| | - Suma Konety
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Peter Hurley
- Division of Hematology/Oncology/Transplantion, University of Minnesota, 420 Delaware Street, S.E., MMC 480, Minneapolis, MN, 55455, USA
| |
Collapse
|
24
|
Mathur P, Paydak H, Thanendrarajan S, van Rhee F. Atrial Fibrillation in Hematologic Malignancies, Especially After Autologous Hematopoietic Stem Cell Transplantation: Review of Risk Factors, Current Management, and Future Directions. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:70-5. [DOI: 10.1016/j.clml.2015.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 10/13/2015] [Accepted: 10/16/2015] [Indexed: 12/19/2022]
|
25
|
Tonorezos ES, Stillwell EE, Calloway JJ, Glew T, Wessler JD, Rebolledo BJ, Pham A, Steingart RM, Lazarus H, Gale RP, Jakubowski AA, Schaffer WL. Arrhythmias in the setting of hematopoietic cell transplants. Bone Marrow Transplant 2015; 50:1212-6. [PMID: 26030046 PMCID: PMC4558298 DOI: 10.1038/bmt.2015.127] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 03/15/2015] [Accepted: 04/09/2015] [Indexed: 11/15/2022]
Abstract
Prior studies report 9–27% of persons receiving a hematopoietic cell transplant develop arrhythmias, but the effect on outcomes is largely unknown. We reviewed data from 1177 consecutive patients {greater than or equal to}40 years old receiving a hematopoietic cell transplant at one center during 1999–2009. Transplant indication was predominately leukemia, lymphoma and multiple myeloma. Overall, 104 patients were found to have clinically significant arrhythmia: 43 prior to and 61 following transplant. Post-transplant arrhythmias were most frequently atrial fibrillation(N=30), atrial flutter(N=7) and supraventricular tachycardia(N=11). Subjects with an arrhythmia post-transplant were more likely to have longer median hospital stays (32 days vs 23, P=<.001,) a greater probability of an ICU admission (52% vs 7%; P<.001), more inhospital deaths (28% vs 3%, P<0.001), and more deaths within one year of transplant (41% vs 15%; P<0.001) than patients without arrhythmia at any time. In a multivariate model including age at transplant, diagnosis, history of pre-transplant arrhythmia, and transplant-related variables, post-transplant arrhythmia was associated with a greater risk of death within a year of transplant (OR 3.5, 95% CI: 2.1, 5.9; P < 0.001). Our data suggest arrhythmias after transplants are associated with significant morbidity and mortality. A prospective study of arrhythmia in the transplant setting is warranted.
Collapse
Affiliation(s)
- E S Tonorezos
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - E E Stillwell
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - J J Calloway
- Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - T Glew
- Department of Medicine, Beth Israel Medical Center, New York, NY, USA
| | - J D Wessler
- Department of Medicine, New York Presbyterian-Columbia, New York, NY, USA
| | - B J Rebolledo
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - A Pham
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - R M Steingart
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - H Lazarus
- Department of Medicine, UH Case Medical Center, Cleveland, OH, USA
| | - R P Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK
| | - A A Jakubowski
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - W L Schaffer
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
26
|
Gul Z, Bashir Q, Cremer M, Yusuf SW, Gunaydin H, Arora S, Slone S, Nieto Y, Sherwani N, Parmar S, Shah N, Dinh YT, Hosing CM, Popat UR, Kebriaei P, Shpall EJ, Giralt SA, Champlin RE, Qazilbash MH. Short-term cardiac toxicity of autologous hematopoietic stem cell transplant for multiple myeloma. Leuk Lymphoma 2015; 56:533-5. [PMID: 24882259 DOI: 10.3109/10428194.2014.926346] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Zartash Gul
- Department of Hematology/BMT, Markey Cancer Center, University of Kentucky Medical Center , Lexington, KY , USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Tamargo J, Caballero R, Delpón E. Cancer Chemotherapy and Cardiac Arrhythmias: A Review. Drug Saf 2015; 38:129-52. [DOI: 10.1007/s40264-014-0258-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
28
|
Aljitawi OS, Ganguly S, Abhyankar SH, Ferree M, Marks R, Pipkin JD, McGuirk JP. Phase IIa cross-over study of propylene glycol-free melphalan (LGD-353) and alkeran in multiple myeloma autologous transplantation. Bone Marrow Transplant 2014; 49:1042-5. [DOI: 10.1038/bmt.2014.120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/27/2014] [Accepted: 04/11/2014] [Indexed: 11/09/2022]
|
29
|
Incidence of supraventricular arrhythmias during autologous peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2013; 19:1233-7. [PMID: 23747600 DOI: 10.1016/j.bbmt.2013.05.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 05/29/2013] [Indexed: 11/19/2022]
