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Ha J, Choi S, Moon S, Han J, Lee J, Baek KH, Han S, Park SS, Min CK. Major cardiovascular events in long-term multiple myeloma survivors: a Korean case-control study (the CAREMM-2105 study). Clin Exp Med 2024; 24:125. [PMID: 38864999 PMCID: PMC11169014 DOI: 10.1007/s10238-024-01368-2] [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: 03/30/2024] [Accepted: 04/29/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Despite improvements in multiple myeloma (MM) survival rates, data on cardiovascular outcomes in long-term survivors remain lacking. METHODS This retrospective case-control study utilized the Korean National Health Insurance Service database (2009-2020) to compare the incidence of cardiovascular disease (CVD) between patients with MM and a matched control group, focusing on long-term (> 5 years) survivors. A preliminary case cohort (n = 15,402 patients with MM) and a matched control cohort (n = 123,216 patients without MM) were established based on birth year and sex. Following 1:1 propensity score matching, the final matched cohorts each comprised 15,402 participants. RESULTS The case and control cohorts were comparable in mean age (66.2 ± 11.5 years vs. 66.1 ± 11.3 years), sex, age distribution, and comorbidities. By the 8-year follow-up, the cumulative incidence of CV events (12.5% vs. 22.1%) and CVD risk were significantly lower in the case cohort. The 5-year landmark analysis revealed significant differences in CVD incidence between the cohorts (7.8% [case cohort] vs. 9.8% [control cohort]), with variations across age groups and sex, highlighting a significantly higher CVD risk among patients aged < 50 years in the case cohort (P < 0.001). CONCLUSIONS These findings underscore the need for vigilant CVD monitoring in MM long-term survivors, particularly those aged < 50 years at first diagnosis. IMPLICATION FOR CANCER SURVIVORS This study highlights the importance of integrating cardiovascular monitoring and risk management into long-term care for MM survivors, with a focus on younger patients and personalized interventions.
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Affiliation(s)
- Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Suein Choi
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Seulji Moon
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Jinseon Han
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Jeongyoon Lee
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Ki-Hyun Baek
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Seunghoon Han
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea.
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea.
| | - Sung-Soo Park
- Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea.
- Leukemia Research Institute, The Catholic University of Korea, Seoul, 06591, Republic of Korea.
| | - Chang-Ki Min
- Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Leukemia Research Institute, The Catholic University of Korea, Seoul, 06591, Republic of Korea
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Yuan N, Oesterle A, Botting P, Chugh S, Albert C, Ebinger J, Ouyang D. High-Throughput Assessment of Real-World Medication Effects on QT Interval Prolongation: Observational Study. JMIR Cardio 2023; 7:e41055. [PMID: 36662566 PMCID: PMC9898836 DOI: 10.2196/41055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Drug-induced prolongation of the corrected QT interval (QTc) increases the risk for Torsades de Pointes (TdP) and sudden cardiac death. Medication effects on the QTc have been studied in controlled settings but may not be well evaluated in real-world settings where medication effects may be modulated by patient demographics and comorbidities as well as the usage of other concomitant medications. OBJECTIVE We demonstrate a new, high-throughput method leveraging electronic health records (EHRs) and the Surescripts pharmacy database to monitor real-world QTc-prolonging medication and potential interacting effects from demographics and comorbidities. METHODS We included all outpatient electrocardiograms (ECGs) from September 2008 to December 2019 at a large academic medical system, which were in sinus rhythm with a heart rate of 40-100 beats per minute, QRS duration of <120 milliseconds, and QTc of 300-700 milliseconds, determined using the Bazett formula. We used prescription information from the Surescripts pharmacy database and EHR medication lists to classify whether a patient was on a medication during an ECG. Negative control ECGs were obtained from patients not currently on the medication but who had been or would be on that medication within 1 year. We calculated the difference in mean QTc between ECGs of patients who are on and those who are off a medication and made comparisons to known medication TdP risks per the CredibleMeds.org database. Using linear regression analysis, we studied the interaction of patient-level demographics or comorbidities on medication-related QTc prolongation. RESULTS We analyzed the effects of 272 medications on 310,335 ECGs from 159,397 individuals. Medications associated with the greatest QTc prolongation were dofetilide (mean QTc difference 21.52, 95% CI 10.58-32.70 milliseconds), mexiletine (mean QTc difference 18.56, 95% CI 7.70-29.27 milliseconds), amiodarone (mean QTc difference 14.96, 95% CI 13.52-16.33 milliseconds), rifaximin (mean QTc difference 14.50, 95% CI 12.12-17.13 milliseconds), and sotalol (mean QTc difference 10.73, 95% CI 7.09-14.37 milliseconds). Several top QT prolonging medications such as rifaximin, lactulose, cinacalcet, and lenalidomide were not previously known but have plausible mechanistic explanations. Significant interactions were observed between demographics or comorbidities and QTc prolongation with many medications, such as coronary disease and amiodarone. CONCLUSIONS We demonstrate a new, high-throughput technique for monitoring real-world effects of QTc-prolonging medications from readily accessible clinical data. Using this approach, we confirmed known medications for QTc prolongation and identified potential new associations and demographic or comorbidity interactions that could supplement findings in curated databases. Our single-center results would benefit from additional verification in future multisite studies that incorporate larger numbers of patients and ECGs along with more precise medication adherence and comorbidity data.
