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Groarke JD, Crawford J, Collins SM, Lubaczewski SL, Breen DM, Harrington MA, Jacobs I, Qiu R, Revkin J, Rossulek MI, Saxena AR. Phase 2 study of the efficacy and safety of ponsegromab in patients with cancer cachexia: PROACC-1 study design. J Cachexia Sarcopenia Muscle 2024. [PMID: 38500292 DOI: 10.1002/jcsm.13435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/06/2023] [Accepted: 12/27/2023] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Cancer cachexia is a multifactorial metabolic wasting syndrome characterized by anorexia, unintentional loss of weight involving both skeletal muscle and adipose tissues, progressive functional impairment and reduced survival. Therapeutic strategies for this serious condition are very limited. Growth differentiation factor 15 (GDF-15) is a cytokine that is implicated in cancer cachexia and may represent both a biomarker of cancer cachexia and a potential therapeutic target. Ponsegromab is a potent and selective humanized monoclonal antibody that inhibits GDF-15-mediated signalling. Preclinical and preliminary phase 1 data suggest that ponsegromab-mediated inactivation of circulating GDF-15 may lead to improvement in key characteristics of cachexia. The primary objective of this phase 2 study is to assess the effect of ponsegromab on body weight in patients with cancer, cachexia and elevated GDF-15 concentrations. Secondary objectives include assessing physical activity, physical function, actigraphy, appetite, nausea and vomiting, fatigue and safety. Exploratory objectives include evaluating pharmacokinetics, pharmacodynamics, immunogenicity, lumbar skeletal muscle index and Response Evaluation Criteria in Solid Tumors. METHODS Approximately 168 adults with non-small-cell lung, pancreatic or colorectal cancers who have cachexia and elevated GDF-15 concentrations will be randomized in a double-blind, placebo-controlled study (NCT05546476). Participants meeting eligibility criteria will be randomized 1:1:1:1 to one of three dose groups of ponsegromab (100, 200 or 400 mg) or matching placebo administered subcutaneously every 4 weeks for an initial 12-week treatment period. This is followed by optional open-label treatment with ponsegromab of 400 mg administered every 4 weeks for up to 1 year. The primary endpoint is mean change from baseline in body weight at Week 12. A mixed model for repeated measures followed by a Bayesian Emax model will be used for the primary analysis. Secondary endpoints include physical activity, physical function and actigraphy measured by remote digital sensors; patient-reported appetite-related symptoms assessed by Functional Assessment of Anorexia-Cachexia Therapy subscale scores; anorexia/appetite, nausea and vomiting, and fatigue evaluated according to questions from the Cancer-Related Cachexia Symptom Diary; and incidence of adverse events, safety laboratory tests, vital signs and electrocardiogram abnormalities. PERSPECTIVE Cancer-related cachexia is an area of significant unmet medical need. This study will support the clinical development of ponsegromab as a novel inhibitor of GDF-15, which may ameliorate key pathologies of cancer cachexia to improve patient symptoms, functionality and quality of life. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT05546476.
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Affiliation(s)
- John D Groarke
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, MA, USA
| | - Jeffrey Crawford
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Susie M Collins
- Global Biometrics and Data Management, Pfizer R&D UK Ltd, Sandwich, Kent, UK
| | - Shannon L Lubaczewski
- Early Clinical Development and Biomedicine Artificial Intelligence, Pfizer Inc, Collegeville, PA, USA
| | - Danna M Breen
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, MA, USA
| | | | - Ira Jacobs
- Global Product Development, Pfizer Inc, New York, NY, USA
| | - Ruolun Qiu
- Clinical Pharmacology, Pfizer Inc, Cambridge, MA, USA
| | - James Revkin
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, MA, USA
| | | | - Aditi R Saxena
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, MA, USA
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Dagenais S, Clark S, Fielding RA, Cantu C, Prasad S, Dai F, Groarke JD. Risk of mortality in older adults with loss of appetite: An analysis of Medicare fee-for-service data. J Nutr Health Aging 2024; 28:100035. [PMID: 38308921 DOI: 10.1016/j.jnha.2023.100035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/20/2023] [Accepted: 12/28/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVES Prior research suggested that loss of appetite (LOA) among adults with Medicare fee-for-service (FFS) insurance in the United States increased the risk of mortality within 1 year; those findings were not adjusted for risk factors and confounders. The objective of this study was to compare the risk of mortality among Medicare FFS beneficiaries with LOA to a control group without LOA while controlling or adjusting for age, comorbidities, body mass index (BMI), and weight loss. DESIGN Retrospective and observational analysis of Medicare FFS health insurance claims data from October 1, 2015 to December 31, 2021. SETTING Claims from all settings (e.g., hospital inpatient/outpatient, office, assisted living facility, skilled nursing facility, hospice, rehabilitation facility, home) were included in these analyses. PARTICIPANTS The LOA group included all individuals aged 65-115 years with continuous Medicare FFS medical coverage (Parts A and/or B) for at least 12 months before a claim with ICD-10 diagnosis code "R63.0 Anorexia". The control group was drawn from individuals aged 65-115 years with continuous Medicare FFS coverage who did not have a diagnosis of R63.0. Individuals with LOA were matched 1:3 to those in the control group based on age, sex, and race/ethnicity. MEASUREMENTS Mortality in the LOA group was compared to mortality in the control group using Kaplan-Meier and Cox regression analyses and stratified or adjusted in terms of Charlson Comorbidity Index (CCI), claims-based frailty index (CFI), BMI, and weight loss. RESULTS The study population of 1,707,031 individuals with LOA and 5,121,093 controls without LOA was 61.7% female and 82.2% White. More individuals with LOA compared with the control group had a CCI score 5+ (52.4% vs. 19.4%), CFI score 5+ (31.6% vs. 6.4%), and BMI < 20 kg/m2 (11.2% vs. 2.1%). Median follow-up was 12 months (individuals with LOA) and 49 months (control group). In a matched population, the risk of mortality was significantly higher (unadjusted hazard ratio 4.40, 95% confidence interval 4.39-4.42) for individuals with LOA than the control group. Median survival time was 4 months (individuals with LOA) and 26 months (control group); differences in survival time remained when stratifying by CCI, BMI, and weight loss. CONCLUSION Individuals with LOA had a substantially increased risk of death even after matching for age, sex, race/ethnicity, and adjusting for comorbidities. These findings highlight the burden of illness in older adults with LOA and the need for therapies.