Abstract
Arrhythmias, especially supraventricular arrhythmias, often complicate the clinical course during autologous hematopoietic cell transplantation (AHCT). We wanted to determine the incidence and risk factors for cardiac arrhythmias during AHCT. The study included 983 patients (median age, 58 years [range, 19 to 77]; 61% male) who underwent AHCT between August 2006 and December 2010 at a single institution and for whom all relevant medical records were available for review. AHCT was done for plasma cell disorders in 58% patients and for lymphoma or leukemia in the remaining. Overall, 92 patients (9.4%) developed a supraventricular tachyarrhythmia at a median of 9 days posttransplantation (range, 0 to 18) and with a median duration of less than 1 day (range, <1 to 17 days). Atrial fibrillation was the most common and seen in 71 patients (7%), followed by atrial flutter and supraventricular tachycardia in 12 (1%) and 8 (1%) patients, respectively. In multivariate analysis, age older than 63 years, presence of premature supraventricular complexes or atrioventricular conduction delay on pretransplantation electrocardiogram, and history of any prior arrhythmia increased the risk of arrhythmia. Development of arrhythmia resulted in longer outpatient follow-up after AHCT, with the median follow-up for those developing an arrhythmia of 22 days compared with 19 days for the rest; P < .001. In conclusion, 9% of patients undergoing ASCT developed supraventricular arrhythmias posttransplantation, and this risk was elevated among older patients, those with a prior history of arrhythmias, and those with pretransplantation electrocardiographic abnormalities.
Collapse
|
30
|
Martino M, Olivieri A, Offidani M, Vigna E, Moscato T, Fedele R, Montanari M, Console G, Gentile M, Messina G, Irrera G, Morabito F. Addressing the questions of tomorrow: melphalan and new combinations as conditioning regimens before autologous hematopoietic progenitor cell transplantation in multiple myeloma. Expert Opin Investig Drugs 2013; 22:619-34. [DOI: 10.1517/13543784.2013.788643] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Martino
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Attilio Olivieri
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Massimo Offidani
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Ernesto Vigna
- Divisione di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera, Cosenza, Italy
| | - Tiziana Moscato
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Roberta Fedele
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Mauro Montanari
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Giuseppe Console
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Massimo Gentile
- Divisione di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera, Cosenza, Italy
| | - Giuseppe Messina
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Giuseppe Irrera
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Fortunato Morabito
- Divisione di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera, Cosenza, Italy
| |
Collapse
|
31
|
Factors affecting the development of atrial fibrillation and atrial flutter (AF/AFL) following autologous hematopoietic SCT (auto-HSCT). Bone Marrow Transplant 2012; 48:963-5. [PMID: 23222385 DOI: 10.1038/bmt.2012.253] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/29/2012] [Accepted: 11/06/2012] [Indexed: 11/08/2022]
Abstract
The use of autologous hematopoietic SCT (auto-HSCT) has expanded to include older patients. Increasing age is a well-appreciated risk factor for the development of atrial fibrillation and/or atrial flutter (AF/AFL) in the general population. As more elderly patients undergo auto-HSCT, the risk of developing AF/AFL post transplant may also increase. However, few data evaluating other risk factors for the development of AF/AFL following auto-HSCT exist. Therefore, we performed a retrospective study to determine the incidence of AF/AFL following auto-HSCT and to determine the risk factors associated with the development of AF/AFL. Patients who developed AF/AFL were compared with a group of patients who received auto-HSCT within the same time period (April 1999 to May 2005) and were within 5 years of age. Of the 516 patients who underwent auto-HSCT at the University of Nebraska Medical Center 44 (8.5%) developed AF/AFL at a median time of 4 days (range, days 1-9) following auto-HSCT. In multivariate analysis, risk factors for developing AF/AFL were older age, odds ratio and 95% CI of 1.14 (1.07-1.21), elevated serum creatinine level, 2.69 (1.00-7.22), history of previous arrhythmia, 9.33 (3.01-28.99), and history of previous mediastinal irradiation, 11.12 (1.33-92.96).