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Affiliation(s)
- Neal Yuan
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Adam Oesterle
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Patrick Botting
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sumeet Chugh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Christine Albert
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David Ouyang
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Yuan S, Zhou JY, Yang BZ, Xie ZL, Zhu TJ, Hu HX, Li R. Prediction of cardiovascular adverse events in newly diagnosed multiple myeloma: Development and validation of a risk score prognostic model. Front Oncol 2023; 13:1043869. [PMID: 37025590 PMCID: PMC10070977 DOI: 10.3389/fonc.2023.1043869] [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: 09/14/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
Background Multiple myeloma (MM) is the second most common hematological malignancy, and the treatments markedly elevate the survival rate of the patients in recent years. However, the prevalence of cardiovascular adverse events (CVAEs) in MM had been increasing recently. CVAEs in MM patients are an important problem that we should focus on. Clinical tools for prognostication and risk-stratification are needed. Patients and methods This is a retrospective study that included patients who were newly diagnosed with multiple myeloma (NDMM) in Shanghai Changzheng Hospital and Affiliated Jinhua Hospital, Zhejiang University School of Medicine from June 2018 to July 2020. A total of 253 patients from two medical centers were divided into training cohort and validation cohort randomly. Univariable analysis of the baseline factors was performed using CVAEs endpoints. Multivariable analysis identified three factors for a prognostic model that was validated in internal validation cohorts. Results Factors independently associated with CVAEs in NDMM were as follows: age>61 years old, high level of baseline office blood pressure, and left ventricular hypertrophy (LVH). Age contributed 2 points, and the other two factors contributed 1 point to a prognostic model. The model distinguished the patients into three groups: 3-4 points, high risk; 2 points, intermediate risk; 0-1 point, low risk. These groups had significant difference in CVAEs during follow-up days in both training cohort (p<0.0001) and validation cohort (p=0.0018). In addition, the model had good calibration. The C-indexes for the prediction of overall survival of CVAEs in the training and validation cohorts were 0.73 (95% CI, 0.67-0.79) and 0.66 (95% CI, 0.51-0.81), respectively. The areas under the receiver operating characteristic curve (AUROCs) of the 1-year CVAEs probability in the training and validation cohorts were 0.738 and 0.673, respectively. The AUROCs of the 2-year CVAE probability in the training and validation cohorts were 0.722 and 0.742, respectively. The decision-curve analysis indicated that the prediction model provided greater net benefit than the default strategies of providing assessment or not providing assessment for all patients. Conclusion A prognostic risk prediction model for predicting CVAEs risk of NDMM patients was developed and internally validated. Patients at increased risk of CVAEs can be identified at treatment initiation and be more focused on cardiovascular protection in the treatment plan.
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Affiliation(s)
- Shuai Yuan
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie-Yi Zhou
- Department of Nuclear Radiation Injury Protection and Treatment Department, Naval Medical Center, Naval Medical University, Shanghai, China
| | - Ben-Zhao Yang
- Department of Cardiology, Naval Medical Center, Naval Medical University, Shanghai, China
| | - Zhong-Lei Xie
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ting-Jun Zhu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Hui-Xian Hu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
- *Correspondence: Hui-Xian Hu, ; Rong Li,
| | - Rong Li
- Department of Nuclear Radiation Injury Protection and Treatment Department, Naval Medical Center, Naval Medical University, Shanghai, China
- Department of Hematology, The Myeloma and Lymphoma Center, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Hui-Xian Hu, ; Rong Li,
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Thalambedu N, Al Hadidi S. Thromboprophylaxis in multiple myeloma. Leuk Lymphoma 2022; 63:2807-2815. [PMID: 35759648 DOI: 10.1080/10428194.2022.2092856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Venous thromboembolism (VTE) in multiple myeloma (MM) can be secondary to patient-, disease-, and/or treatment-related factors. The development of VTE may result in significant morbidity with the highest risk during the first year after diagnosis. This clinical review provides an evidence-based summary to guide practicing oncologists in the use of anticoagulation to prevent VTE in multiple myeloma and includes anticoagulation efficacy and adverse effect profile. We highlight the pathophysiology of VTE in MM, the use of various risk prediction tools, and the current recommendations for the use of different anticoagulants in prophylaxis of VTE.
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Affiliation(s)
- Nishanth Thalambedu
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Toppila I, Kysenius K, Miettinen T, Lassenius MI, Lievonen J, Anttila P. Comorbidity characteristics of multiple myeloma patients diagnosed in Finland 2005-2016. Ann Hematol 2022; 101:2485-2495. [PMID: 36098791 PMCID: PMC9546994 DOI: 10.1007/s00277-022-04959-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/14/2022] [Indexed: 11/03/2022]
Abstract
Multiple myeloma (MM) patients are predominantly elderly with comorbidities that have an impact on patient mortality and treatment decisions. We previously reported the patient characteristics and overall survival outcomes of the Finnish MM cohort diagnosed between 2005 and 2016 in a nationwide retrospective registry study comprising 3,851 adults. Here, we report detailed comorbidity characteristics for this real-world Finnish MM population at cohort entry and during follow-up. Data on diagnoses and causes of death were obtained from Finnish healthcare data registries and interrogated using various multistate time-to-event models. In the year preceding MM diagnosis, comorbidities (as per Charlson Comorbidity Index definition) were recorded in 38.0% of the cohort, of which 27.9% presented with pre-existing cardiovascular disease (CVD) and 4.8% had suffered a major adverse cardiac event (MACE). At 2 years post-MM diagnosis, cumulative incidence for CVD and MACE more than doubled to 57.1% and 11.4%, respectively, and only 31.9% of the cohort remained CVD-free. Prevalent secondary malignancies were recorded in 16.8% of the patient population at MM diagnosis, with cumulative incidence increasing steadily to 27.5% at 2 years and 33% at 5 years post-diagnosis. The main cause of mortality attributed to MM, CVD, secondary malignancy, or other causes remained stable throughout the follow-up, at an average of 74.2%, 9.4%, 9.8%, and 6.5%, respectively. Prevalence of CVDs and secondary malignancies is high in Finnish patients at MM diagnosis, with older male patients suffering from higher MACE and mortality risk. Proper recording and management of comorbidities alongside novel treatments remain crucial for optimal MM management.