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Affiliation(s)
| | | | - Roger A Fielding
- Nutrition, Exercise Physiology and Sarcopenia Laboratory, Jean Mayer USDA Human Nutrition Research Center, Tufts University, Boston, MA, USA
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Itzhaki Ben Zadok O, Groarke JD, Caron J, Novak P, Redd RA, Ng A, Neilan TG, Nohria A. Ivabradine in the management of elevated resting heart rate associated with mediastinal radiation therapy. Heart Rhythm 2024; 21:230-232. [PMID: 37967758 DOI: 10.1016/j.hrthm.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/04/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts; School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jesse Caron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts; University of Florida School of Medicine, Gainesville, Florida
| | - Peter Novak
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert A Redd
- Department of Data Science, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Andrea Ng
- Division of Radiation Oncology, Dana Farber Brigham Cancer Center, Boston, Massachusetts
| | - Tomas G Neilan
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anju Nohria
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Dagenais S, Fielding RA, Clark S, Cantu C, Prasad S, Groarke JD. Anorexia in Medicare Fee-for-Service Beneficiaries: A Claims-Based Analysis of Epidemiology and Mortality. J Nutr Health Aging 2023; 27:184-191. [PMID: 36973924 PMCID: PMC9841141 DOI: 10.1007/s12603-023-1882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/27/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Loss of appetite in older adults can lead to malnutrition, weight loss, frailty, and death, but little is known about its epidemiology in the United States (US). The objective of this study was to estimate the annual prevalence and incidence of anorexia in older adults with Medicare fee-for-service (FFS) health insurance. DESIGN Retrospective and observational analysis of administrative health insurance claims data. SETTING This study included Medicare FFS claims from all settings (eg, hospital inpatient/outpatient, office, assisted living facility, skilled nursing facility, hospice, rehabilitation facility, home). PARTICIPANTS This study included all individuals aged 65 to 115 years old with continuous Medicare FFS medical coverage (Parts A and/or B) for at least one 12-month period from October 1, 2015, to September 30, 2021 (ie, approximately 30 million individuals each year). INTERVENTION Not applicable. MEASUREMENTS Anorexia was identified using medical claims with the ICD-10 diagnosis code "R63.0: Anorexia". This study compared individuals with anorexia to a control group without anorexia with respect to demographics, comorbidities using the Charlson Comorbidity Index (CCI), Claims-based Frailty Index (CFI), and annual mortality. The annual prevalence and incidence of anorexia were estimated for each 12-month period from October 1, 2015, to September 30, 2021. RESULTS The number of individuals with anorexia ranged from 317,964 to 328,977 per year, a mean annual prevalence rate of 1.1%. The number of individuals newly diagnosed with anorexia ranged from 243,391 to 281,071 per year, a mean annual incidence rate of 0.9%. Individuals with anorexia had a mean (±standard deviation) age of 80.5±8.7 years (vs 74.9±7.5 years without anorexia; p<.001), 64.4% were female (vs 53.8%; p<.001), and 78.4% were White (vs 83.2%; p<.001). The most common CCI comorbidities for those with anorexia were chronic pulmonary disease (39.4%), dementia (38.3%), and peripheral vascular disease (38.0%). Median (interquartile range [IQR]) CCI with anorexia was 4 [5] (vs 1 [3] without anorexia; p<.001). The annual mortality rate among those with anorexia was 22.3% (vs 4.1% without anorexia; relative risk 5.49 [95% confidence interval, 5.45-5.53]). CONCLUSION Approximately 1% of all adults aged 65-115 years old with Medicare FFS insurance are diagnosed with anorexia each year based on ICD-10 codes reported in claims. These individuals have a higher comorbidity burden and an increased risk of annual mortality compared to those without a diagnosis of anorexia. Further analyses are needed to better understand the relationship between anorexia, comorbidities, frailty, mortality, and other health outcomes.