Collapse
|
32
|
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia and an important cause of hospitalization, morbidity, and mortality. A myriad of drugs can induce AF. However, drug-induced AF (DIAF) receives little attention. Thus, this review is an attempt to attract the attention on this adverse effect. AREAS COVERED Published reports of drug-induced AF (DIAF) are reviewed in this paper, from January 1974 to December 2011, using the PubMed/Medline database and lateral references. EXPERT OPINION In most cases, DIAF is paroxysmal and terminates spontaneously, but sometimes AF persists and it is necessary to perform a cardioversion to restore sinus rhythm and avoid progression to persistent AF. Because of the short duration of DIAF, in addition to physicians/patients not being knowledgeable about this side effect, the real incidence and clinical consequences of DIAF are presently unknown. DIAF is an increasing problem, as some widely prescribed drugs can present this adverse effect. The risk is expected to increase in the elderly and in patients with comorbidities. It is important that physicians understand the significance of DIAF, to increase the collaboration between cardiac and non-cardiac professionals, and to educate patients to make them aware of this adverse side effect.
Collapse
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, 28040 Madrid, Spain.
| | | | | |
Collapse
|
33
|
Sureddi RK, Amani F, Hebbar P, Williams DK, Leonardi M, Paydak H, Mehta J. Atrial fibrillation following autologous stem cell transplantation in patients with multiple myeloma: incidence and risk factors. Ther Adv Cardiovasc Dis 2012; 6:229-36. [DOI: 10.1177/1753944712464102] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: Atrial fibrillation (AF) often develops in patients with multiple myeloma following autologous stem cell transplantation (ASCT), but the exact incidence of, and the risk factors for AF have not been described. In this study, we sought to determine the incidence of AF in patients with multiple myeloma undergoing ASCT. Methods: Patients who received ASCT for multiple myeloma between January 2000 and December 2009 were identified using the ICD-9 codes for multiple myeloma and ASCT, and formed the basis of this report. Results: The study included 278 patients (mean age, 63 ± 9.5 years). A total of 75 (27%) patients developed AF at a mean duration of 14.8 days following ASCT. On multiple regression analysis, baseline renal dysfunction (odds ratio 15.2 [confidence interval 5.08–45.6]), left ventricular systolic dysfunction (9.55 [2.78–32.79]), dilated left atrium on echocardiogram (4.97 [1.8–13.78]), and hypertension (3.6 [1.36–9.52]) were significantly associated with the development of AF after ASCT. The presence of light-chain secretion (0.21 [0.07–0.6]) was associated with a lower incidence of AF. Age, gender, and race were not significantly associated with the development of AF after ASCT. Conclusions: AF is very frequent in patients with multiple myeloma when they receive ASCT. The presence of abnormal renal function, left ventricular systolic dysfunction, dilated left atrium, or hypertension at baseline identifies patients at high risk of developing AF following ASCT.
Collapse
Affiliation(s)
- Ravi K. Sureddi
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot #532, Little Rock, AR 72211, USA
| | - Fariba Amani
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Prabhat Hebbar
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David K. Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Marino Leonardi
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hakan Paydak
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J.L. Mehta
- Division of Cardiology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
34
|
Bayraktar UD, Bashir Q, Qazilbash M, Champlin RE, Ciurea SO. Fifty years of melphalan use in hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 19:344-56. [PMID: 22922522 DOI: 10.1016/j.bbmt.2012.08.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/17/2012] [Indexed: 12/22/2022]
Abstract
Melphalan remains the most widely used agent in preparative regimens for hematopoietic stem cell transplantation (SCT). From its initial discovery more than 50 years ago, it has been gradually incorporated in the conditioning regimens for both autologous and allogeneic transplantations because of its myeloablative properties and broad antitumor effects as a DNA alkylating agent. Melphalan remains the mainstay conditioning for multiple myeloma and lymphomas, and it has been used successfully in preparative regimens of a variety of other hematological and nonhematological malignancies. The addition of newer agents to conditioning, such as bortezomib or lenalidomide for myeloma or clofarabine for myeloid malignancies, may improve antitumor effects for transplantation, whereas melphalan in combination with alemtuzumab may represent a backbone for future cellular therapy because of reliable engraftment and low toxicity profile. This review summarizes the development and the current use of this remarkable drug in hematopoietic SCT.
