Incidence and risk of hypertension in patients newly treated for multiple myeloma: a retrospective cohort study

Competing risk analysis of cardiovascular mortality in multiple myeloma survivors

Background

The survival of multiple myeloma (MM) patients has significantly improved, and several factors increase the risk of cardiovascular death (CVD) mortality in MM. This study aims to determine the prognostic significance of factors associated with long-term CVD risk in MM survivors.

Methods

The data of MM survivors whose survival time was longer than 36 months were retrieved from the Surveillance, Epidemiology, and End Result (SEER) database between 2000 and 2015. Cox proportional hazards regressions and competing risk survival analyses were utilized to assess the CVD-associated risk factors. Propensity score matching (PSM) was further conducted to ensure the comparability of cardiovascular risk factors. The nomogram was based on these epidemiological factors to estimate individualized CVD probabilities for MM survivors, and its performance was assessed by Harrell's concordance index (C-index) and calibration curve.

Results

A total of 32,528 survivors with MM were enrolled, and 2,061 (6.34%) suffered from CVD. In Cox proportional hazards regressions and competing risk survival analyses, age, period of diagnosis, sex, race, married status, income, chemotherapy, and radiotherapy were the independent risk factors for CVD. After PSM, there was a significant difference in cumulative incidence curves, using a competing-risks method, between the following matched groups: male vs. female group, white vs. non-white group, married vs. unmarried group, income <$75,000 vs. income ≥$75,000 group, chemotherapy vs. non-chemotherapy group, and radiotherapy vs. non-radiotherapy group. The nomogram predicted CVD probabilities with a training C-index of 0.700 and a validation C-index of 0.726. Calibration curves validated that the nomograms could accurately predict the CVD probabilities both in the training and validation group.

Conclusions

Among MM survivors, the mortality risk of cardiovascular diseases differs with age, sex, period at diagnosis, race/ethnicity, marital status, chemotherapy, and radiotherapy. Our nomograms, based on epidemiological variables, may be used to predict 5-, 10-, and 15-year cardiovascular disease outcomes of MM survivors.

Description of multiple myeloma cases and assessment of survival and mortality factors in Madagascar

INTRODUCTION

In Madagascar, the epidemiologic, therapeutic, and evolutionary aspects of multiple myeloma remain poorly understood. Our objectives were to describe the cases, report factors associated with mortality, and estimate patient survival.

PATIENTS AND METHOD

This was a retrospective descriptive and analytical study conducted in five teaching hospitals in Madagascar: HJRA and CENHOSOA (Antananarivo), CHUPZAGA (Mahajanga), CHUAT (Toamasina) and CHUT (Fianarantsoa). The study included patients diagnosed with multiple myeloma between January 1, 2010 and December 31, 2021.

RESULTS

Of the 11,374 cancer patients, 75 (0.66%) had multiple myeloma. The mean age of the patients was 59.9 years (±8.9) and the sex ratio was 1.5. Arterial hypertension was observed in 32% of the patients. The most common symptom of myeloma was bone pain (n = 48; 64%). Forty-six patients (61%) were diagnosed with stage III myeloma and 28 patients (37.3%) with stage IIIA myeloma according to the Durie-Salmon classification. Anemia, renal failure, hypercalcemia and fractures were present in 53%, 37%, 21% and 28% of cases, respectively. Fifty-four patients received specific treatment. The combination of melphalan-prednisone-thalidomide was used in 79.63% of cases, and one patient had received autologous stem cell transplantation. Eleven patients (14.67%) died. Chronic kidney disease (p = 0.009), smoking (p = 0.028) and two associated comorbidities (p = 0.035) were associated with mortality. The median overall survival was 45.5 months.

CONCLUSION

Patient survival is shorter than reported in the literature. The high mortality rate is due to comorbidities and limited access to recommended therapies.