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Affiliation(s)
| | | | - Tatu Miettinen
- Medaffcon Oy, Espoo, Finland.,Takeda Oy, Helsinki, Finland
| | | | - Juha Lievonen
- Department of Hematology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Anttila
- Department of Hematology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Lucà F, Parrini I, Abrignani MG, Rao CM, Piccioni L, Di Fusco SA, Ceravolo R, Bisceglia I, Riccio C, Gelsomino S, Colivicchi F, Gulizia MM. Management of Acute Coronary Syndrome in Cancer Patients: It's High Time We Dealt with It. J Clin Med 2022; 11:jcm11071792. [PMID: 35407399 PMCID: PMC8999526 DOI: 10.3390/jcm11071792] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 02/05/2023] Open
Abstract
Cancer patients have an increased risk of cardiovascular disease and, notably, a significant prevalence of acute coronary syndrome (ACS). It has been shown that an elevated presence of cardiovascular risk factors in this setting leads to an interaction between these two conditions, influencing their therapeutic strategies and contributing to higher mortality. Nonetheless, cancer patients have generally not been evaluated in ACS trials, so that the treatment in these cases is still not fully known. We reviewed the current literature and discussed the best management for these very high-risk patients. The treatment strategy must be tailored based on the cancer type and stage, balancing thrombotic and bleeding risks. When the prognosis is longer than six months, especially if a clinical instability coexists, patients with ACS and cancer should be referred for percutaneous coronary intervention (PCI) as soon as possible. Moreover, an invasive strategy should be preferred in STEMI patients as well as in NSTEMI patients who are considered as high risk. On the contrary, in clinically stable NSTEMI patients, a conservative non-invasive strategy could be adopted, especially in cases of a poor life expectancy and/or of high risk of bleeding. Drug-Eluting-Stents (DES) should be the first choice if an invasive strategy is adopted. Conservative therapy could instead be considered in cancer patients with more stable CAD at an increased risk of major bleeding complications. However, the duration of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended, but it should be as short as possible, whereas triple antithrombotic therapy is non-advised because it significantly increases the risk of bleeding. ACS management among cancer patients should be based on an accurate evaluation of the risk of thrombosis and bleeding. Future studies focused on choosing optimal strategies in tumor patients with ACS should be performed to treat this subset of patients better.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
- Correspondence:
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano Umberto I, 10128 Torino, Italy;
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Laura Piccioni
- Cardiology Department, Ospedale “G. Mazzini”, 64100 Teramo, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, 10128 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Roberto Ceravolo
- Cardiology Department, Ospedale Lamezia Terme, 88046 Catanzaro, Italy;
| | - Irma Bisceglia
- Integrated Cardiology Services, Cardio-Thoracic-Vascular Department, Azienda Ospedaliera San Camillo Forlanini, 00152 Roma, Italy;
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant’Anna e San Sebastiano, 81100 Caserta, Italy;
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, 6221 Maastricht, The Netherlands;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, 10128 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Michele Massimo Gulizia
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, 95126 Catania, Italy;
- Fondazione per il Tuo Cuore-Heart Care Foundation, 50121 Firenze, Italy
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Sundaravel SH, Marar RI, Abbasi MA, Baljevic M, Stone JR. Bortezomib-Induced Reversible Cardiomyopathy: Recovered with Guideline-Directed Medical Therapy. Cureus 2021; 13:e20295. [PMID: 35024253 PMCID: PMC8742456 DOI: 10.7759/cureus.20295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/29/2022] Open
Abstract
Bortezomib (BTZ) is a proteasome inhibitor (PI) used for the treatment of several hematologic malignancies, including multiple myeloma (MM), and various lymphomas including mantle cell lymphoma (MCL). It acts via disruption of the ubiquitin-proteasome pathway which plays a major role in regulating cell cycle and inhibiting synthesis of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-KB). The ubiquitin-proteasome pathway is also important in maintaining the integral signaling in cardiac myocytes. By inhibiting this system, BTZ induces cellular apoptosis in cancer cells, and possibly the cardiomyocytes. BTZ-induced cardiotoxicity in monotherapy and combination treatments is not well described in the literature. We observed a series of three patients who developed cardiotoxicity after treatment with BTZ. All patients had echocardiograms every 3 months until recovery to assess ejection fraction (EF) and global longitudinal strain (GLS). Two of the patients had a cardiac MRI (CMR) conducted during follow-up to assess for late gadolinium enhancement (LGE). The median age of our patients was 55 years (range 37-74). Two of them had MM, while one patient had MCL. Table 1 demonstrates patient demographics, past medical histories, and the cumulative dose and duration of BTZ therapy. Of the three patients, only one had a heart failure exacerbation at diagnosis. The other two patients were diagnosed with asymptomatic left ventricular systolic dysfunction on routine pre-transplant echocardiograms. Most importantly, all three patients had improvement or normalization of cardiac function with discontinuation of BTZ and initiation of guideline-directed medical therapy (GDMT) for heart failure. The median duration to recovery was 5 months (range 3-13). One patient had underlying non-compaction cardiomyopathy, and although EF did not normalize, it recovered to his previous baseline. All 3 patients had improvement in GLS. Two patients underwent CMRI at the time of cardiomyopathy diagnosis and neither of them had any late gadolinium enhancement. Since there was no routine pre-treatment echocardiogram, using the GLS trend to detect subclinical cardiac dysfunction was not possible. This case series demonstrates that BTZ-induced cardiomyopathy is potentially reversible with discontinuation of the drug and early initiation of GDMT. Further studies are needed to determine the ideal surveillance strategy for BTZ-induced cardiomyopathy.
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Li Y, Tang M, Zhong L, Wei S, Song J, Liu H, Sun C, Wang J. Incidence of Arrhythmias and Their Prognostic Value in Patients With Multiple Myeloma. Front Cardiovasc Med 2021; 8:753918. [PMID: 34869663 PMCID: PMC8634844 DOI: 10.3389/fcvm.2021.753918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/13/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Arrhythmias are common cardiovascular complications in multiple myeloma (MM) patients and are related to a poor prognosis. Objective: This study aimed to assess the burden of arrhythmias and their prognostic value in patients with MM. Methods: This was a retrospective study of patients with MM between January 2015 and April 2020 at the First Affiliated Hospital of Xi'an Jiaotong University. The incidence of arrhythmia and associated risk factors were evaluated. The relationship between the type of arrhythmia and survival was analyzed. Results: A total of 319 patients with MM were identified, and 48.0% (153/319) had arrhythmias. The most common type of arrhythmia was sinus tachycardia (ST) (15.0%, 48/319), followed by sinus bradycardia (SB) (14.4%, 46/319), premature atrial contractions (PACs) (6.3%, 20/319), conduction disorders (CDs) (6.0%, 19/319), atrial fibrillation (AF) (6.0%, 19/319), premature ventricular contractions (PVCs) (4.4%, 14/319) and paroxysmal supraventricular tachycardia (PSVT) (0.6%, 2/319). The patients with arrhythmias had higher levels of log NT-proBNP and creatinine, greater bortezomib use, and a higher incidence of diabetes than those without arrhythmias (P < 0.05). The all-cause mortality rates of patients without arrhythmias and those with AF, ST, PACs, CDs, SB, and PVCs were 50.6% (84/166), 73.7% (14/19), 60.4% (29/48), 60.0% (12/20), 52.6% (10/19), 34.8% (16/46), and 28.6% (4/14), respectively. In a subgroup analysis of patients experiencing different types of arrhythmias, patients with SB had lower all-cause mortality than patients with AF (P < 0.01). Univariate and multivariate Cox analyses showed that there was a positive statistically significant association between SB and survival (HR: 0.592 [0.352–0.998], P = 0.049) in a subgroup analysis of different arrhythmias. Conclusions: Patients with MM had a heavy arrhythmia burden, and in this study, approximately half of MM patients had arrhythmias. MM patients with SB were associated with lower all-cause mortality than those with AF. SB might be an independent positive factor for prognosis.