Collapse
Affiliation(s)
- Ulas D Bayraktar
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | | | | | | |
Collapse
|
35
|
Bleeker JS, Gertz MA, Pellikka PA, Larson DR, Buadi F, Dingli D, Dispenzieri A, Hayman SR, Hogan W, Kumar S, Rajkumar SV, Lacy MQ. Evaluation of pretransplant factors predicting cardiac dysfunction following high-dose melphalan conditioning and autologous peripheral blood stem cell transplantation. Eur J Haematol 2012; 89:228-35. [PMID: 22672722 DOI: 10.1111/j.1600-0609.2012.01815.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac complications following hematopoietic stem cell transplantation (HSCT) are emerging as a significant concern given the increasing utilization of HSCT for a variety of hematologic malignancies. METHODS We utilized an existing database to determine the frequency of cardiac dysfunction (CD), namely a decrease in left ventricular ejection fraction, following conditioning with high-dose melphalan (HDM) and autologous HSCT for multiple myeloma (MM) and systemic amyloidosis (AL). We then performed a case-control study to examine variables associated with increased risk of CD in this population. RESULTS In MM patients undergoing HSCT, the rate of CD was 1.6% (17/1050, 95% CI: [0.9, 2.6]). None of the examined pre-HSCT variables or HDM dose were significantly associated with development of CD in this population. In patients with AL, the rate of CD was 5.6% (24/426, 95% CI: [3.6, 8.3]). On univariate analysis, decision to administer an HDM dose <200 mg/m(2) [odds ratio (OR): 4.59 (1.27-16.57) P = 0.02], pretransplant left ventricular ejection fraction <60% [OR: 17.78 (2.29-138.33) P = 0.006], and documented amyloid involvement of ≥ 3 organs [OR: 4.0 (1.03-15.6) P = 0.046] were associated with the development of CD in the AL population. No other examined peri-transplant factors were associated with development of CD. CONCLUSION To our knowledge, this is the first series to report a significant rate of CD following HDM conditioning and autologous HSCT in patients with AL.
Collapse
|
36
|
A Phase I Trial: Dose Escalation of Melphalan in the “BEAM” Regimen Using Amifostine Cytoprotection. Biol Blood Marrow Transplant 2011; 17:1033-42. [DOI: 10.1016/j.bbmt.2010.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 11/02/2010] [Indexed: 11/22/2022]
|
37
|
Feliz V, Saiyad S, Ramarao SM, Khan H, Leonelli F, Guglin M. Melphalan-induced supraventricular tachycardia: incidence and risk factors. Clin Cardiol 2011; 34:356-9. [PMID: 21538392 DOI: 10.1002/clc.20904] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 01/30/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cardiotoxicity of aggressive chemotherapeutic regimens includes cardiomyopathy and arrhythmias. Although cardiomyopathy is a well-recognized entity, arrhythmias are poorly studied. HYPOTHESIS Certain chemotherapeutic regimes are associated with supraventricular arrhythmias, particularly atrial fibrillation. METHODS We retrospectively reviewed the data on patients who received hematopoietic stem cell transplant (bone marrow transplant; BMT) from 1998 to 2005 and developed supraventricular tachycardia (SVT) during the same hospital admission. The Fisher χ2 test and the Student t test were used for comparison of categorical and continuous variables, respectively. RESULTS During the period of 1998-2005, there were 1221 BMTs, 62 (5.1%) of which were complicated by SVT. Melphalan-based regimens demonstrated a significantly higher rate of SVT than any other chemotherapy. Out of 438 patients who received melphalan, 48 (11%) developed atrial fibrillation (n = 35) or SVT (n = 13) during the same hospital admission, and 390 did not. Patients with SVT were older, had higher baseline creatinine, larger size of the left atrium, and more cardiac comorbidities. Incidence of SVT was associated with greater length of stay (24.9 ± 8.9 d vs 19.6 ± 5.8 days, P<0.0001), even after adjustment for comorbidities. CONCLUSIONS Supraventricular tachycardia, mostly atrial fibrillation, complicates about 5% of chemotherapeutic treatments used with BMT. Melphalan is the most arrhythmogenic agent, and is associated with SVT in 11% of patients. Development of SVT results in about a 4-day increase in the length of hospital stay.