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Affiliation(s)
- S Dagenais
- Simon Dagenais, 94 Hillcrest Parkway, Winchester, MA, 01890, USA, E-mail address:
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Divakaran S, Caron JP, Zhou W, Hainer J, Bibbo CF, Skali H, Taqueti VR, Dorbala S, Blankstein R, Groarke JD, Nohria A, Di Carli MF. Coronary vasomotor dysfunction portends worse outcomes in patients with breast cancer. J Nucl Cardiol 2022; 29:3072-3081. [PMID: 34820770 PMCID: PMC9126993 DOI: 10.1007/s12350-021-02825-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/17/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Impaired MFR in the absence of flow-limiting CAD is associated with adverse events. Cardiovascular disease is an important cause of morbidity and mortality in patients with breast cancer. We sought to test the utility of MFR to predict outcomes in a cohort of patients with breast cancer. METHODS We retrospectively studied consecutive patients with breast cancer or breast cancer survivors who underwent cardiac stress PET imaging from 2006 to 2017 at Brigham and Women's Hospital. Patients with a history of clinically overt CAD, LVEF < 45%, or abnormal myocardial perfusion were excluded. Subjects were followed from time of PET to the occurrence of a first major adverse cardiovascular event (MACE) and all-cause death. RESULTS The final cohort included 87 patients (median age 69.0 years, 98.9% female, mean MFR 2.05). Over a median follow-up of 7.6 years after PET, the lowest MFR tertile was associated with higher cumulative incidence of MACE (adjusted subdistribution hazard ratio 4.91; 95% CI 1.68-14.38; p = 0.004) when compared with the highest MFR tertile. CONCLUSIONS In patients with breast cancer, coronary vasomotor dysfunction was associated with incident cardiovascular events. MFR may have potential as a risk stratification biomarker among patients with/survivors of breast cancer.
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Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jesse P Caron
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, ASB-L1 037C, Boston, MA, 02115, USA.
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Gong J, Castro RRT, Caron JP, Bay CP, Hainer J, Opotowsky AR, Mehra MR, Maron BA, Di Carli MF, Groarke JD, Nohria A. Usefulness of ventilatory inefficiency in predicting prognosis across the heart failure spectrum. ESC Heart Fail 2021; 9:293-302. [PMID: 34931762 PMCID: PMC8788025 DOI: 10.1002/ehf2.13761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/04/2021] [Accepted: 11/24/2021] [Indexed: 01/09/2023] Open
Abstract
Aims The minute ventilation–carbon dioxide production relationship (VE/VCO2 slope) is widely used for prognostication in heart failure (HF) with reduced left ventricular ejection fraction (LVEF). This study explored the prognostic value of VE/VCO2 slope across the spectrum of HF defined by ranges of LVEF. Methods and results In this single‐centre retrospective observational study of 1347 patients with HF referred for cardiopulmonary exercise testing, patients with HF were categorized into HF with reduced (HFrEF, LVEF < 40%, n = 598), mid‐range (HFmrEF, 40% ≤ LVEF < 50%, n = 164), and preserved (HFpEF, LVEF ≥ 50%, n = 585) LVEF. Four ventilatory efficiency categories (VC) were defined: VC‐I, VE/VCO2 slope ≤ 29; VC‐II, 29 < VE/VCO2 slope < 36; VC‐III, 36 ≤ VE/VCO2 slope < 45; and VC‐IV, VE/VCO2 slope ≥ 45. The associations of these VE/VCO2 slope categories with a composite outcome of all‐cause mortality or HF hospitalization were evaluated for each category of LVEF. Over a median follow‐up of 2.0 (interquartile range: 1.9, 2.0) years, 201 patients experienced the composite outcome. Compared with patients in VC‐I, those in VC‐II, III, and IV demonstrated three‐fold, five‐fold, and eight‐fold increased risk for the composite outcome. This incremental risk was observed across HFrEF, HFmrEF, and HFpEF cohorts. Conclusions Higher VE/VCO2 slope is associated with incremental risk of 2 year all‐cause mortality and HF hospitalization across the spectrum of HF defined by LVEF. A multilevel categorical approach to the interpretation of VE/VCO2 slope may offer more refined risk stratification than the current binary approach employed in clinical practice.