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Affiliation(s)
- Yongxin Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Manyun Tang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Liang Zhong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Suhua Wei
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingzhuo Song
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hui Liu
- Biobank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jie Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Horowitz NA, Brenner B. Thrombosis in hematological malignancies: mechanisms and implications. Thromb Res 2021; 191 Suppl 1:S58-S62. [PMID: 32736780 DOI: 10.1016/s0049-3848(20)30398-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/12/2020] [Accepted: 01/13/2020] [Indexed: 12/21/2022]
Abstract
A B S T R A C T Thrombotic events are a major cause of morbidity and mortality in cancer. While the association of venous thromboembolic events with cancer is well documented, in recent years arterial events (i.e. acute myocardial infarction and ischemic strokes) have also emerged as relatively common complications among cancer patients. In hematological malignancies incorporating a heterogeneous group of diseases, the prediction of thrombosis occurrence and/or recurrence is challenging, due to unique disease characteristics. Furthermore, the treatment of thrombosis in these patients is often complicated because of disease- or therapy-related thrombocytopenia. In addition, patients with hematological cancers are poorly represented in randomized control clinical trials; hence, evidence-based guidelines are limited. This review will discuss the incidence of venous and arterial thrombotic events in common myeloid and lymphoproliferative diseases. Several new mechanisms contributing to cancer- associated thrombosis will be elaborated. The complicated issue of risk assessment and management of venous thrombosis in patients with hematological malignancies will be delineated.
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Affiliation(s)
- Netanel A Horowitz
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Fleming MR, Xiao L, Jackson KD, Beckman JA, Barac A, Moslehi JJ. Vascular Impact of Cancer Therapies: The Case of BTK (Bruton Tyrosine Kinase) Inhibitors. Circ Res 2021; 128:1973-1987. [PMID: 34110908 PMCID: PMC10185355 DOI: 10.1161/circresaha.121.318259] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Novel targeted cancer therapies have revolutionized oncology therapies, but these treatments can have cardiovascular complications, which include heterogeneous cardiac, metabolic, and vascular sequelae. Vascular side effects have emerged as important considerations in both cancer patients undergoing active treatment and cancer survivors. Here, we provide an overview of vascular effects of cancer therapies, focusing on small-molecule kinase inhibitors and specifically inhibitors of BTK (Bruton tyrosine kinase), which have revolutionized treatment and prognosis for B-cell malignancies. Cardiovascular side effects of BTK inhibitors include atrial fibrillation, increased risk of bleeding, and hypertension, with the former 2 especially providing a treatment challenge for the clinician. Cardiovascular complications of small-molecule kinase inhibitors can occur through either on-target (targeting intended target kinase) or off-target kinase inhibition. We will review these concepts and focus on the case of BTK inhibitors, highlight the emerging data suggesting an off-target effect that may provide insights into development of arrhythmias, specifically atrial fibrillation. We believe that cardiac and vascular sequelae of novel targeted cancer therapies can provide insights into human cardiovascular biology.
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Affiliation(s)
- Matthew R Fleming
- Division of Cardiovascular Medicine (M.R.F., J.A.B., J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ling Xiao
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston (L.X.)
| | - Klarissa D Jackson
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill (K.D.J.)
| | - Joshua A Beckman
- Division of Cardiovascular Medicine (M.R.F., J.A.B., J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ana Barac
- Georgetown University and MedStar Heart and Vascular Institute, MedStar Washing Hospital Center, DC (A.B.)
| | - Javid J Moslehi
- Division of Cardiovascular Medicine (M.R.F., J.A.B., J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Cardio-Oncology Program (J.J.M.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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11
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Giudice V, Vecchione C, Selleri C. Cardiotoxicity of Novel Targeted Hematological Therapies. Life (Basel) 2020; 10:life10120344. [PMID: 33322351 PMCID: PMC7763613 DOI: 10.3390/life10120344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 12/16/2022] Open
Abstract
Chemotherapy-related cardiac dysfunction, also known as cardiotoxicity, is a group of drug-related adverse events negatively affecting myocardial structure and functions in patients who received chemotherapy for cancer treatment. Clinical manifestations can vary from life-threatening arrythmias to chronic conditions, such as heart failure or hypertension, which dramatically reduce quality of life of cancer survivors. Standard chemotherapy exerts its toxic effect mainly by inducing oxidative stress and genomic instability, while new targeted therapies work by interfering with signaling pathways important not only in cancer cells but also in myocytes. For example, Bruton’s tyrosine kinase (BTK) inhibitors interfere with class I phosphoinositide 3-kinase isoforms involved in cardiac hypertrophy, contractility, and regulation of various channel forming proteins; thus, off-target effects of BTK inhibitors are associated with increased frequency of arrhythmias, such as atrial fibrillation, compared to standard chemotherapy. In this review, we summarize current knowledge of cardiotoxic effects of targeted therapies used in hematology.
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Affiliation(s)
- Valentina Giudice
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (C.V.); (C.S.)
- Clinical Pharmacology, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
- Correspondence: ; Tel.: +39-089-672-493
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (C.V.); (C.S.)
- IRCCS Neuromed (Mediterranean Neurological Institute), 86077 Pozzilli, Italy
| | - Carmine Selleri
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (C.V.); (C.S.)