Collapse
Affiliation(s)
- Victor Feliz
- Department of Medicine, Division of Cardiology, University of South Florida, Tampa, Florida 33606, USA
| | | | | | | | | | | |
Collapse
|
38
|
Guglin M, Aljayeh M, Saiyad S, Ali R, Curtis AB. Introducing a new entity: chemotherapy-induced arrhythmia. Europace 2009; 11:1579-86. [DOI: 10.1093/europace/eup300] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
39
|
Cardiac complications in patients undergoing a reduced-intensity conditioning hematopoietic stem cell transplantation. Bone Marrow Transplant 2009; 45:149-52. [PMID: 19465940 DOI: 10.1038/bmt.2009.97] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Reduced-intensity conditioning (RIC) extends hematopoietic stem cell transplants (HSCT) to elderly or debilitated patients who are not candidates for HSCT. The incidence and outcomes of cardiac complications have been reported following myeloablative HSCT. We assessed the incidence and outcomes of cardiac complications in 278 recipients of RIC from July 2000 to July 2006. All patients received conditioning with BU, fludarabine and TBI. Patients were evaluated from conditioning therapy until 100 days after HSCT. Median age was 56 years. Cardiac events were defined as either one or more of the following: arrhythmias, myocardial infarction or congestive heart failure. Twenty-five patients developed arrhythmias at a median of 3 days post transplant, in 19 patients hemodynamic compromise occurred and mechanical ventilation was required in 15 patients. The arrhythmias included atrial fibrillation (n=17), atrial flutter (n=6) and supraventricular tachycardia (n=2). Troponin was elevated in 12 out of 25 patients. The mean brain natriuretic peptide was 679. All patients converted to a normal rhythm by medical therapy at a median of 2 days. Recurrence of arrhythmia occurred in 76% of patients. Day 100 mortality was 40% in this group. A history of high-dose anthracycline treatment and a low ejection fraction were risk factors for the development of cardiac complications.
Collapse
|
40
|
Jones RL, Ewer MS. Cardiac and cardiovascular toxicity of nonanthracycline anticancer drugs. Expert Rev Anticancer Ther 2006; 6:1249-69. [PMID: 17020459 DOI: 10.1586/14737140.6.9.1249] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anthracyclines are a well-known cause of cardiotoxicity, but a number of other drugs used to treat cancer can also result in cardiac and cardiovascular adverse effects. Cardiotoxicity can result in the alteration of cardiac rhythm, changes in blood pressure and ischemia, and can also alter the ability of the heart to contract and/or relax. The clinical spectrum of these toxicities can range from subclinical abnormalities to catastrophic life-threatening, and sometimes fatal, sequelae. These events may occur acutely or may only become apparent months or years following completion of oncological treatment. Ischemia and rhythm abnormalities are treated symptomatically in most cases. Knowledge of these toxicities can aid clinicians to choose the optimal and least toxic regimen suitable for an individual patient.
Collapse
Affiliation(s)
- Robin L Jones
- Royal Marsden Hospital, Department of Medicine, Fulham Road, London SW3 6JJ, UK.
| | | |
Collapse
|
41
|
Morandi P, Ruffini PA, Benvenuto GM, Raimondi R, Fosser V. Cardiac toxicity of high-dose chemotherapy. Bone Marrow Transplant 2005; 35:323-34. [PMID: 15543194 DOI: 10.1038/sj.bmt.1704763] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac toxicity is an uncommon but potentially serious complication of high-dose (HD) chemotherapy and little is known about incidence, severity and underlying mechanisms. We have systematically reviewed the literature of the last 30 years to summarize and appraise the published evidence on cardiac toxicity associated with HD chemotherapy. HD cyclophosphamide-containing regimens have been most commonly associated with cardiac toxicity, with a progressively decreasing incidence over time. Dosage, application regimens and coadministration of other chemotherapeutic agents emerged as risk factors. While cardiac toxicity has been rarely associated with other cytotoxic drugs, an unexpected incidence of severe cardiotoxicity resulted from reduced-intensity conditioning regimens containing melphalan and fludarabine. Predictive value of cardiologic examination of patients is limited, and patients with a slight depression of cardiac performance could tolerate HD chemotherapy. Clinical examination, resting electrocardiography and dosage adjustment in overweight patients remain the mainstay of prevention, with bidimensional echocardiography (2D echo) for patients with a history of anthracycline exposure. Strategies to decrease the long-term negative impact of anthracycline administration on cardiac performance are being investigated. New 2D echo-based techniques and circulating markers of cardiac function hold promise for allowing identification of patients at high risk for and early diagnosis of cardiac toxicity.