Multimorbidity in patients with monoclonal gammopathy of undetermined significance

Monoclonal gammopathy of undetermined significance (MGUS), a precursor to multiple myeloma, is present in over 5% of adults aged 70 and older, a population with a high prevalence of multimorbidity. MGUS is often diagnosed incidentally when patients seek care for unrelated conditions. Our study sought to examine patterns of multimorbidity among MGUS patients, as overall health may impact patient care and the prioritization of MGUS surveillance. We examined patterns of comorbidities in 429 patients diagnosed with MGUS (2007-2015) and 1287 matched controls. Twenty-seven conditions were defined at diagnosis/index date using algorithms developed by the Centers for Medicare and Medicaid Chronic Conditions Warehouse. Patterns of common comorbidities were identified individually, in dyads and triads, and compared between MGUS cases and controls. We conducted a latent class analysis to identify comorbidity patterns among cases only. We also examined comorbidity patterns among a subset of 32 MGUS cases who progressed to cancer during the study period. The most common comorbidities among both MGUS cases and controls included hypertension and hyperlipidemia. Anemia (cases: 43%; controls: 16%) and chronic kidney disease (CKD; cases: 36%; controls: 18%), and dyads and triads containing those conditions, were more common among cases. Latent class analysis identified three classes of comorbidity among MGUS cases: hypertension-hyperlipidemia plus anemia and CKD (31%); low comorbidity burden (17%); and hypertension-hyperlipidemia alone (52%). The higher prevalence among cases of anemia and CKD, which may be involved in the pathogenesis of, or surveillance for, MGUS, warrants additional investigation.

Heart Failure Among Patients with Multiple Myeloma Treated with Carfilzomib-Based Versus Non-Carfilzomib-Based Regimens in the United States by Race

BACKGROUND

Carfilzomib treatment for multiple myeloma (MM) can increase heart failure risk. Whether this risk differs by race is unknown.

PATIENTS AND METHODS

We sought to estimate the incidence rates (IRs) of heart failure hospitalization among mostly 65-years-and-older US patients with MM by race treated with carfilzomib- and non-carfilzomib-based regimens in the real-world using Centers for Medicare & Medicaid Services Medicare Fee-for-Service data, Optum Clinformatics Data Mart, and Humana Research Database. The risk of heart failure hospitalization associated with a carfilzomib-based regimen was evaluated using propensity score matching among Black and White patients receiving second or later lines of therapy.

RESULTS

Most patient-episodes (88%) were in persons 65 years or older for the 3 cohorts combined. The IR (95% CI) of heart failure hospitalization was higher for patient-episodes treated with a carfilzomib-based regimen than those with a non-carfilzomib-based regimen for both White (14.5 [12.2-17.0] vs. 10.7 [10.3-11.2] events per person-years) and Black patients (15.8 [10.1-23.5] vs. 12.1 [10.9-13.4] events per person-years) in the Medicare cohort. After propensity score matching, the hazard ratio (95% CI) of increased heart failure hospitalization comparing carfilzomib-based to non-carfilzomib-based regimens for White patients (1.6 [1.3-2.0]) was similar to that of Black patients (1.7 [1.0-2.9]) in the Medicare Database, and in the Humana Database (1.4 [0.8-2.6] and 1.2 [0.4-3.5], respectively).

CONCLUSION

Although the IR of heart failure among patients with MM treated with a carfilzomib-based regimen was slightly higher, no evidence suggested the relative risk was different between White and Black patients with MM.

Association between metabolic obesity phenotypes and multiple myeloma hospitalization burden: A national retrospective study

Background & purpose

Obesity and metabolic disorders were associated with increased risk of MM, a disease characterized by high risk of relapsing and require frequent hospitalizations. In this study, we conducted a retrospective cohort study to explore the association of metabolic obesity phenotypes with the readmission risk of MM.

Patients & methods

We analyzed 34,852 patients diagnosed with MM from the Nationwide Readmissions Database (NRD), a nationally representative database from US. Hospitalization diagnosis of patients were obtained using ICD-10 diagnosis codes. According to obesity and metabolic status, the population was divided into four phenotypes: metabolically healthy non-obese (MHNO), metabolically unhealthy non-obese (MUNO), metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO). The patients with different phenotypes were observed for hospital readmission at days 30-day, 60-day, 90-day and 180-day. Multivariate cox regression model was used to estimate the relationship between obesity metabolic phenotypes and readmissions risk.

Results

There were 5,400 (15.5%), 7,255 (22.4%), 8,025 (27.0%) and 7,839 (35.6%) unplanned readmissions within 30-day, 60-day, 90-day and 180-day follow-up, respectively. For 90-day and 180-day follow-up, compared with patients with the MHNO phenotype, those with metabolic unhealthy phenotypes MUNO (90-day: P = 0.004; 180-day: P = < 0.001) and MUO (90-day: P = 0.049; 180-day: P = 0.004) showed higher risk of readmission, while patients with only obesity phenotypes MHO (90-day: P = 0.170; 180-day: P = 0.090) experienced no higher risk. However, similar associations were not observed for 30-day and 60-day. Further analysis in 90-day follow-up revealed that, readmission risk elevated with the increase of the combined factor numbers, with aHR of 1.068 (CI: 1.002-1.137, P = 0.043, with one metabolic risk factor), 1.109 (CI: 1.038-1.184, P = 0.002, with two metabolic risk factors) and 1.125 (95% CI: 1.04-1.216, P = 0.003, with three metabolic risk factors), respectively.