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
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12
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Sodavarapu S, Mahajan A. Ischemic Stroke in a Patient With Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Protein, and Skin Changes Syndrome Treated With Lenalidomide. Cureus 2020; 12:e9346. [PMID: 32850219 PMCID: PMC7444892 DOI: 10.7759/cureus.9346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes (POEMS) syndrome is an uncommon multisystemic disease associated with plasma cell dyscrasia. Due to the disease's rarity and an even rarer presentation of stroke in afflicted patients, a direct association between POEMS syndrome and stroke remains ambiguous. Thrombocytosis, hyperfibrinogenemia, and increased levels of inflammatory cytokines occur in this disease, which can predispose patients to thromboembolic events. Immunomodulators can also enhance thrombosis, the chances of which increase when they are combined with dexamethasone. We present a case of a 28-year-old patient with an ischemic stroke, which may have been triggered by the combination of POEMS syndrome-associated vasculitis and the thrombogenic nature of lenalidomide-dexamethasone therapy.
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Affiliation(s)
| | - Arshian Mahajan
- Family Medicine, San Joaquin General Hsopital, French Camp, USA
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13
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Cornell RF, Goldhaber SZ, Engelhardt BG, Moslehi J, Jagasia M, Harrell S, Rubinstein SM, Hall R, Wyatt H, Piazza G. Primary prevention of venous thromboembolism with apixaban for multiple myeloma patients receiving immunomodulatory agents. Br J Haematol 2020; 190:555-561. [PMID: 32314352 DOI: 10.1111/bjh.16653] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 12/13/2022]
Abstract
Immunomodulatory drugs (IMiDs) have improved survival of patients with multiple myeloma (MM) and comprise the therapeutic backbone at all phases of therapy. Although well-tolerated, IMiDs increase rates of venous thromboembolism (VTE). In this phase IV, single-arm pilot study, fifty patients with MM on IMiDs received apixaban 2·5 mg orally twice daily for primary prevention of VTE and were prospectively monitored for six months. The primary safety outcomes were rates of major haemorrhage and clinically relevant non-major haemorrhage over six months. The primary efficacy outcome was the rate of symptomatic VTE over six months. IMiDs used were lenalidomide (58%) or pomalidomide (42%). During the six-month evaluation period, no patients experienced major haemorrhage or VTE. Three patients experienced clinically relevant, non-major haemorrhage which was managed medically, and all were able to resume apixaban. One patient stopped therapy shortly after initiation due to an allergic reaction to apixaban. No patients experienced stroke, myocardial infarction, or death. In this pilot study, low-dose apixaban was safe and well-tolerated as a primary prevention therapy of VTE for patients with MM receiving IMiDs. Further studies are needed to validate low-dose apixaban as a standard primary prevention anti-thrombotic strategy for patients with MM receiving IMiDs.
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Affiliation(s)
- Robert F Cornell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian G Engelhardt
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Javid Moslehi
- Division of Cardiovascular Medicine, Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Madan Jagasia
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shelton Harrell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Samuel M Rubinstein
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert Hall
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Houston Wyatt
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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14
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Cardinale DM, Barac A, Torbicki A, Khandheria BK, Lenihan D, Minotti G. Cardio-oncological management of patients. Semin Oncol 2019; 46:408-413. [DOI: 10.1053/j.seminoncol.2019.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022]
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15
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Breccia M, Carver JR, Szmit S, Jurczak W, Salvatorelli E, Minotti G. Mechanisms and clinical course of cardiovascular toxicity of cancer treatment II. Hematology☆. Semin Oncol 2019; 46:403-407. [DOI: 10.1053/j.seminoncol.2019.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 10/09/2019] [Indexed: 11/11/2022]
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16
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Case of Stroke from Cerebral Vasculitis following Carfilzomib, Lenalidomide, and Dexamethasone Therapy in a Patient with Relapsing Multiple Myeloma. Case Rep Hematol 2019; 2019:5180424. [PMID: 31885953 PMCID: PMC6907054 DOI: 10.1155/2019/5180424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/22/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022] Open
Abstract
Lenalidomide, a synthetic derivation of thalidomide, in recent years, has been the backbone of multiple myeloma treatment leading to improved survival. Common adverse effects from lenalidomide-based regimens include hypertension, heart disease, and venous thromboembolism. Hence, thromboprophylaxis is recommended to reduce the risk of stroke. We report a case of stroke from cerebral vasculitis in a patient receiving carfilzomib, lenalidomide, and dexamethasone for relapsing multiple myeloma, not previously published. Medical oncologists should be aware of other causes of stroke among multiple myeloma patients receiving a lenalidomide-based regimen to prevent its occurrence.
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17
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Patel VG, Cornell RF. Cardiovascular Complications Associated with Multiple Myeloma Therapies: Incidence, Pathophysiology, and Management. Curr Oncol Rep 2019; 21:29. [PMID: 30834998 DOI: 10.1007/s11912-019-0784-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Multiple myeloma is a common hematologic malignancy characterized by recurrent relapsing disease course requiring use of various therapies. Over the past few decades, significant advancements in the treatment of myeloma have occurred including routine use of proteasome inhibitors and immunomodulatory drugs. These have effectively improved survival; however, some also have increased risk of cardiovascular toxicity. Here, we will review the incidence, pathophysiology, and management of cardiovascular complications associated with antimyeloma agents. RECENT FINDINGS Cardiovascular complications associated with myeloma treatment are common. These cardiovascular complications include accelerated hypertension, ischemic heart disease, congestive heart failure, arrhythmia, pulmonary hypertension, venous thromboembolism, and arterial thromboembolism. Thromboprophylactic strategies during treatment with immunomodulatory agents and screening strategies to detect changes in myocardial function prior to the development of overt heart failure have occurred. Cardiovascular complications associated with proteasome inhibitors and immunomodulatory drugs are an important component in supportive care of patients with myeloma. The incidence of cardiotoxicity is high, and, as such, early intervention and collaborative efforts between cardiologists and oncologists to mitigate and effectively manage these complications are imperative. Additional studies are needed to clarify the underlying pathophysiology and evaluate effective strategies for prevention and treatment.