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Affiliation(s)
- Jingyi Gong
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Renata R T Castro
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jesse P Caron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Camden P Bay
- Brigham and Women's Hospital Center for Clinical Investigation, Boston, MA, USA
| | - Jon Hainer
- Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Alexander R Opotowsky
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Marcelo F Di Carli
- Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiovascular Division) and Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - John D Groarke
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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Groarke JD, Divakaran S, Nohria A, Killoran JH, Dorbala S, Dunne RM, Hainer J, Taqueti VR, Blankstein R, Mamon HJ, Di Carli MF. Coronary vasomotor dysfunction in cancer survivors treated with thoracic irradiation. J Nucl Cardiol 2021; 28:2976-2987. [PMID: 32691348 PMCID: PMC7855471 DOI: 10.1007/s12350-020-02255-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND We sought to test the hypothesis that thoracic radiation therapy (RT) is associated with impaired myocardial flow reserve (MFR), a measure of coronary vasomotor dysfunction. METHODS We retrospectively studied thirty-five consecutive patients (71% female, mean ± standard deviation (SD) age: 66 ± 11 years) referred clinically for positron emission tomography/computed tomography (PET/CT) myocardial perfusion imaging at a median (interquartile range, IQR) interval of 4.3 (2.1, 9.7) years following RT for a variety of malignancies. Radiation dose-volume histograms were generated for the heart and coronary arteries for each patient. RESULTS The median (IQR) of mean cardiac radiation doses was 12.0 (1.2, 24.2) Gray. There were significant inverse correlations between mean radiation dose and global MFR (MFRGlobal) and MFR in the left anterior descending artery territory (MFRLAD): Pearson's correlation coefficient = - .37 (P = .03) and - .38 (P = .03), respectively. For every one Gray increase in mean cardiac radiation dose, there was a mean ± standard error decrease of .02 ± .01 in MFRGlobal (P = .04) and MFRLAD (P = .03) after adjustment. CONCLUSIONS In patients with a history of RT clinically referred for cardiac stress PET, we found an inverse correlation between mean cardiac radiation dose and coronary vasomotor function.
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Affiliation(s)
- John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Killoran
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ruth M Dunne
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Lee M, Campbell RT, Claggett BL, Lewis EF, Groarke JD, Docherty KF, Lindner M, Liu J, Solomon SD, McMurray JJV, Platz E. Lung ultrasound in acute heart failure: association between quality of life, symptoms and B-lines. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Impaired health-related quality of life (HRQL) and pulmonary congestion are common and important findings among patients hospitalized for acute heart failure (AHF). There are few data describing the association between HQRL, symptoms and pulmonary congestion in AHF.
Purpose
This study investigates whether worse HRQL and symptoms is associated with more pulmonary congestion. Pulmonary congestion measured by lung ultrasound (LUS) in patients with AHF is a marker of worse prognosis at baseline and pre-discharge.
Methods
In this 2-site, prospective, observational study, four-zone LUS was performed at baseline (LUS1) and within 72h of hospital discharge (LUS2) in patients hospitalized for AHF. B-lines were quantified off-line, blinded to clinical findings and outcomes, by a core laboratory. Clinicians managing the patients were blinded to LUS findings. HRQL was assessed at baseline using the patient-reported Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS). Physician assessment of functional limitation at baseline was reported using the NYHA classification. In a subset of participants, patient-reported dyspnea at rest was also examined, at baseline and pre-discharge, using a numeric ranking scale (range 0–10; 10 worst). Dyspnea on exertion was also examined at baseline.
Results
Among 322 patients (mean age 72, 60% men, mean LVEF 39%) the median [interquartile range] KCCQ-TSS score was 33 [18–48]. Those with worse KCCQ-TSS scores, analyzed in tertiles, were younger, more likely to be obese and have diabetes mellitus and asthma/COPD, more likely to be on diuretics and report worse dyspnea at rest. At baseline, worse KCCQ-TSS was associated with worse NYHA class (Spearman's rho = −0.33, p<0.0001), dyspnea at rest (Spearman's rho = −0.41, p<0.0001) and dyspnea on exertion (Spearman's rho = −0.44, p<0.0001). A higher number of B-lines on LUS1 was weakly associated with worse NYHA class (Spearman's rho = 0.15, p=0.007) (Figure 1) but was not significantly associated with KCCQ-TSS (p=0.91), dyspnea at rest (p=0.74) or dyspnea on exertion (p=0.96). Among 118 patients with LUS2 performed within 72h of hospital discharge, pre-discharge dyspnea at rest was not significantly associated with B-lines (p=0.98).
