Top Things to Know: The Cardiovascular Management of Patients Undergoing Hematopoietic Stem Cell Transplantation: From Pre-Transplant to Survivorship
Published: March 11, 2024
Prepared by Christopher W. Hoeger, MD, Instructor, Harvard Medical School
- Hematopoietic stem cell transplantation (HSCT) can cure various disorders including malignancies, bone marrow failure and other genetic disorders, but poses cardiovascular (CV) risks, especially for older patients and those with CV diseases.
- The most frequent acute CV complications of HSCT include new-onset arrhythmias, primarily atrial fibrillation and flutter (2-10%) and heart failure (0.4-2.2%). Other complications including myocardial infarction, stroke, ventricular arrhythmia, pericardial effusions, pericarditis, and myocarditis, are rare in adult patients.
- Long term, HSCT survivors have increased rates of CV events, including arrhythmias, ischemic heart disease, stroke, and vascular disease compared to the general population, as well as comorbidities including hypertension, hyperlipidemia, and type 2 diabetes mellitus. The 5-year incidence of CV events in pediatric patients is 1%, but these patients are at high risk of diabetes (7%) and dyslipidemia (63%), potentially increasing CV risk later in life.
- Patient comorbidities, conditioning regimen, HSCT type, and cancer-related factors modulate the risk of CV complications of HSCT. Significant risk factors include older age at transplant, allogenic vs autologous HSCT, and cumulative anthracycline dose of 250 mg/m2 or greater.
- Pre-HSCT CV evaluation consists of initial risk stratification, exclusion of high-risk CV disease, and assessment and optimization of cardiac reserve. High-risk CV conditions include advanced heart failure, untreated severe valvular heart disease, severe triple-vessel or left main coronary artery disease and preclude candidacy from HSCT unless corrective intervention is possible.
- Baseline assessment of cardiac function, preferably with echocardiography is important to assess left ventricular (LV) function and for evaluation of valvular heart disease. Patients with adequate cardiopulmonary reserve of >= 4 METS are appropriate candidates for HSCT regardless of LVEF.
- Poor cardiopulmonary fitness is common in patients with cancer. Patient assessment prior to transplant includes baseline cardiac reserve with a detailed assessment of symptoms and signs of CV disease, with consideration given to quantitative assessment of functional capacity.
- High dose alkylating agents such as cyclophosphamide are associated with heart failure, atrial arrhythmia, pericardial effusion, and myocarditis, mediated through inflammation, oxidative stress, alterations in calcium homeostasis, and programmed cell death. Other conditioning agents, including busulfan, carmustine, and melphalan are rarely associated with cardiotoxicity.
- Iatrogenic volume overload is common in patients with cancer and may trigger atrial arrhythmias such as atrial fibrillation. In asymptomatic and hemodynamically stable patients, treatment of hypervolemia with diuretics precedes rate control initiation, reserving rhythm control strategies for hemodynamically unstable patients given the high rates of peri-transplant thrombocytopenia precluding use of systemic anticoagulation.
- In acute myocardial infarction during HSCT with underlying thrombocytopenia, urgent percutaneous coronary angiography is reserved for high-risk scenarios, including ST-elevation, ischemic cardiomyopathy, or ischemic chest pain unresponsive to medical intervention given the risk of life-threatening bleeding complications associated with dual antiplatelet therapy and systemic anticoagulation. If antiplatelet therapies are used, periprocedural platelet transfusions, avoidance of glycoprotein IIb/IIIa inhibitors, and postponing use of a second antiplatelet therapy until improvement of thrombocytopenia can reduce bleeding risk.
- In HSCT survivors, there is a low threshold to evaluate for CV causes of symptoms. High-risk individuals may benefit from routine imaging surveillance with echocardiography. For childhood cancer survivors, monitoring with serial echocardiography based on the total anthracycline and chest radiation dose received is an important aspect of care.
Citation
Hayek SS, Zaha VG, Bogle C, Deswal A, Langston A, Rotz S, Vasbinder A, Yang E, Okwuosa T; on behalf of the American Heart Association Cardio-Oncology Committee of the Council on Clinical Cardiology and Council on Genomic and Precision Medicine; and the Council on Cardiovascular and Stroke Nursing. The cardiovascularmanagement of patients undergoing hematopoietic stem cell transplantation: from pretransplantation tosurvivorship: a scientific statement from the American Heart Association. Circulation. Published online March 11, 2024. doi: 10.1161/CIR.0000000000001220