Conclusion

Metabolic disorders, rather than obesity, were independently associated with higher readmission risk in patients with MM, whereas the risk elevated with the increase of the number of combined metabolic factors. However, the effect of metabolic disorders on MM readmission seems to be time-dependent. For MM patient combined with metabolic disorders, more attention should be paid to advance directives to reduce readmission rate and hospitalization burden.

Risks and management of hypertension in cancer patients undergoing targeted therapy: a review

Background

Rapid progress over the last decade has added numerous agents targeting specific cellular signaling pathways to the treatment armamentarium for advanced cancer. However, many of these agents can cause hypertension resulting in major adverse cardiovascular event.

Methods and results

A systematic literature search was performed on the databases PubMed and Google Scholar for papers published in English until December 2020. This review summarizes the risk, mechanism, diagnosis, and management of hypertension in cancer patients undergoing targeted therapy. The risk and pathogenesis of hypertension vary widely with different classes of targeted agents. Currently there is a paucity of data investigating optimal management of hypertension with targeted therapy. A practical approach is discussed with a focus on the goal of blood pressure control as well as drug selection based on the mechanism of hypertension in the context of advanced cancer, treatment toxicity, comorbidity, and drug-drug interactions. This review also discusses many studies that have explored hypertension as a biomarker for cancer treatment efficacy and as a pharmacodynamic biomarker to titrate drug dose.

Conclusions

The diversity of targeted agents has provided important insights into the pathogenesis of hypertension in cancer patients. The underlying mechanism may provide a guidance to the management of hypertension. Further studies are needed to investigate optimal treatment and hypertension as a biomarker for cancer treatment.

Optimising cardiovascular care of patients with multiple myeloma

Multiple myeloma (MM) is the third most common haematological malignancy, with increasing prevalence over recent years. Advances in therapy have improved survival, changing the clinical course of MM into a chronic condition and meaning that management of comorbidities is fundamental to improve clinical outcomes. Cardiovascular (CV) events affect up to 7.5% of individuals with MM, due to a combination of patient, disease and treatment-related factors and adversely impact survival. MM typically affects older people, many with pre-existing CV risk factors or established CV disease, and the disease itself can cause renal impairment, anaemia and hyperviscosity, which exacerabate these further. Up to 15% of patients with MM develop systemic amyloidosis, with prognosis determined by the extent of cardiac involvement. Management of MM generally involves administration of multiple treatment lines over several years as disease progresses, with many drug classes associated with adverse CV effects including high rates of venous and arterial thrombosis alongside heart failure. Recommendations for holistic management of patients with MM now include routine baseline risk stratification including ECG and echocardiography and administration of thromboprophylaxis drugs for patients treated with immunomodulatory drugs. Close surveillance of high-risk patients with collaboration between haematology and cardiology is required, with prompt investigation in the event of CV symptoms, in order to identify and treat complications early. Decisions regarding discontinuation of cardiotoxic therapies should be made in a multidisciplinary setting, taking into account the severity of the complication, prognosis, expected benefits and the availability of effective alternatives.

Metabolic Disorders in Multiple Myeloma

Multiple myeloma (MM) is the second most common hematological malignancy and is attributed to monoclonal proliferation of plasma cells in the bone marrow. Cancer cells including myeloma cells deregulate metabolic pathways to ensure proliferation, growth, survival and avoid immune surveillance, with glycolysis and glutaminolysis being the most identified procedures involved. These disorders are considered a hallmark of cancer and the alterations performed ensure that enough energy is available for rapid cell proliferation. An association between metabolic syndrome, inflammatory cytokinesand incidence of MM has been also described, while the use of metformin and statins has been identified as a positive prognostic factor for the disease course. In this review, we aim to present the metabolic disorders that occur in multiple myeloma, the potential defects on the immune system and the potential advantage of targeting the dysregulated pathways in order to enhance antitumor therapeutics.