Conclusion
Among patients hospitalized for AHF, at baseline, worse KCCQ-TSS was associated with worse NYHA class, dyspnea at rest and dyspnea on exertion but was not significantly associated with pulmonary congestion assessed by LUS. A higher number of B-lines at baseline was associated with worse NYHA class. Patient-reported breathlessness and HQRL measures, although important, may not consistently reflect the degree of pulmonary congestion in patients with AHF.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health/National Heart, Lung, and Blood Institute (NIH/NHLBI) (K23HL123533 to E.P.) and the British Heart Foundation (PG/13/17/30050 to R.T.C. and J.J.V.M.) Association of LUS1 B-lines & NYHA class
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Affiliation(s)
- M Lee
- University of Glasgow, Glasgow, United Kingdom
| | | | - B L Claggett
- Brigham and Women's Hospital, Harvard Medical School, Boston, United States of America
| | - E F Lewis
- Stanford University Medical Center, Stanford, United States of America
| | - J D Groarke
- Brigham and Women's Hospital, Harvard Medical School, Boston, United States of America
| | | | - M Lindner
- Brigham and Women's Hospital, Harvard Medical School, Boston, United States of America
| | - J Liu
- Brigham and Women's Hospital, Harvard Medical School, Boston, United States of America
| | - S D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, United States of America
| | | | - E Platz
- Brigham and Women's Hospital, Harvard Medical School, Boston, United States of America
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9
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Johannessen Ø, Claggett B, Lewis EF, Groarke JD, Swamy V, Lindner M, Solomon SD, Platz E. A-lines and B-lines in patients with acute heart failure. Eur Heart J Acute Cardiovasc Care 2021; 10:909-917. [PMID: 34160009 DOI: 10.1093/ehjacc/zuab046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/27/2021] [Accepted: 06/02/2021] [Indexed: 11/14/2022]
Abstract
AIMS Lung ultrasound (LUS) relies on detecting artefacts, including A-lines and B-lines, when assessing dyspnoeic patients. A-lines are horizontal artefacts and characterize normal lung, whereas multiple vertical B-lines are associated with increased lung density. We sought to assess the prevalence of A-lines and B-lines in patients with acute heart failure (AHF) and examine their clinical correlates and their relationship with outcomes. METHODS AND RESULTS In a prospective cohort study of adults with AHF, eight-zone LUS and echocardiography were performed early during the hospitalization and pre-discharge at an imaging depth of 18 cm. A- and B-lines were analysed separately off-line, blinded to clinical and outcome data. Of 164 patients [median age 71 years, 61% men, mean ejection fraction (EF) 40%], the sum of A-lines at baseline ranged from 0 to 19 and B-line number from 0 to 36. One hundred and fifty-six patients (95%) had co-existing A-lines and B-lines at baseline. Lower body mass index and lower chest wall thickness were associated with a higher number of A-lines (P trend < 0.001 for both). In contrast to B-lines, there was no significant change in the number of A-lines from baseline to discharge (median 6 vs. 5, P = 0.80). While B-lines were associated with 90-day HF readmission or death, A-lines were not [HR 1.67, 95% confidence interval (CI) 1.11-2.51 vs. HR 0.97, 95% CI 0.65-1.43]. CONCLUSIONS A-lines and B-lines on LUS co-exist in the vast majority of hospitalized patients with AHF. In contrast to B-lines, A-lines were not associated with adverse outcomes.
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Affiliation(s)
- Øyvind Johannessen
- Faculty of Medicine,Institute of Clinical Medicine, University of Oslo, Oslo 0316, Norway.,Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, 360 Longwood Ave., 7th Floor, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | | | - John D Groarke
- Cardiovascular Division, Brigham and Women's Hospital, 360 Longwood Ave., 7th Floor, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Varsha Swamy
- Cardiovascular Division, Brigham and Women's Hospital, 360 Longwood Ave., 7th Floor, Boston, MA 02115, USA
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, 360 Longwood Ave., 7th Floor, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital, 360 Longwood Ave., 7th Floor, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
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10
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Espersen C, Campbell RT, Claggett B, Lewis EF, Groarke JD, Docherty KF, Lee MM, Lindner M, Biering‐Sørensen T, Solomon SD, McMurray JJ, Platz E. Sex differences in congestive markers in patients hospitalized for acute heart failure. ESC Heart Fail 2021; 8:1784-1795. [PMID: 33709520 PMCID: PMC8120385 DOI: 10.1002/ehf2.13300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/12/2021] [Accepted: 02/28/2021] [Indexed: 01/06/2023] Open
Abstract
AIMS We sought to examine sex differences in congestion in patients hospitalized for acute heart failure (AHF). Understanding congestive patterns in women and men with AHF may provide insights into sex differences in the presentation and prognosis of AHF patients. METHODS AND RESULTS In a prospective, two-site study in adults hospitalized for AHF, four-zone lung ultrasound (LUS) was performed at the time of echocardiography at baseline (LUS1) and, in a subset, pre-discharge (LUS2). B-lines on LUS and echocardiographic images were analysed offline, blinded to clinical information and outcomes. Among 349 patients with LUS1 data (median age 74, 59% male, and 87% White), women had higher left ventricular ejection fraction (mean 43% vs. 36%, P < 0.001), higher tricuspid annular plane systolic excursion (mean 17 vs. 15 mm, P = 0.021), and higher measures of filling pressures (median E/e' 20 vs. 16, P < 0.001). B-line number on LUS1 (median 6 vs. 6, P = 0.69) and admission N-terminal pro-B-type natriuretic peptide levels (median 3932 vs. 3483 pg/mL, P = 0.77) were similar in women and men. In 121 patients with both LUS1 and LUS2 data, there was a similar and significant decrease in B-lines from baseline to discharge in both women and men. The risk of the composite 90 day outcome increased with higher B-line number on four-zone LUS2: unadjusted hazard ratio for each B-line tertile was 1.86 (95% confidence interval 1.08-3.20, P = 0.025) in women and 1.65 (95% confidence interval 1.03-2.64, P = 0.037) in men (interaction P = 0.72). CONCLUSIONS Among patients with AHF, echocardiographic markers differed between women and men at baseline, whereas B-line number on LUS did not. The dynamic changes in B-lines during a hospitalization for AHF were similar in women and men.