Collapse
Affiliation(s)
- P Morandi
- Divisione Oncologia Medica, Ospedale San Bortolo, Vicenza, Italy.
| | | | | | | | | |
Collapse
|
42
|
Hidalgo JD, Krone R, Rich MW, Blum K, Adkins D, Fan MY, Brown R, Devine S, Graubert T, Blum W, Tomasson M, Goodnough LT, Vij R, DiPersio J, Khoury H. Supraventricular tachyarrhythmias after hematopoietic stem cell transplantation: incidence, risk factors and outcomes. Bone Marrow Transplant 2005; 34:615-9. [PMID: 15258562 DOI: 10.1038/sj.bmt.1704623] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent studies suggest that cancer patients may be at increased risk for supraventricular tachyarrhythmias (SVTA). We have observed clinically significant SVTA in patients undergoing hematopoietic stem cell transplantation occurring at a median of 6 days post transplant, manifesting as atrial fibrillation/flutter or regular narrow-complex tachycardia and persisting for a median of 3 days (range, 0-8). All patients received aggressive medical therapy and/or electrical cardioversion to restore sinus rhythm and to re-establish hemodynamic stability. Non-Hodgkin's lymphoma (NHL) was the most common diagnosis (53%), and a case control analysis in those patients demonstrated that SVTA occurred in 12% of patients and was associated with older age and pre-existing cardiac conditions. In conclusion, patients undergoing HSCT are at moderate risk for developing SVTA, particularly older patients with a diagnosis of NHL. These arrhythmias are clinically significant, and are a marker for increased mortality and prolonged hospital stay. Additional studies are needed to identify high-risk patients who may benefit from prophylactic anti-arrhythmic therapy.
Collapse
Affiliation(s)
- J D Hidalgo
- Division of Oncology, Section of BMT and Leukemia, and Division of Cardiology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
van der Hooft CS, Heeringa J, van Herpen G, Kors JA, Kingma JH, Stricker BHC. Drug-induced atrial fibrillation. J Am Coll Cardiol 2004; 44:2117-24. [PMID: 15582307 DOI: 10.1016/j.jacc.2004.08.053] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Revised: 08/06/2004] [Accepted: 08/16/2004] [Indexed: 12/18/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained rhythm disorder observed in clinical practice and predominantly associated with cardiovascular disorders such as coronary heart disease and hypertension. However, several classes of drugs may induce AF in patients without apparent heart disease or may precipitate the onset of AF in patients with preexisting heart disease. We reviewed the literature on drug-induced AF, using the PubMed/Medline and Micromedex databases and lateral references. Successively, we discuss the potential role in the onset of AF of cardiovascular drugs, respiratory system drugs, cytostatics, central nervous system drugs, genitourinary system drugs, and some miscellaneous agents. Drug-induced AF may play a role in only a minority of the patients presenting with AF. Nevertheless, it is important to recognize drugs or other agents as a potential cause, especially in the elderly, because increasing age is associated with multiple drug use and a high incidence of AF. This may contribute to timely diagnosis and management of drug-induced AF.