Prognostic Potential of Heart Rate and Hypertension in Multiple Myeloma Patients

Background: The prognosis of patients with multiple myeloma (MM) is variable and partly depends on their cardiovascular status. The presence of arrhythmias can lead to worse outcomes. Therefore, this study aimed to evaluate the potential of heart rate (HR) and hypertension in predicating the outcomes of MM patients. Methods: This study retrospectively enrolled patients with MM between January 1, 2010, and December 31, 2018, at the First Affiliated Hospital of Xi'an Jiaotong University. The endpoint was all-cause mortality. The Pearson's chi-square test was used to assess the association between hypertension and outcomes. Univariate and multivariate Cox proportional hazards models were developed to evaluate the relationship between HR and all-cause mortality. Results: A total of 386 patients were included. The mean HR was 83.8 ± 23.1 beats per minute (bpm). Patients with HR >100 bpm had a higher all-cause mortality (79.4%, 50/63) than those with 60 ≤ HR ≤ 100 bpm (39.9%, 110/276) and <60 bpm (19.1%, 9/47) (p < 0.001). Subgroup analysis based on the International Staging System and sex revealed similar relationships (p < 0.01). When stratified by age, patients with HR >100 bpm had higher all-cause mortality than those with a lower HR when age was <65 years or 65-75 years (p < 0.001) but not >75 years. The proportion of patients with hypertension was 54.7% (211/386). However, hypertension was not associated with all-cause mortality in MM patients (χ²=1.729, p > 0.05). MM patients with HR >100 bpm had the highest all-cause mortality. Conclusions: The prognostic potential of HR may be useful in aiding risk stratification and promoting the management of these patients.

Investigation of demographic features, performance, comorbidity status and mortality causes among multiple myeloma patients: real-life data

BACKGROUND

The demographic characteristics, performance status, frequency of comorbidities and survival rate of patients with multiple myeloma (MM) show variability geographically and different risk scoring systems have been used to assess this population. Here, we present data from a Turkish cohort, focusing on identifying similarities and differences, relative to other reports in the literature.

RESEARCH DESIGN AND METHODS

A total of 310 patients diagnosed with MM were enrolled. Their demographic characteristics were investigated retrospectively. For performance assessment; the ECOG-IMWG Myeloma Frailty Score, R-MCI and HCT-SCI scoring indexes were used. PFS and OS periods, as well as the causes of deaths, were determined.

RESULTS

The mean age of all study participants was 65 ± 10 years. The mean PFS and OS periods were 24.14± 26.11 and 65.3 ± 4.4 months, respectively. The median R-MCI, CCI and HCT-CI scores were five, four and three points, respectively. Myeloma-related complications were the leading cause of death, with a frequency of 51%.

CONCLUSION

Among the scoring systems utilised, R-MCI was more convenient to apply due to its ease of use and practicality. Our study supports the heterogeneous course of myeloma and highlights geographic differences including comorbidities, causes of death and overall survival.

Cardio-oncology: rationale, aims and future directions

PURPOSE OF REVIEW

Cardiovascular comorbidity among cancer patients is a growing clinical problem with the dramatic improvements in cancer survival. Cardio-oncology has developed as a new medical field dedicated to addressing the complex issues faced by patients who have both cancer and cardiovascular disease. This article explains to the reader what cardio-oncology services provide and the nature of cardiovascular problems caused by the growing array of modern cancer therapies.

RECENT FINDINGS

The list of potentially cardiotoxic cancer therapeutic agents is ever growing and dedicated cardio-oncology experts are required to tackle cardiovascular complications with minimal delay to necessary cancer therapy. Cardio-oncology services originated in academic centres but are now being set up around the world in all hospitals and clinics that provide care to cancer patients. Cardio-oncology plays an increasingly active role at every stage of cancer therapy including baseline risk assessment pretreatment, surveillance and prevention during treatment, response to acute complications and assessment in survivors post cardiotoxic treatments. New treatment strategies exist to optimize cancer treatment so it can be completed safely.

SUMMARY

In the present review, we explore the rationale, aims and roles of cardio-oncology, as well as future directions, which will certainly require multidisciplinary international collaboration.