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Affiliation(s)
- Caroline Espersen
- Cardiovascular Division/Department of Emergency MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMAUSA
| | - Ross T. Campbell
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Brian Claggett
- The Division of Cardiovascular MedicineStanford University Medical CenterCAUSA
| | - Eldrin F. Lewis
- The Division of Cardiovascular MedicineStanford University Medical CenterCAUSA
| | - John D. Groarke
- The Division of Cardiovascular MedicineStanford University Medical CenterCAUSA
| | - Kieran F. Docherty
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Matthew M.Y. Lee
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Moritz Lindner
- Cardiovascular Division/Department of Emergency MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMAUSA
| | - Tor Biering‐Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, Faculty of Health SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Scott D. Solomon
- Cardiovascular Division/Department of Emergency MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMAUSA
| | - John J.V. McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Elke Platz
- Cardiovascular Division/Department of Emergency MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMAUSA
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11
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Drobni ZD, Zafar A, Zubiri L, Zlotoff DA, Alvi RM, Lee C, Hartmann S, Gilman HK, Villani A, Nohria A, Groarke JD, Sullivan RJ, Reynolds KL, Zhang L, Neilan TG. Decreased Absolute Lymphocyte Count and Increased Neutrophil/Lymphocyte Ratio With Immune Checkpoint Inhibitor-Associated Myocarditis. J Am Heart Assoc 2020; 9:e018306. [PMID: 33190570 PMCID: PMC7763791 DOI: 10.1161/jaha.120.018306] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/07/2020] [Indexed: 12/21/2022]
Abstract
Background Myocarditis attributable to immune checkpoint inhibitor (ICI) therapy is a potentially fatal immune-related adverse event. Limited data have suggested an association between baseline and on-treatment absolute lymphocyte count (ALC) and neutrophil/lymphocyte ratio (NLR) and the development of other immune-related adverse events; there are no data characterizing the role of ALC and NLR in ICI-associated myocarditis. Methods and Results This was a case control study of 55 patients with ICI myocarditis and 55 controls without any post-ICI immune-related adverse events. We leveraged clinical testing, where patients underwent routine serial blood counts before and with each ICI cycle to compare the baseline and change in ALC and NLR between cases and controls. The association between the change in these parameters with clinical variables and major adverse cardiac events was also tested. In cases, there was a statistically significant decrease in ALC with myocarditis from baseline (1.6 thousands per cubic milliliter (K/μL); interquartile range, 1.1-1.9 K/μL) to admission (1.1 K/μL; interquartile range, 0.7-1.3 K/μL; P<0.001). Similarly, there was an increase in NLR from baseline (3.5; interquartile range, 2.3-5.4) to admission (6.6; interquartile range, 4.5-14.1; P<0.001). There was no statistically significant change in controls. In follow-up, there were 20 events; larger decreases in ALC (44.6% versus 18.2%; P<0.001) or increases in NLR (156.5% versus 65.1%; P=0.019) were associated with major adverse cardiac events. Conclusions A reduction in ALC and an increase in NLR was seen with ICI myocarditis. A greater decrease in ALC or increase in NLR was associated with subsequent major adverse cardiac events.
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Affiliation(s)
- Zsofia D. Drobni
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
- Cardiovascular Imaging Research Group, Heart and Vascular CenterSemmelweis UniversityBudapestHungary
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Amna Zafar
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Leyre Zubiri
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Daniel A. Zlotoff
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Raza M. Alvi
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Charlotte Lee
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Sarah Hartmann
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Hannah K. Gilman
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Alexandra‐Chloe Villani
- Division of Oncology and HematologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Anju Nohria
- Cardio‐Oncology ProgramDivision of CardiologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - John D. Groarke
- Cardio‐Oncology ProgramDivision of CardiologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Ryan J. Sullivan
- Division of Oncology and HematologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Kerry L. Reynolds
- Division of Oncology and HematologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Lili Zhang
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMontefiore Medical CenterAlbert Einstein College of MedicineBronxNY
| | - Tomas G. Neilan
- Cardiovascular Imaging Research CenterDepartment of Radiology and Division of CardiologyMassachusetts General HospitalHarvard Medical SchoolBostonMA
- Cardio‐Oncology ProgramDivision of CardiologyDepartment of MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
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12
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Gong J, Payne D, Caron J, Bay CP, McGregor BA, Hainer J, Partridge AH, Neilan TG, Di Carli M, Nohria A, Groarke JD. Reduced Cardiorespiratory Fitness and Increased Cardiovascular Mortality After Prolonged Androgen Deprivation Therapy for Prostate Cancer. JACC CardioOncol 2020; 2:553-563. [PMID: 34396266 PMCID: PMC8352085 DOI: 10.1016/j.jaccao.2020.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 01/25/2023]
Abstract
Background Prolonged androgen deprivation therapy (ADT) is favored over short-term use in patients with localized high-risk prostate cancer (PC). Objectives This study sought to compare cardiorespiratory fitness (CRF) and cardiovascular (CV) mortality among patients with PC with and without ADT exposure and to explore how duration of ADT exposure influences CRF and CV mortality. Methods Retrospective cohort study of patients referred for exercise treadmill testing (ETT) after a PC diagnosis. PC risk classification was based on Gleason score (GS): high risk if GS ≥8; intermediate risk if GS = 7; and low risk if GS <7. CRF was categorized by metabolic equivalents (METs): METs >8 defined as good CRF and METs ≤8 as reduced CRF. ADT exposure was categorized as short term (≤6 months) versus prolonged (>6 months). Results A total of 616 patients underwent an ETT a median of 4.8 years (interquartile range: 2.0, 7.9 years) after PC diagnosis. Of those, 150 patients (24.3%) received ADT prior to the ETT; 99 with short-term and 51 with prolonged exposure. 504 patients (81.8%) had ≥2 CV risk factors. Prolonged ADT was associated with reduced CRF (odds ratio [OR]: 2.71; 95% confidence interval [CI]: 1.31 to 5.61; p = 0.007) and increased CV mortality (hazard ratio [HR]: 3.87; 95% CI: 1.16 to 12.96; p = 0.028) in adjusted analyses. Although the association between short-term ADT exposure and reduced CRF was of borderline significance (OR: 1.71; 95% CI: 1.00 to 2.94; p = 0.052), there was no association with CV mortality (HR: 1.60; 95% CI: 0.51 to 5.01; p = 0.420) in adjusted Cox regression models. Conclusions Among patients with PC and high baseline CV risk, prolonged ADT exposure was associated with reduced CRF and increased CV mortality.