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Affiliation(s)
- Vivek G Patel
- Department of Internal Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Robert F Cornell
- Department of Internal Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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18
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Cornell RF, Goldhaber SZ, Engelhardt BG, Moslehi J, Jagasia M, Patton D, Harrell S, Hall R, Wyatt H, Piazza G. Apixaban for Primary Prevention of Venous Thromboembolism in Patients With Multiple Myeloma Receiving Immunomodulatory Therapy. Front Oncol 2019; 9:45. [PMID: 30873378 PMCID: PMC6401636 DOI: 10.3389/fonc.2019.00045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/17/2019] [Indexed: 12/21/2022] Open
Abstract
Immunomodulatory drugs (IMiDs), including thalidomide, lenalidomide, and pomalidomide, have improved survival of patients with multiple myeloma (MM). However, these therapies are associated with an increased risk of venous thromboembolism (VTE). Apixaban has been approved for treatment of acute VTE and for risk reduction of recurrent VTE following initial therapy. In this phase IV single-arm study (NCT02958969), we aim to prospectively evaluate the safety and efficacy of apixaban for primary prevention of VTE in patients with MM. The primary efficacy objective of this trial is to determine the rate of symptomatic VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), over 6 months. The primary safety objective is to determine the rate of major bleeding in MM patients receiving apixaban prophylaxis. If proven safe and effective, apixaban will emerge as a promising option for oral VTE prophylaxis in MM patients.
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Affiliation(s)
- Robert Frank Cornell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, United States
| | - Brian G Engelhardt
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Javid Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center Nashville, TN, United States
| | - Madan Jagasia
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Daryl Patton
- Vanderbilt Institute for Clinical and Translational Research Nashville, TN, United States
| | - Shelton Harrell
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Robert Hall
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Houston Wyatt
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center Nashville, TN, United States
| | - Greg Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, MA, United States
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19
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Visweshwar N, Jaglal M, Sokol L, Djulbegovic B. Hematological Malignancies and Arterial Thromboembolism. Indian J Hematol Blood Transfus 2019; 35:611-624. [PMID: 31741612 PMCID: PMC6825093 DOI: 10.1007/s12288-019-01085-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 01/21/2019] [Indexed: 01/10/2023] Open
Abstract
Established guidelines exist for prevention and treatment of venous thromboembolism in hematological malignancies, but none for arterial thromboembolism. However, arterial and venous thromboembolism share the same provoking features—including altered procoagulant factors and defective fibrinolytic system. The morbidity for arterial thromboembolism is increasing in hematological malignancies, with the advent of immunomodulatory and targeted therapy. However, survival rate for hematological malignancy is improving. Consequently, as patients with hematological malignancies live longer, comorbidities including diabetes, hypertension and dyslipidemia, may accentuate arterial thrombosis. Thus far, the scientific literature on prophylaxis and treatment for arterial thromboembolism in hematological malignancies is limited. This review highlights the pathogenesis, incidence and clinical features of arterial thromboembolism in hematological malignancies.
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Affiliation(s)
- Nathan Visweshwar
- 1Division of Hematology, University of South Florida, Tampa, FL 33612 USA
| | - Michael Jaglal
- 2Division of Medical Oncology, Moffitt Cancer Center, Tampa, FL 35316 USA
| | - Lubomir Sokol
- 2Division of Medical Oncology, Moffitt Cancer Center, Tampa, FL 35316 USA
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20
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Increased Risk of Ischemic Stroke in Multiple Myeloma Associated With Lenalidomide Treatment: A Case Report and Review of the Literature. Clin Neuropharmacol 2018; 41:232-235. [PMID: 30273192 DOI: 10.1097/wnf.0000000000000310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The aim of the study was to illustrate the increased risk of ischemic stroke in the context of multiple myeloma (MM) under treatment with lenalidomide combined with dexamethasone. METHODS This is a case report and literature review. RESULTS A 62-year-old woman diagnosed with relapsed MM under treatment with lenalidomide and dexamethasone presented with acute onset disorientation, disturbed behavior, and aphasia. Cranial computed tomography scan revealed an acute cerebral infarction in the left middle cerebral artery territory, and brain magnetic resonance imaging showed additional silent ischemic lesions in other arterial territories. Common stroke etiologies were excluded after an extensive study, leading to a final diagnosis of cerebral infarction of uncommon cause probably related to MM and treatment with lenalidomide plus dexamethasone. A literature review provided 84 reports from the license holder, 2 more cases of stroke in patients with MM receiving lenalidomide and a recurrent stroke in a patient experiencing polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS syndrome) treated with lenalidomide. CONCLUSIONS Our case exemplifies the need to raise awareness about the risk of ischemic stroke associated with MM that might be increased by treatment with lenalidomide and to establish consistent recommendations regarding thromboprophylaxis to reduce comorbidities and mortality in these patients.
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21
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Aronson D, Brenner B. Arterial thrombosis and cancer. Thromb Res 2018; 164 Suppl 1:S23-S28. [PMID: 29703480 DOI: 10.1016/j.thromres.2018.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/17/2017] [Accepted: 01/02/2018] [Indexed: 12/21/2022]
Abstract
Cancer-associated arterial thrombotic events (ATEs) are increasingly recognized in specific malignancies and in association with the expanding armamentarium of novel chemotherapeutic agents. The improved cancer survival led to cardiovascular complications becoming clinically relevant many years after cancer diagnosis. The pathobiology of ATEs in cancer is complex and the individual patient risk for an ATE entails a multifactorial interaction between the traditional cardiovascular risk factors and comorbidities, the specific malignancy and selected therapy. Treatment with several specific chemotherapeutic agents, immunomodulatory drugs, vascular endothelial growth factor pathway inhibitors, tyrosine kinase inhibitors, and radiotherapy, impart increased risk for ATEs that result from specific therapy-related mechanisms, often involving endothelial injury. Cancer cell-specific prothrombotic properties are important players in the pathogenesis of cancer-associated hypercoagulability. There are distinct biological and molecular processes preferentially activated in specific cancer cells which can trigger ATEs, including platelet activation, increased expression of procoagulants and suppression of fibrinolytic activity. ATEs portend adverse prognosis in cancer patients. Prevention and treatment of cancer-associated ATEs may be improved by greater awareness and careful monitoring for vascular toxicity, aggressive effort to optimize conventional cardiovascular risk factors, and use of antiplatelet and antithrombotic agents in selected patients. These issues are targets for future studies aimed to reduce ATEs in patients with cancer.