Analysis of the effectiveness of multiple myeloma treatment based on the clinical experience of European countries

Aim. The main aim of this study was to model the effectiveness of multiple myeloma (MM) therapy using machine learning, which was based on the analysis of various methods of MM treatment, a number of prognostic factors and their results in the daily routine clinical practice of medical centers in European countries. Materials and methods. The present study was retrospective, non-interventional, multicenter. A structured database of MM patients provided by the Oncology Information service (O.I.s.) was used for the study. Registration took place in medical institutions in eight countries: Austria, Belgium, Switzerland, Germany, Spain, France, Greece and Great Britain. Results. In total, 57% of men and 43% of women were analyzed in the base of 6074 patients with MM. The median age was 71 years. The median follow-up time along the lines was 387 days. High-risk cytogenetics are represented in 15% of cases. The efficacy endpoint was the best response to each line of therapy, as measured by time to death (TTD) as an indirect indicator of overall survival and time to next treatment (TTNT) as an indirect indicator of progression-free survival. The median TTD and TTNT were 730 and 399 days respectively. After a multi-step selection process, characteristics with the greatest importance for the therapy prognosis were selected: age at the beginning of therapy, line of therapy, time after MM verification, ECOG (Eastern Cooperative Oncology Group), cytogenetic risk, transplant eligibible or not, TTNT after the previous line of therapy, therapy regimen. Discussion. To continue the study it is necessary to analyze literature data and compare with real practice. Also analysis and comparison with Russian data on the treatment of patients with MM is required. Conclusion. The analysis of the presented data provides a basis for modeling a tool for assessing the effectiveness of MM therapy (prognosis of TTD and TTNT) for each patient, based on a number of prognostic factors and the results of routine clinical practice in various medical centers in European countries.

Kinetics of Renal Function during Induction in Newly Diagnosed Multiple Myeloma: Results of Two Prospective Studies by the German Myeloma Study Group DSMM

Simple Summary

Renal insufficiency is frequently seen in newly diagnosed multiple myeloma and can be due to the disease itself but also caused by medical interventions or infections. Patients with severe renal insufficiency are known to have an adverse prognosis, but recently, it was shown that even moderately impaired kidney function can have long-term sequelae. Achieving quick disease control by effective antimyeloma therapy can lead to the recovery of renal function. We investigated the kidney-specific variables in a large cohort of 770 myeloma patients receiving three different three-drug regimens for initial myeloma treatment to learn more about the differential effects on kidney function in an early disease phase. All regimens had a positive impact on kidney function without a difference in the proportion of patients who reached normal renal function after three cycles. Interestingly, patients who received bortezomib, lenalidomide, and dexamethasone tended to have higher risk for a worse renal function following induction when compared to the initial values.

Abstract

Background: Preservation of kidney function in newly diagnosed (ND) multiple myeloma (MM) helps to prevent excess toxicity. Patients (pts) from two prospective trials were analyzed, provided postinduction (PInd) restaging was performed. Pts received three cycles with bortezomib (btz), cyclophosphamide, and dexamethasone (dex; VCD) or btz, lenalidomide (len), and dex (VRd) or len, adriamycin, and dex (RAD). The minimum required estimated glomerular filtration rate (eGFR) was >30 mL/min. We analyzed the percent change of the renal function using the International Myeloma Working Group (IMWG) criteria and Kidney Disease: Improving Global Outcomes (KDIGO)-defined categories. Results: Seven hundred and seventy-two patients were eligible. Three hundred and fifty-six received VCD, 214 VRd, and 202 RAD. VCD patients had the best baseline eGFR. The proportion of pts with eGFR <45 mL/min decreased from 7.3% at baseline to 1.9% PInd (p < 0.0001). Thirty-seven point one percent of VCD versus 49% of VRd patients had a decrease of GFR (p = 0.0872). IMWG-defined “renal complete response (CRrenal)” was achieved in 17/25 (68%) pts after VCD, 12/19 (63%) after RAD, and 14/27 (52%) after VRd (p = 0.4747). Conclusions: Analyzing a large and representative newly diagnosed myeloma (NDMM) group, we found no difference in CRrenal that occurred independently from the myeloma response across the three regimens. A trend towards deterioration of the renal function with VRd versus VCD may be explained by a better pretreatment “renal fitness” in the latter group.