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Key Words
- ADT, androgen deprivation therapy
- BMI, body mass index
- CI, confidence interval
- CRF, cardiorespiratory fitness
- CV, cardiovascular
- ETT, exercise treadmill test
- HR, hazard ratio
- IQR, interquartile range
- MET, metabolic equivalent
- OR, odds ratio
- PC, prostate cancer
- androgen deprivation therapy
- cardio-oncology
- cardiorespiratory fitness
- cardiovascular mortality
- cardiovascular risk
- prostate cancer
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Affiliation(s)
- Jingyi Gong
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David Payne
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jesse Caron
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Camden P Bay
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bradley A McGregor
- Lank Center for Genitourinary Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jon Hainer
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ann H Partridge
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcelo Di Carli
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anju Nohria
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - John D Groarke
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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13
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Lyon AR, Dent S, Stanway S, Earl H, Brezden-Masley C, Cohen-Solal A, Tocchetti CG, Moslehi JJ, Groarke JD, Bergler-Klein J, Khoo V, Tan LL, Anker MS, von Haehling S, Maack C, Pudil R, Barac A, Thavendiranathan P, Ky B, Neilan TG, Belenkov Y, Rosen SD, Iakobishvili Z, Sverdlov AL, Hajjar LA, Macedo AV, Manisty C, Ciardiello F, Farmakis D, de Boer RA, Skouri H, Suter TM, Cardinale D, Witteles RM, Fradley MG, Herrmann J, Cornell RF, Wechelaker A, Mauro MJ, Milojkovic D, de Lavallade H, Ruschitzka F, Coats AJ, Seferovic PM, Chioncel O, Thum T, Bauersachs J, Andres MS, Wright DJ, López-Fernández T, Plummer C, Lenihan D. Baseline cardiovascular risk assessment in cancer patients scheduled to receive cardiotoxic cancer therapies: a position statement and new risk assessment tools from the Cardio-Oncology Study Group of the Heart Failure Association of the European Society of Cardiology in collaboration with the International Cardio-Oncology Society. Eur J Heart Fail 2020; 22:1945-1960. [PMID: 32463967 PMCID: PMC8019326 DOI: 10.1002/ejhf.1920] [Citation(s) in RCA: 317] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 12/11/2022] Open
Abstract
This position statement from the Heart Failure Association of the European Society of Cardiology Cardio-Oncology Study Group in collaboration with the International Cardio-Oncology Society presents practical, easy-to-use and evidence-based risk stratification tools for oncologists, haemato-oncologists and cardiologists to use in their clinical practice to risk stratify oncology patients prior to receiving cancer therapies known to cause heart failure or other serious cardiovascular toxicities. Baseline risk stratification proformas are presented for oncology patients prior to receiving the following cancer therapies: anthracycline chemotherapy, HER2-targeted therapies such as trastuzumab, vascular endothelial growth factor inhibitors, second and third generation multi-targeted kinase inhibitors for chronic myeloid leukaemia targeting BCR-ABL, multiple myeloma therapies (proteasome inhibitors and immunomodulatory drugs), RAF and MEK inhibitors or androgen deprivation therapies. Applying these risk stratification proformas will allow clinicians to stratify cancer patients into low, medium, high and very high risk of cardiovascular complications prior to starting treatment, with the aim of improving personalised approaches to minimise the risk of cardiovascular toxicity from cancer therapies.