Collapse
Affiliation(s)
- Cornelis S van der Hooft
- Pharmaco-epidemiology Unit, Department of Epidemiology & Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
44
|
Phillips GL, Meisenberg B, Reece DE, Adams VR, Badros A, Brunner J, Fenton R, Filicko J, Grosso D, Hale GA, Howard DS, Johnson VP, Kniska A, Marshall KW, Nath R, Reed E, Rapoport AP, Takebe N, Vesole DH, Wagner JL, Flomenberg N. Amifostine and autologous hematopoietic stem cell support of escalating-dose melphalan: A phase I study. Biol Blood Marrow Transplant 2004; 10:473-83. [PMID: 15205668 DOI: 10.1016/j.bbmt.2004.03.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study was conducted to define a new maximum tolerated dose and the dose-limiting toxicity (DLT) of melphalan and autologous hematopoietic stem cell transplantation (AHSCT) when used with the cytoprotective agent amifostine. Fifty-eight patients with various types of malignancy who were ineligible for higher-priority AHSCT protocols were entered on a phase I study of escalating doses of melphalan beginning at 220 mg/m(2) and advancing by 20 mg/m(2) increments in planned cohorts of 4 to 8 patients until severe regimen-related toxicity (RRT) was encountered. In all patients, amifostine 740 mg/m(2) was given on 2 occasions before the first melphalan dose (ie, 24 hours before and again 15 minutes before). AHSCT was given 24 hours after the first melphalan dose. Melphalan was given in doses up to and including 300 mg/m(2). Hematologic depression was profound, although it was rapidly and equally reversible at all melphalan doses. Although mucosal RRT was substantial, it was not the DLT, and some patients given the highest melphalan doses (ie, 300 mg/m(2)) did not develop mucosal RRT. The DLT was not clearly defined. Cardiac toxicity in the form of atrial fibrillation occurred in 3 of 36 patients treated with melphalan doses >/=280 mg/m(2) and was deemed fatal in 1 patient given melphalan 300 mg/m(2). (Another patient with a known cardiomyopathy was given melphalan 220 mg/m(2) and died as a result of heart failure but did not have atrial fibrillation.) Another patient given melphalan 300 mg/m(2) died of hepatic necrosis. The maximum tolerated dose of melphalan in this setting was thus considered to be 280 mg/m(2), and 27 patients were given this dose without severe RRT. Moreover, 38 patients were evaluable for delayed toxicity related to RRT; none was noted. Tumor responses have been noted at all melphalan doses and in all diagnostic groups, and 21 patients are alive at median day +1121 (range, day +136 to day +1923), including 16 without evidence of disease progression at median day +1075 (range, day +509 to day +1638). Amifostine and AHSCT permit the safe use of melphalan 280 mg/m(2), an apparent increase over the dose of melphalan that can be safely administered with AHSCT but without amifostine. Further studies are needed not only to confirm these findings, but also to define the antitumor efficacy of this regimen. Finally, it may be possible to evaluate additional methods of further dose escalation of melphalan in this setting.
Collapse
Affiliation(s)
- G L Phillips
- Blood and Marrow Transplant Program, University of Kentucky, Lexington, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Phillips GL. The potential of amifostine in high-dose chemotherapy and autologous hematopoietic stem cell transplantation. Semin Oncol 2002. [DOI: 10.1016/s0093-7754(02)70011-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
46
|
Ritchie DS, Seymour JF, Roberts AW, Szer J, Grigg AP. Acute left ventricular failure following melphalan and fludarabine conditioning. Bone Marrow Transplant 2001; 28:101-3. [PMID: 11498753 DOI: 10.1038/sj.bmt.1703098] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2000] [Accepted: 04/16/2001] [Indexed: 11/08/2022]
Abstract
Cardiotoxicity has rarely been reported as a complication of melphalan or fludarabine administration as single agents. Recently, melphalan and fludarabine have been used in combination as non-myeloablative conditioning chemotherapy prior to allogeneic stem cell transplantation. We have observed the development of severe left ventricular failure in three of 21 patients treated with this combination. Cardiotoxicity in this context has not previously been reported and has implications for the assessment, monitoring and treatment of patients undergoing pre-transplant conditioning with melphalan and fludarabine.
Collapse
Affiliation(s)
- D S Ritchie
- Bone Marrow Transplant Service, Department of Clinical Haematology and Medical Oncology, Royal Melbourne Hospital, Melbourne, Australia
| | | | | | | | | |
Collapse
|
47
|
Abstract
Although patients with cancer may derive much benefit from treatment, they are at risk for developing life-threatening complications. Hypersensitivity reactions can be severe, as in the case of anaphylaxis with L-asparaginase. Cardiac toxicities consist of arrhythmias with various drugs, hemorrhagic myocarditis with cyclophosphamide and ifosfamide, cardiomyopathy with anthracyclines, and pericardial disease. Acute respiratory failure may occur as a result of ARDS caused by ATRA or cytarabine, from interstitial fibrosis, or from pulmonary veno-occlusive disease. Hemorrhagic cystitis caused by cyclophosphamide and ifosfamide can be severe and result in exsanguination if unresponsive to treatment. Disseminated intravascular coagulation and thrombotic microangiopathy can produce thrombotic or hemorrhagic complications. Gastrointestinal toxicities include significant hepatotoxicity with a variety of drugs and development of acute surgical abdomen.