Hypertensive Cardiotoxicity in Cancer Treatment-Systematic Analysis of Adjunct, Conventional Chemotherapy, and Novel Therapies-Epidemiology, Incidence, and Pathophysiology

Cardiotoxicity is the umbrella term for cardiovascular side effects of cancer therapies. The most widely recognized phenotype is left ventricular dysfunction, but cardiotoxicity can manifest as arrhythmogenic, vascular, myocarditic and hypertensive toxicities. Hypertension has long been regarded as one of the most prevalent and modifiable cardiovascular risk factors in the general population, but its relevance during the cancer treatment journey may be underestimated. Hypertensive cardiotoxicity occurs de novo in a substantial proportion of treated cancer patients. The pathology is incompletely characterized—natriuresis and renin angiotensin system interactions play a role particularly in conventional treatments, but in novel therapies endothelial dysfunction and the interaction between the cancer and cardiac kinome are implicated. There exists a treatment paradox in that a significant hypertensive response not only mandates anti-hypertensive treatment, but in fact, in certain cancer treatment scenarios, hypertension is a predictor of cancer treatment efficacy and response. In this comprehensive review of over 80,000 patients, we explored the epidemiology, incidence, and mechanistic pathophysiology of hypertensive cardiotoxicity in adjunct, conventional chemotherapy, and novel cancer treatments. Conventional chemotherapy, adjunct treatments, and novel targeted therapies collectively caused new onset hypertension in 33–68% of treated patients. The incidence of hypertensive cardiotoxicity across twenty common novel therapies for any grade hypertension ranged from 4% (imatinib) to 68% (lenvatinib), and high grade 3 or 4 hypertension in <1% (imatinib) to 42% (lenvatinib). The weighted average effect was all-grade hypertension in 24% and grade 3 or 4 hypertension in 8%.

Components of metabolic syndrome in patients with multiple myeloma and smoldering multiple myeloma

BACKGROUND

The prevalences of diabetes mellitus and hypertension, both of which are components of metabolic syndrome, are known to be increased among patients with multiple myeloma (MM), but remain undetermined among patients with smoldering MM (SMM).

METHODS

Changes in various components of metabolic syndrome were investigated during the follow-up of patients with either MM or SMM compared to healthy controls. The data of 153 patients (105 with MM and 48 with SMM) and 138 controls were accessed from our medical center's records between 2008 and 2015. We analyzed the patients' data at diagnosis (baseline) and after 1, 3, and 5 years of follow-up.

RESULTS

Patients with SMM had a significantly higher prevalence of diabetes, hypertension, and dyslipidemia at baseline compared to controls. A multivariate Cox regression analysis revealed a higher risk to develop dyslipidemia after 1, 3, and 5 years of follow-up among the SMM patients. The MM patients had a higher risk to develop diabetes after 1 year, hypertension after 5 years, and dyslipidemia after 1, 3, and 5 years of follow-up.

CONCLUSIONS

These data demonstrate that patients with SMM and those with MM are more prone to develop various components of metabolic syndrome, and they stress the importance of following-up metabolic syndrome components in both groups of patients.

The Association between Metabolic Syndrome and Multiple Myeloma

Multiple myeloma (MM) is a haematological malignancy arising from monoclonal proliferation of plasma cells in the bone marrow, resulting in the presence of paraproteins or M-protein in serum. The involvement of paraproteins produced by malignant plasma cells in the development of hyperlipidaemia and low-HDL cholesterol has been described, as has an association with MM and obesity, hypertension, and type 2 diabetes mellitus, and insulin resistance, that is, features of the metabolic syndrome (MS). There is an association between MS components, inflammatory cytokines, and the development of MM, and some drugs used in the treatment of MS such as statins and metformin may improve outcomes in MM.

Randomized Clinical Trial Representativeness and Outcomes in Real-World Patients: Comparison of 6 Hallmark Randomized Clinical Trials of Relapsed/Refractory Multiple Myeloma

BACKGROUND

Concern has been increasing in oncology regarding randomized clinical trial (RCT) eligibility limiting the generalizability of the findings to real-world populations. Using a large US electronic health record database, we investigated the real-world generalizability of the findings from recent RCTs for relapsed and/or refractory multiple myeloma (RRMM).

PATIENTS AND METHODS

Patients with RRMM initiating second-to fourth-line therapy with the control arm of the following RCTs were retrospectively identified and categorized as "RCT eligible" or "RCT ineligible" according to the eligibility criteria: (1) Rd (lenalidomide, dexamethasone)-ASPIRE, TOURMALINE-MM1, POLLUX, and ELOQUENT-2; and (2) Vd (bortezomib, dexamethasone)-CASTOR and ENDEAVOR. Predictors of RCT ineligibility and overall survival were analyzed using logistic regression and Cox regression analysis.

RESULTS

Variations in the individual trial ineligibility rates were noted, with up to 72.3% (range, 47.9%-72.3%) of patients not meeting the eligibility criteria for 1 of the 6 hallmark RCTs (n = 788 for Rd; n = 477 for Vd). Other malignancies, cardiovascular disease, acute infection, and renal dysfunction were the common reasons for ineligibility. Advanced age, Charlson comorbidity score of ≥ 2, later therapy lines (3-4), and refractory status to the previous line were independently predictive of RCT ineligibility. RCT-ineligible versus RCT-eligible patients had a significantly greater mortality risk (hazard ratio, Rd, 1.46; Vd, 1.51).

CONCLUSION

Most real-world patients with RRMM were ineligible for the hallmark RCTs. The eligibility rates varied across the RCTs, underlining the flawed nature of cross-study comparisons without RCT validation. Overall survival was significantly affected by the inability to meet the criteria, highlighting the limited generalizability of the RCT results. Greater efforts are required to broaden the eligibility criteria to reflect real-world clinical characteristics and narrow the gap between RCT efficacy and the observed effectiveness in real-world patients with RRMM.

In vitro and in vivo investigation of cardiotoxicity associated with anticancer proteasome inhibitors and their combination with anthracycline

Although proteasome inhibitors (PIs) are modern targeted anticancer drugs, they have been associated with a certain risk of cardiotoxicity and heart failure (HF). Recently, PIs have been combined with anthracyclines (ANTs) to further boost their anticancer efficacy. However, this raised concerns regarding cardiac safety, which were further supported by several in vitro studies on immature cardiomyocytes. In the present study, we investigated the toxicity of clinically used PIs alone (bortezomib (BTZ), carfilzomib (CFZ)) as well as their combinations with an ANT (daunorubicin (DAU)) in both neonatal and adult ventricular cardiomyocytes (NVCMs and AVCMs) and in a chronic rabbit model of DAU-induced HF. Using NVCMs, we found significant cytotoxicity of both PIs around their maximum plasma concentration (c_max) as well as significant augmentation of DAU cytotoxicity. In AVCMs, BTZ did not induce significant cytotoxicity in therapeutic concentrations, whereas the toxicity of CFZ was significant and more profound. Importantly, neither PI significantly augmented the cardiotoxicity of DAU despite even more profound proteasome-inhibitory activity in AVCMs compared with NVCMs. Furthermore, in young adult rabbits, no significant augmentation of chronic ANT cardiotoxicity was noted with respect to any functional, morphological, biochemical or molecular parameter under study, despite significant inhibition of myocardial proteasome activity. Our experimental data show that combination of PIs with ANTs is not accompanied by an exaggerated risk of cardiotoxicity and HF in young adult animal cardiomyocytes and hearts.

Arterial Hypertension and Multiple Myeloma: Physiopathology and Cardiovascular Risk and 'Practical' Indications in Patients Receiving Carfilzomib

The introduction of carfilzomib in the treatment of relapsing and refractory multiple myeloma has allowed a significant increase in survival. The most frequent adverse effect of Carfilzomib treatment is arterial hypertension, even though the exact physiopathological mechanism are still unclear. MM patients, on the other hand, often present significant cardiovascular risk factors and comorbidities. Uncontrolled hypertension is frequently the cause of cardiovascular complications. It has been estimated that up to 50% of subjects in the general population are unaware of their hypertensive condition and only half of those who are aware of this risk factor present good control of blood pressure. Although the management of arterial hypertension is clearly important in reducing the risk of cardiovascular events, and is well described by the current guidelines, no clear indications are provided on how to approach and treat specifically MM patients undergoing treatment with proteasome inhibitors. The aim of our work is to summarize a practical approach to the stratification of cardiovascular risk of hypertensive in patients who are candidates for or actively treated with carfilzomib for refractory multiple myeloma (MMR). MM patients eligible for carfilzomib treatment should preliminary undergo a careful cardiovascular risk stratification. Perspective studies will help to better identify the specific risk factors that should be considered and treated in these patients.

Management of cardiovascular risk in patients with multiple myeloma

Multiple myeloma (MM) is a plasma cell malignancy that accounts for 10% of hematological cancers. It predominantly affects elderly people; median age at diagnosis is 70 years. Consequently, many patients with MM have cardiovascular comorbidities or risk factors. MM can cause cardiac comorbidities such as cardiomyopathy and heart failure caused by cardiac amyloidosis and/or anemia. Some of the treatments used in MM can also affect cardiovascular health. Advances in pharmacotherapy for MM, such as the introduction of immunomodulators, proteasome inhibitors, histone deacetylase inhibitors, and monoclonal antibodies, have dramatically improved progression-free survival and life expectancy, but new agent classes are associated with adverse events that were not previously observed on a regular basis, including cardiovascular events. However, with careful risk assessment, monitoring, and prophylactic therapy, many of these cardiovascular complications can be managed or treated successfully. Most routine cardiovascular surveillance is undertaken by the treating hemato-oncologist, but a multidisciplinary approach involving cardiologists may help to optimize patient outcomes. In this review, we survey the cardiac complications commonly reported in patients with MM, discuss how they can be prevented and managed, and summarize the role cardiologists can play in delivering the best possible outcomes for patients with MM and cardiovascular comorbidities.

Progressive Elevation of NT-ProBNP During Chemotherapy Is Related to Asymptomatic Cardiovascular Events in Patients With Multiple Myeloma

BACKGROUND

Patients with multiple myeloma (MM) are at risk of cardiovascular events (CVEs) as a result of disease burden- and treatment-related risk factors. Cardiac biomarkers have been reported to be more sensitive than left ventricular ejection fraction in detecting CVEs. We sought to explore CVEs risk factors in MM patients and to establish sensitive predictors of biomarkers.

PATIENTS AND METHODS

We studied 116 newly diagnosed MM patients who received chemotherapy in our department. Echocardiograms were examined at baseline and after 4 cycles of treatment, as well as upon clinical suspicion of a cardiac event or after an adjustment of treatment regimens. Cardiac biomarkers, including troponin T, myohemoglobin, and N terminal pro B-type natriuretic peptide (NT-proBNP), were estimated before each cycle and within 24 hours after chemotherapy, which was provided for at least 4 cycles.

RESULTS

Thirteen patients (11.2%) experienced CVEs, seven of which were subclinical. There was no significant difference between the CVE group and the non-CVE group in terms of general patient characteristics, MM disease factors, or chemotherapy drugs. The baseline levels of left ventricular ejection fraction and NT-proBNP were comparable between the 2 groups. NT-proBNP levels increased rapidly after chemotherapy and fell to normal levels before administration of the next cycle in all patients (60 pg/mL vs. 446 pg/mL, P < .001). Patients with asymptomatic CVEs showed a significantly higher proportion of progressively elevated NT-proBNP compared to symptomatic CVE and non-CVE patients (57% vs. 0 vs. 6.1%, P = .035).

CONCLUSION

The dynamic change in NT-proBNP may predict early asymptomatic cardiac damage and allow interventional strategies to avoid cardiac decompensation.

Analysis of carfilzomib cardiovascular safety profile across relapsed and/or refractory multiple myeloma clinical trials

Carfilzomib is a selective proteasome inhibitor approved for the treatment of relapsed and/or refractory multiple myeloma (RRMM). It has significantly improved outcomes, including overall survival (OS), and shown superiority vs standard treatment with lenalidomide plus dexamethasone and bortezomib plus dexamethasone. The incidence rate of cardiovascular (CV) events with carfilzomib treatment has varied across trials. This analysis evaluated phase 1-3 trials with >2000 RRMM patients exposed to carfilzomib to describe the incidence of CV adverse events (AEs). In addition, the individual CV safety data of >1000 patients enrolled in the carfilzomib arm of phase 3 studies were compared with the control arms to assess the benefit-risk profile of carfilzomib. Pooling data across carfilzomib trials, the CV AEs (grade ≥3) noted included hypertension (5.9%), dyspnea (4.5%), and cardiac failure (4.4%). Although patients receiving carfilzomib had a numeric increase in the rates of any-grade and grade ≥3 cardiac failure, dyspnea, and hypertension, the frequency of discontinuation or death due to these cardiac events was low and comparable between the carfilzomib and control arms. Serial echocardiography in a blinded cardiac substudy showed no objective evidence of cardiac dysfunction in the carfilzomib and control arms. Moreover, carfilzomib had no significant effect on cardiac repolarization. Our results, including the OS benefit, showed that the benefit of carfilzomib treatment in terms of reducing progression or death outweighed the risk for developing cardiac failure or hypertension in most patients. Appropriate carfilzomib administration and risk factor management are recommended for elderly patients and patients with underlying risk factors.