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Affiliation(s)
- Alexander R. Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College, London, UK
- Corresponding author. Cardio-Oncology Service, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Tel: +44 20 7352 8121,
| | - Susan Dent
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | | | - Helena Earl
- Department of Oncology, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Alain Cohen-Solal
- UMR-S 942, Paris University, Cardiology Department, Lariboisiere Hospital, AP-HP, Paris, France
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Javid J. Moslehi
- Cardio-Oncology Program, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John D. Groarke
- Cardio-Oncology Program, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Vincent Khoo
- Department of Clinical Oncology, Royal Marsden Hospital and Institute of Cancer Research, London, UK
- Department of Medical Imaging and Radiation Sciences, Monash University and Department of Medicine, Melbourne University, Melbourne, Australia
| | - Li Ling Tan
- Department of Cardiology, National University Heart Centre, Singapore, National University Health System, Singapore, Singapore
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Charité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research), partner site Berlin and Department of Cardiology, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Goettingen Medical Center, Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen, Goettingen, Germany
| | - Christoph Maack
- Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Radek Pudil
- First Department of Medicine – Cardioangiology, Charles University Prague, Medical Faculty and University Hospital Hradec Kralove, Prague, Czech Republic
| | - Ana Barac
- MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention and Joint Division of Medical Imaging, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Bonnie Ky
- University of Pennsylvania, Philadelphia, PA, USA
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stuart D. Rosen
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College, London, UK
| | - Zaza Iakobishvili
- Department of Community Cardiology, Tel Aviv Jaffa District, Clalit Health Fund and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aaron L. Sverdlov
- School of Medicine and Public Health, University of Newcastle and “Cancer and the Heart” Program, Hunter New England LHD, Newcastle, Australia
| | - Ludhmila A. Hajjar
- Cardio-Oncology, Department of Cardio-Pneumology, University of São Paulo, São Paulo, Brazil
| | - Ariane V.S. Macedo
- Santa Cardio-Oncology, Santa Casa de São Paulo and Rede Dor São Luiz, São Paulo, Brazil
| | | | - Fortunato Ciardiello
- Department of Precision Medicine, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Dimitrios Farmakis
- University of Cyprus Medical School, Nicosia, Cyprus
- Cardio-Oncology Clinic, Heart Failure Unit, “Attikon” University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Rudolf A. de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Thomas M. Suter
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Dragana Milojkovic
- Department of Haematology, Hammersmith Hospital, Imperial College, London, UK
| | | | - Frank Ruschitzka
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Andrew J.S. Coats
- University of Warwick, Warwick, UK
- Pharmacology, Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
| | - Petar M. Seferovic
- Faculty of Medicine and Serbian Academy of Sciences and Arts, University of Belgrade, Belgrade, Serbia
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - M. Sol Andres
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College, London, UK
| | - David J. Wright
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Teresa López-Fernández
- Cardiology Service, Cardio-Oncology Unit, La Paz University Hospital and IdiPAz Research Institute, Ciber CV, Madrid, Spain
| | - Chris Plummer
- Department of Cardiology, The Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle, UK
| | - Daniel Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, MO, USA
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14
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Groarke JD, Payne DL, Claggett B, Mehra MR, Gong J, Caron J, Mahmood SS, Hainer J, Neilan TG, Partridge AH, Di Carli M, Jones LW, Nohria A. Association of post-diagnosis cardiorespiratory fitness with cause-specific mortality in cancer. Eur Heart J Qual Care Clin Outcomes 2020; 6:315-322. [PMID: 32167560 PMCID: PMC9989596 DOI: 10.1093/ehjqcco/qcaa015] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
AIMS The prognostic importance of post-diagnosis assessment of cardiorespiratory fitness (CRF) in cancer patients is not well established. We sought to examine the association between CRF and mortality in cancer patients. METHODS AND RESULTS This was a single-centre cohort analysis of 1632 patients (58% male; 64 ± 12 years) with adult-onset cancer who were clinically referred for exercise treadmill testing a median of 7 [interquartile range (IQR): 3-12] years after primary diagnosis. Cardiorespiratory fitness was defined as peak metabolic equivalents (METs) achieved during standard Bruce protocol and categorized by tertiles. The association between CRF and all-cause and cause-specific mortality was assessed using multivariable Cox proportional hazard models adjusting for important covariates. Median follow-up was 4.6 (IQR: 2.6-7.0) years; a total of 411 deaths (229, 50, and 132 all-cause, cardiovascular (CV), and cancer related, respectively) occurred during this period. Compared with low CRF (range: 1.9-7.6 METs), the adjusted hazard ratio (HR) for all-cause mortality was 0.38 [95% confidence interval (CI): 0.28-0.52] for intermediate CRF (range: 7.7-10.6 METs) and 0.17 (95% CI: 0.11-0.27) for high CRF (range: 10.7-22.0 METs). The corresponding HRs were 0.40 (95% CI: 0.19-0.86) and 0.41 (95% CI: 0.16-1.05) for CV mortality and 0.40 (95% CI: 0.26-0.60) and 0.16 (95% CI: 0.09-0.28) for cancer mortality, respectively. The adjusted risk of all-cause, CV, and cancer mortality decreased by 26%, 14%, and 25%, respectively with each one MET increment in CRF. CONCLUSION Cardiorespiratory fitness is a strong, independent predictor of all-cause, CV, and cancer mortality, even after adjustment for important clinical covariates in patients with certain cancers.
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Affiliation(s)
- John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Adult Survivorship Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA
| | - David L Payne
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Jingyi Gong
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Jesse Caron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Syed S Mahmood
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jon Hainer
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114-2696, USA
| | - Ann H Partridge
- