Atrial Fibrillation in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Abstract

PURPOSE To examine the incidence and risk factors for de novo atrial fibrillation (AF) after allogeneic hematopoietic cell transplantation (HCT) and to describe the impact of AF on HCT-related outcomes. METHODS A retrospective cohort study design was used to examine AF and associated outcomes in 487 patients who underwent allogeneic HCT from 2014 to 2016 and to characterize patient- and HCT-related risk factors. A nested case-control study design was used to describe the association between pre-HCT echocardiographic measures and future AF events. RESULTS The median age at HCT was 52.4 years (18.1-78.6); the median time to AF was 117.5 days (4.0-1,405.0). The 5-year cumulative incidence of AF was 10.6%. Older (≥ 50 years) age (hazard ratio [HR], 2.76; 95% CI, 1.37 to 5.58), HLA-unrelated donor (HR, 2.20; 95% CI, 1.18 to 4.12), dyslipidemia (HR, 2.40; 95% CI, 1.23 to 4.68), and pre-HCT prolonged QTc interval (HR, 2.55; 95% CI, 1.38 to 4.72) were independent risk factors for AF. Despite having comparable left ventricular systolic function, patients who developed AF were significantly more likely to have lower left atrial ejection fraction, left atrial reservoir function, and elevated tricuspid regurgitant jet velocity prior to HCT, compared with patients who did not. The incidence rate of stroke after AF was 143 per 1,000 person-years. In adjusted analyses, AF was associated with a 12.8-fold (HR, 12.76; 95% CI, 8.76 to 18.57) risk of all-cause mortality and 15.8-fold (HR, 15.78; 95% CI, 8.70 to 28.62) risk of nonrelapse mortality. CONCLUSION The burden of AF after allogeneic HCT population is substantial, and the development of AF is associated with poor survival. We identified important associations between patient demographics, pre-HCT cardiac parameters, HCT-related exposures, and risk of AF, setting the stage for targeted prevention strategies during and after HCT.

Trends and in‐hospital cardiac complications in patients with atrial fibrillation undergoing allogeneic stem cell transplant: A National Inpatient Sample analysis (2002–2019)

“…ened in-hospital adverse events, a large portion of which was driven by cardiovascular mortality. 9 The aforementioned trends are reflected in our study which showed greater odds of all-cause mortality and anticipatory cardiac complications including aCHF. Structural T A B L E 2 Summary of total number of events and adjusted odds ratios for in-hospital complications.…”

“…Atrial arrhythmias are common in hematological malignancies and the presence of arrhythmias in patients undergoing ASCT has previously been associated with increased likelihood of ICU admission, longer median hospital stay, and higher in‐hospital mortality 8 . A retrospective study by Chang et al correlated echocardiographic parameters such as increased left atrial ejection fraction and volume index to the development of AF post‐ASCT; they also noted worsened in‐hospital adverse events, a large portion of which was driven by cardiovascular mortality 9 . The aforementioned trends are reflected in our study which showed greater odds of all‐cause mortality and anticipatory cardiac complications including aCHF.…”

“…Thrombocytopenia poses a significant challenge for stroke prophylaxis in patients with hematological malignancies and AF, although withholding anticoagulation short‐term appears to be a safe strategy without an increase in ischemic stroke events 24 . Chang et al in their analysis of patients with new‐onset AF following ASCT reported an incidence rate of 143 per 1000 person‐years during a 34.8 person‐year follow‐up period 9 . Our analysis did not reveal a statistically significant difference between the odds of ischemic stroke in patients with AF indicating a similar short‐term risk of ischemic stroke between the groups.…”

Chemotherapy-Free Targeted Anti-BCR-ABL+ Acute Lymphoblastic Leukemia Therapy May Benefit the Heart

“…The cardiac comorbidity of current anti-tumor therapies may have a tremendous impact on the long-term survival and morbidity of tumor patients, as was most prominently described for anthracycline-induced cardiomyopathy [ 47 ]. Transient cardiac damage during anti-leukemic therapies, as indicated by elevation of cardiac stress or ischemia markers such as N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T, as well as arrhythmias, are regularly seen in patients during intensive anti-leukemic therapies [ 48 ]. Therefore, it seems reasonable to complement the careful clinical monitoring of cardiotoxicity in leukemic patients with further characterization of organ-specific side effects and signaling pathways activated by malignancy and/or anti-tumor therapies in the future.…”

Targeted anti-BCR-ABL+ ALL therapy may benefit the heart

“…Cardiac comorbidity of current anti-tumor therapies may have tremendous impact on long-term survival and morbidity of tumor patients as most prominently described for anthracycline-induced cardiomyopathy (14). On the other side transient cardiac damage during anti-leukemic therapies as indicated by elevation of cardiac stress or ischemia markers such as NT-proBNP and troponin T as well as arrhythmias are regularly seen in patients during intensive anti-leukemic therapies (15). It therefore seems reasonable to complement careful clinical monitoring of cardiotoxicity in leukemic patients with further characterization of organ-specific side effects and signaling pathways activated by malignancy and/or anti-tumor therapies in the future.…”