Collapse
Affiliation(s)
- C Shanholtz
- Department of Medicine, Divisions of Pulmonary and Critical Care Medicine and Hematology and Medical Oncology, University of Maryland School of Medicine, Baltimore, USA.
| |
Collapse
|
48
|
Olivieri A, Capelli D, Montanari M, Brunori M, Massidda D, Poloni A, Lucesole M, Centurioni R, Candela M, Masia MC, Tonnini C, Leoni P. Very low toxicity and good quality of life in 48 elderly patients autotransplanted for hematological malignancies: a single center experience. Bone Marrow Transplant 2001; 27:1189-95. [PMID: 11551030 DOI: 10.1038/sj.bmt.1703034] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Between May 1994 and May 2000, we autotransplanted 48 consecutive patients, 21 females and 27 males aged over 60 years (range: 60-78, median: 63). Sixteen patients had multiple myeloma (MM), 14 high-grade non-Hodgkin's lymphoma (HGNHL), six low-grade non-Hodgkin's lymphoma (LGNHL), nine acute myeloid leukemia (AML), one chronic lymphocytic leukemia (CLL), one Hodgkin's disease (HD) and one breast cancer; the performance status (WHO) was 0-1. Seventeen patients were in 1st CR (35.4%) and one in 2nd CR (2.1%), 25 in PR (52.1%), while five patients had been transplanted with progressive disease (10.4%); seven patients with MM received a double transplant. Patients received high-dose therapy including melphalan alone (13) or associated with other drugs (26), busulfan-cyclophosphamide (three), BEAM (11) and TBI (two). All patients took a median of 11 (range: 8-25) days to reach neutrophils >500/microl, 13 (range: 9-83) days to reach platelets > 20,000/microl and 17 (range: 11-83) days to reach platelets > 50,000/microl. Hematological toxicity, hospital stay and supportive care did not differ from those of a cohort of younger patients. At present, 31 patients are alive (14 in CR, five in PR, five in PD and seven in relapse) and 16 died from PD at a median follow-up of 37 months (1-67). Only one patient died from transplant-related toxicity. Quality of life, evaluated using a QLQ-C30 questionnaire in 25 patients at day +90, was good. In our experience PBPC mobilization and transplantation is feasible in patients aged > or = 60 years and the toxicity of this procedure is acceptable, with an early transplant-related mortality of 1.8%; therefore patients with hematological malignancies potentially curable with high-dose therapy (HDT) should also be candidates for HDT.
Collapse
Affiliation(s)
- A Olivieri
- Hematology Department, University of Ancona, Italy
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Cetkovský P, Skopek P, Schützová M. Causative factors for prolonged hospitalization beyond the point of engraftment in patients after autologous peripheral blood stem cell transplantation. Bone Marrow Transplant 2000; 26:877-80. [PMID: 11081388 DOI: 10.1038/sj.bmt.1702632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In order to assess the incidence and analyze reasons which cause prolongation of hospital stay in patients engrafted after peripheral blood stem cell transplantation (PBSCT), we performed this retrospective analysis. One hundred patients (receiving 123 conditioning regimens) were included in the analysis. Criteria for discharge were presence of myeloid engraftment and absence of severe concomitant problems. Ninety subjects (73%) were discharged just after engraftment was reached on day +12 (10-14). Discharge was delayed in 33 patients (27%) and the mean prolongation was 3 days (1-11). In 31 patients (25%) delayed discharge was due to complications: in 14 patients (11.4%) because of GIT problems, in 16 patients (13%) because of infectious complications and in one patient because of cardiotoxicity. A significantly higher number of infectious complications was found in patients conditioned with BEAM (19.7% vs 4.2%, P < 0.05) while GIT toxicity was the most common reason for discharge delays in patients conditioned with melfalan 200 mg/m2 (8.2% vs 14.7%, NS). No risk factors of hospital stay prolongation were determined. We conclude that in spite of rapid engraftment, non-hematological toxicities and infections remain important limitations for further reduction of the length of patient hospitalization in a significant number of patients after PBSCT.
Collapse
Affiliation(s)
- P Cetkovský
- Department of Hematology and Oncology, Charles University Hospital, Plzen (Pilsen), Czech Republic
| | | | | |
Collapse
|