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Affiliation(s)
- Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; The Ruth & Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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22
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Seijkens TTP, Lutgens E. Cardiovascular oncology: exploring the effects of targeted cancer therapies on atherosclerosis. Curr Opin Lipidol 2018; 29:381-388. [PMID: 30074493 DOI: 10.1097/mol.0000000000000538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Targeted cancer therapies have revolutionized the treatment of cancer in the past decade, but cardiovascular toxicity is a rising problem in cancer patients. Here we discuss the effects of targeted cancer therapies on atherosclerosis. Increasing the awareness of these adverse effects will promote the development of evidence-based preventive strategies in the emerging field of cardiovascular oncology. RECENT FINDINGS Vascular endothelial growth factor inhibitors, immunomodulatory imide drugs, tyrosine kinase inhibitors and immune checkpoint inhibitors are successfully used as treatment for many types of solid and hematologic malignancies. However, clinical and experimental studies have demonstrated that these drugs can drive atherosclerosis, thereby causing adverse cardiovascular events such as myocardial infarction, stroke and peripheral arterial occlusive diseases. SUMMARY In this review, we discuss how on-target and off-target effects of novel cancer drugs may affect atherosclerosis and we postulate how these cardiovascular adverse events can be prevented in the future.
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Affiliation(s)
- Tom T P Seijkens
- Department of Medical Biochemistry, Subdivision Experimental Vascular Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilians University, Munich, Germany
| | - Esther Lutgens
- Department of Medical Biochemistry, Subdivision Experimental Vascular Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilians University, Munich, Germany
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23
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Tuzovic M, Herrmann J, Iliescu C, Marmagkiolis K, Ziaeian B, Yang EH. Arterial Thrombosis in Patients with Cancer. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:40. [PMID: 29627870 PMCID: PMC7658957 DOI: 10.1007/s11936-018-0635-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cancer is a common cause of morbidity and mortality in the USA. While the association between venous thrombosis and malignancy is well established, arterial thrombosis has more recently been recognized as a serious complication of cancer and certain chemotherapeutic agents. This review aims to summarize the most recent literature regarding the incidence and risk factors for cancer-related arterial thrombosis, understand the pathophysiologic mechanisms of thrombosis, and highlight the specific diagnostic and treatment considerations relevant to cancer patients. RECENT FINDINGS Based on a recent study looking at the Surveillance, Epidemiology, and End Results (SEER) database, the incidence of arterial thromboembolic events (ATEs) in patients with cancer at 6 months is 4.7%; the presence of an ATE is predictive of worse outcomes. Certain drugs such as platinum-based agents, vascular endothelial growth factor inhibitors, tyrosine kinase inhibitors, and taxanes have been associated with high rates of ATEs. Increased platelet reactivity appears crucial to development of arterial thrombosis in cancer patients. Cancer patients have an increased risk of arterial thrombosis that is likely due to both a cancer-associated procoagulant state as well as the adverse effects of certain chemotherapeutic agents. Treatment of arterial thromboembolism in cancer patients typically requires a multidisciplinary approach in part due to high rates of thrombocytopenia and stent thrombosis in the setting of percutaneous interventions. More studies are needed to investigate optimal prophylaxis, surveillance strategies, and treatments of cancer-related arterial thromboembolic disease.
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Affiliation(s)
- Mirela Tuzovic
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA
| | - Joerg Herrmann
- Division of Cardiovascular Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Cezar Iliescu
- Division of Cardiology, Department of Medicine, MD Anderson Cancer Center, University of Texas at Houston, Houston, TX, USA
| | | | - Boback Ziaeian
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA.
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24
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Lee DH, Fradley MG. Cardiovascular Complications of Multiple Myeloma Treatment: Evaluation, Management, and Prevention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:19. [DOI: 10.1007/s11936-018-0618-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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25
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Yang EH, Courtney C, Garg V, Fradley MG, Schiller GJ. Recurrent heart failure with preserved ejection fraction associated with carfilzomib administration for multiple myeloma. CARDIO-ONCOLOGY 2018; 4:2. [PMID: 32154003 PMCID: PMC7048019 DOI: 10.1186/s40959-018-0028-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/14/2018] [Indexed: 11/30/2022]
Abstract
Carfilzomib, an epoxyketone proteasome inhibitor, has demonstrated improved progression-free survival in patients when used with standard treatment (lenalidomide and dexamethasone) in patients with relapsed multiple myeloma (MM). However, there are reports of adverse cardiac events with carfilzomib manifested by dyspnea and heart failure. A patient is presented who had recurrent, clinically mild cardiotoxicity, as manifested by recurrent heart failure with preserved ejection fraction, with ongoing maintenance carfilzomib in a patient with resistant MM is presented.
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Affiliation(s)
- Eric H Yang
- 1UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine UCLA Cardiovascular Center, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095 USA
| | - Cynthia Courtney
- 2Division of Hematology and Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Vinisha Garg
- 1UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine UCLA Cardiovascular Center, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095 USA
| | - Michael G Fradley
- 3Cardio-oncology Program, Department of Cardiovascular Sciences, University of South Florida Morsani College of Medicine and H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL USA
| | - Gary J Schiller
- 2Division of Hematology and Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
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Zheng P, Li J, Kros JM. Breakthroughs in modern cancer therapy and elusive cardiotoxicity: Critical research-practice gaps, challenges, and insights. Med Res Rev 2018; 38:325-376. [PMID: 28862319 PMCID: PMC5763363 DOI: 10.1002/med.21463] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 12/16/2022]
Abstract
To date, five cancer treatment modalities have been defined. The three traditional modalities of cancer treatment are surgery, radiotherapy, and conventional chemotherapy, and the two modern modalities include molecularly targeted therapy (the fourth modality) and immunotherapy (the fifth modality). The cardiotoxicity associated with conventional chemotherapy and radiotherapy is well known. Similar adverse cardiac events are resurging with the fourth modality. Aside from the conventional and newer targeted agents, even the most newly developed, immune-based therapeutic modalities of anticancer treatment (the fifth modality), e.g., immune checkpoint inhibitors and chimeric antigen receptor (CAR) T-cell therapy, have unfortunately led to potentially lethal cardiotoxicity in patients. Cardiac complications represent unresolved and potentially life-threatening conditions in cancer survivors, while effective clinical management remains quite challenging. As a consequence, morbidity and mortality related to cardiac complications now threaten to offset some favorable benefits of modern cancer treatments in cancer-related survival, regardless of the oncologic prognosis. This review focuses on identifying critical research-practice gaps, addressing real-world challenges and pinpointing real-time insights in general terms under the context of clinical cardiotoxicity induced by the fourth and fifth modalities of cancer treatment. The information ranges from basic science to clinical management in the field of cardio-oncology and crosses the interface between oncology and onco-pharmacology. The complexity of the ongoing clinical problem is addressed at different levels. A better understanding of these research-practice gaps may advance research initiatives on the development of mechanism-based diagnoses and treatments for the effective clinical management of cardiotoxicity.
