ST-elevation myocardial infarction and myelodysplastic syndrome with acute myeloid leukemia transformation

Cardiotoxicity in Acute Myeloid Leukemia in Adults: A Scoping Study

Introduction: According to the National Cancer Institute of the NIH, acute myeloid leukemia (AML) is a rapidly growing cancer with a large quantity of myeloblasts. AML is most often observed in adults over the age of 35, accounting for 1% of all cancer types. In 2023, the number of new cases being reported was estimated to reach around 20,380 in total and the rate of mortality in the same year was 1.9%, or 11,310 cases, in the US. Purpose: This scoping study aims to extensively assess and explore the degree of cardiotoxicity in patients with AML that can be caused due to pharmaceutical treatments prescribed by hematologists. This is achieved by performing extensive searches of different scientific databases including PubMed, Scopus, and ScienceDirect. Results: A variety of options are available that are summarized in tables included herein, with each having their advantages and risks of adverse effects, among these being cardiotoxicity. Important medications found to play a significant role include gemtuzumab ozogamicin, venetoclax, and vyxeos. Conclusions: It is understandable that being familiar with all the treatment options available and every potential adverse effect is impossible. However, hematologists and, in general, physicians must try to be updated with the most recent information released to improve the quality of life of their patients and minimize the risk of additional complications.

Blasting Into Acute Coronary Syndrome

Acute coronary syndrome (ACS) is a condition that develops from reduced blood flow and oxygen delivery through the coronary arteries which leads to cardiac ischemia. In the case presented here, the patient's ACS was precipitated by his underlying condition of chronic myelogenous leukemia (CML). Several complications can arise in patients with CML, one of them being blast crisis. Blast crisis is defined by 20% or greater blasts in the peripheral blood, or extramedullary proliferation of blasts. There is a known phenomenon of blood hyperviscosity that can develop in such patients which can lead to complications of stroke-like symptoms, congestive heart failure, and acute respiratory failure. In such cases, leukostasis rarely leads to myocardial ischemia. We present a challenging case of a patient with an acute coronary syndrome (ACS) precipitated by a blast crisis. This case highlights a potentially life-threatening cardiac complication of CML in patients with coronary artery disease and aimed to provide an optimal treatment strategy to improve outcomes.

A case of acute myelogenous leukemia characterized by arterial and venous thrombosis

Acute myelogenous leukemia (AML) is a malignant disease of the hematopoietic system, characterized by features of bone marrow insufficiency and organ infiltration by leukemic cells. Venous thrombosis in AML patients is uncommon, compared to bleeding; therefore in patients with AML, simultaneous occurrence of venous and arterial thrombosis is a rather rare presentation. We reported an unusual case of anti-phospholipid antibody syndrome secondary to AML characterized by venous and arterial thrombosis. A 70-year-old man with deep venous thrombosis (DVT) of the left leg confirmed by Doppler was seen in our clinic. During treatment with a Vitamin K antagonist (3 mg daily of Warfarin) and a low molecular weight heparin (LMWH), he developed an acute pulmonary embolism and an acute inferior wall ST elevation myocardial infarction (STEMI), a result of right coronary artery embolism. His full blood count showed leukocytosis and thrombocytopenia. Lupus anticoagulant and anti-cardiolipin antibodies were positive. A bone marrow aspirate test showed results consistent with AML (FAB class M1). A diagnosis of antiphospholipid antibody syndrome secondary to AML characterized by coronary artery embolism, pulmonary embolism and left leg DVT was eventually established. He received anticoagulation with a low dose of warfarin after refusing chemotherapy. He however died of cerebral hemorrhage despite the fact that the INR was in the normal therapeutic range. It is challenging to anticoagulated AML patients complicated by multiple vascular thromboses and thrombocytopenia.

Identifying Hemostatic Thresholds in Cancer Patients Undergoing Coronary Angiography Based on Platelet Count and Thromboelastography

Objectives: To evaluate the role of platelet count and thromboelastogram (TEG) in the treatment of thrombocytopenic cancer patients with suspected coronary artery disease (CAD).

Background: Cancer patients with CAD and thrombocytopenia are often treated non-invasively (i.e., without coronary angiography when clinically indicated) due to perceived high risk of bleeding. We sought to evaluate coagulability based on TEG and determine if platelet count and TEG could predict bleeding risk/mortality among cancer patients undergoing coronary angiography (CA).

Methods: Baseline demographics, platelet count, and TEG parameters were recorded among cancer patients that underwent CA and had a concomitant TEG. Logistic regression and univariate proportional hazards regression analysis were performed to determine the impact of platelet count and coagulability on 24-month overall survival (OS).

Results: All patients with platelet count <20,000/mm³ and nearly all patients with platelet count 20,000–49,000/mm³ were hypocoagulable based on TEG results. In contrast, nearly all patients with platelet counts of 50,000–99,999/mm³ had normal TEG results and OS similar to those with platelet counts of ≥100,000/mm³. Coagulability based on TEG was not associated with OS. However, a platelet count of <50,000/mm³ was associated with worse 24-month OS (hazard ratio = 2.76; p = 0.0072) when compared with a platelet count of ≥100,000/mm³. No major bleeding complications were observed in all groups.

Conclusion: The majority of cancer patients with platelet counts of <50,000/mm³ were hypocoagulable based on TEG and had worse OS at 24 months. The relatively normal TEGs in the >50,000/mm³ groups, as well as the improved survival, suggest that with appropriate clinical indication and risk/benefit assessment, a cut-off of 50,000/mm³ platelets can be considered for CA in cancer patients.

Safety of Diagnostic and Therapeutic Cardiac Catheterization in Cancer Patients With Acute Coronary Syndrome and Chronic Thrombocytopenia

Little data is available on the bleeding risk and outcomes of cancer patients with chronic thrombocytopenia who underwent cardiac catheterization. We sought to assess the safety of coronary angiography, percutaneous coronary intervention, and antiplatelet therapy in cancer patients with acute coronary syndrome (ACS) and chronic thrombocytopenia. We performed a retrospective study of patients with chronic thrombocytopenia who underwent cardiac catheterization for ACS between November 2009 and November 2015. Preprocedural platelet counts were classified into 3 groups: mild thrombocytopenia (50,000 to 100,000/µL), moderate thrombocytopenia (30,000 to 50,000/µL), and severe thrombocytopenia (<30,000/µL). Postprocedural bleeding complications and overall survival (OS) were recorded. A total of 98 patients were included. Mean platelet count on admission was 47.63 ± 29.85 K/µL. Severe thrombocytopenia was identified in 36 patients (36.7%), moderate thrombocytopenia in 20 patients (20.4%), and mild thrombocytopenia in 42 patients (42.9%). Aspirin therapy (alone or in combination with clopidogrel) was used in 66 patients (67.3%), whereas 27 patients (27.6%) were on dual antiplatelet therapy. One procedure-related retroperitoneal hematoma and 3 procedure-related small hematomas were identified. No cerebrovascular events related to the procedure or the antiplatelet therapy were noted. Moderate thrombocytopenia was associated with decreased OS, whereas aspirin, dual antiplatelet therapy, and statin use showed a trend of improved OS. In conclusion, we suggest that coronary angiography and percutaneous coronary intervention can be performed safely in cancer patients with chronic thrombocytopenia. Aspirin therapy and dual antiplatelet therapy should be considered in cancer patients with chronic thrombocytopenia and ACS.

SCAI Expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologıa intervencionista)

In the United States alone, there are currently approximately 14.5 million cancer survivors, and this number is expected to increase to 20 million by 2020. Cancer therapies can cause significant injury to the vasculature, resulting in angina, acute coronary syndromes (ACS), stroke, critical limb ischemia, arrhythmias, and heart failure, independently from the direct myocardial or pericardial damage from the malignancy itself. Consequently, the need for invasive evaluation and management in the cardiac catheterization laboratory (CCL) for such patients has been increasing. In recognition of the need for a document on special considerations for cancer patients in the CCL, the Society for Cardiovascular Angiography and Interventions (SCAI) commissioned a consensus group to provide recommendations based on the published medical literature and on the expertise of operators with accumulated experience in the cardiac catheterization of cancer patients.

Outcome of patients admitted with acute coronary syndrome on palliative treatment: insights from the nationwide AMIS Plus Registry 1997-2014

OBJECTIVE

Compliance with guidelines is increasingly used to benchmark the quality of hospital care, however, very little is known on patients admitted with acute coronary syndromes (ACS) and treated palliatively. This study aimed to evaluate the baseline characteristics and outcomes of these patients.

DESIGN

Prospective cohort study.

SETTING

Eighty-two Swiss hospitals enrolled patients from 1997 to 2014.

PARTICIPANTS

All patients with ACS enrolled in the AMIS Plus registry (n=45,091) were analysed according to three treatment groups: palliative treatment, defined as use of aspirin and analgesics only and no reperfusion; conservative treatment, defined as any treatment including antithrombotics or anticoagulants, heparins, P2Y12 inhibitors, GPIIb/IIIa but no pharmacological or mechanical reperfusion; and reperfusion treatment (thrombolysis and/or percutaneous coronary intervention during initial hospitalisation). The primary outcome measure was in-hospital mortality and the secondary measure was 1-year mortality.

RESULTS

Of the patients, 1485 (3.3%) were palliatively treated, 11,119 (24.7%) were conservatively treated and 32,487 (72.0%) underwent reperfusion therapy. In 1997, 6% of all patients were treated palliatively and this continuously decreased to 2% in 2013. Baseline characteristics of palliative patients differed in comparison with conservatively treated and reperfusion patients in age, gender and comorbidities (all p<0.001). These patients had more in-hospital complications such as postadmission onset of cardiogenic shock (15.6% vs 5.2%; p<0.001), stroke (1.8% vs 0.8%; p=0.001) and a higher in-hospital mortality (25.8% vs 5.6%; p<0.001).The subgroup of patients followed 1 year after discharge (n=8316) had a higher rate of reinfarction (9.2% vs 3.4%; p=0.003) and mortality (14.0% vs 3.5%; p<0.001).

CONCLUSIONS

Patients with ACS treated palliatively were older, sicker, with more heart failure at admission and very high in-hospital mortality. While refraining from more active therapy may often constitute the most humane and appropriate approach, we think it is important to also evaluate these patients and include them in registries and outcome evaluations.

CLINICAL TRIAL NUMBER

ClinicalTrials.gov Identifier: NCT01 305 785.