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Affiliation(s)
- Ping‐Pin Zheng
- Cardio‐Oncology Research GroupErasmus Medical CenterRotterdamthe Netherlands
- Department of PathologyErasmus Medical CenterRotterdamthe Netherlands
| | - Jin Li
- Department of OncologyShanghai East Hospital, Tongji University School of MedicineShanghaiChina
| | - Johan M Kros
- Department of PathologyErasmus Medical CenterRotterdamthe Netherlands
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Koutsoukis A, Ntalianis A, Repasos E, Kastritis E, Dimopoulos MA, Paraskevaidis I. Cardio-oncology: A Focus on Cardiotoxicity. Eur Cardiol 2018; 13:64-69. [PMID: 30310475 DOI: 10.15420/ecr.2017:17:2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardio-oncology is a recently developed field in cardiology aimed at significantly reducing cardiovascular morbidity and mortality and improving quality of life in cancer survivors. Cancer survival rates have been constantly increasing, mainly because of the advent of new, more potent and targeted therapies. However, many of the new therapies - along with some of the older chemotherapeutic regimens such as anthracyclines - are potentially cardiotoxic, which is reflected increasingly frequently in the published literature. Cardiotoxicity adversely affects prognosis in cancer patients, thus its prevention and treatment are crucial to improve quality and standards of care. This review aims to explore the existing literature relating to chemotherapy- and radiotherapy-induced cardiotoxicity. An overview of the imaging modalities for the identification of cardiotoxicity and therapies for its prevention and management is also provided.
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Affiliation(s)
- Athanasios Koutsoukis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
| | - Argyrios Ntalianis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
| | - Evangelos Repasos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
| | - Efsthathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
| | | | - Ioannis Paraskevaidis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
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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.
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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
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Bertolotti P, Pierre A, Rome S, Faiman B. Evidence-Based Guidelines for Preventing and Managing Side Effects of Multiple Myeloma. Semin Oncol Nurs 2017; 33:332-347. [PMID: 28729122 DOI: 10.1016/j.soncn.2017.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review disease-related symptoms and side effects of treatment in patients with multiple myeloma (MM). DATA SOURCES Peer-reviewed articles, research studies, and clinical guidelines. CONCLUSION New therapies provide patients with extended survival, but in many cases this benefit is counterbalanced by an increased incidence of side effects. Preservation of organ function, while managing side effects, is essential for the care of patients with MM. IMPLICATIONS FOR NURSING PRACTICE Disease- and treatment-related adverse events are prevalent in patients with MM. Patient, family, and health care professional education is essential to monitor and manage these side effects.
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Molecular mechanisms for vascular complications of targeted cancer therapies. Clin Sci (Lond) 2017; 130:1763-79. [PMID: 27612952 DOI: 10.1042/cs20160246] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/22/2016] [Indexed: 12/15/2022]
Abstract
Molecularly targeted anti-cancer therapies have revolutionized cancer treatment by improving both quality of life and survival in cancer patients. However, many of these drugs are associated with cardiovascular toxicities that are sometimes dose-limiting. Moreover, the long-term cardiovascular consequences of these drugs, some of which are used chronically, are not yet known. Although the scope and mechanisms of the cardiac toxicities are better defined, the mechanisms for vascular toxicities are only beginning to be elucidated. This review summarizes what is known about the vascular adverse events associated with three classes of novel anti-cancer therapies: vascular endothelial growth factor (VEGF) inhibitors, breakpoint cluster-Abelson (BCR-ABL) kinase inhibitors used to treat chronic myelogenous leukaemia (CML) and immunomodulatory agents (IMiDs) used in myeloma therapeutics. Three of the best described vascular toxicities are reviewed including hypertension, increased risk of acute cardiovascular ischaemic events and arteriovenous thrombosis. The available data regarding the mechanism by which each therapy causes vascular complication are summarized. When data are limited, potential mechanisms are inferred from the known effects of inhibiting each target on vascular cell function and disease. Enhanced understanding of the molecular mechanisms of vascular side effects of targeted cancer therapy is necessary to effectively manage cancer patients and to design safer targeted cancer therapies for the future.
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Acute Coronary Syndromes in Patients with Hematological Disorders. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2016. [DOI: 10.1515/jce-2016-0024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Abstract
Hematological conditions can lead to serious disturbances in blood rheology, being frequently associated with increased systemic inflammation and increased risk of bleeding. The imbalance between coagulation and thrombolytic factors in patients with acute coronary syndromes may lead to undesirable outcomes, and the success of emergency coronary angioplasty or by-pass grafting may be altered by increased bleeding in coagulopathies such as hemophilia. This paper intends to review the present knowledge in the field of acute coronary syndromes in subjects with hematological and onco-hematological disorders such as thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura, von Willebrand disease, hemophilia, polycythemia vera, erythrocyte disorders, myelodysplastic syndrome, leukemia, lymphoma or myeloma.
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Givertz MM. Cancer and the Heart: Training Subspecialists, Optimizing Care, and Moving the Field Forward. J Card Fail 2016; 22:472-4. [DOI: 10.1016/j.cardfail.2016.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 04/18/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
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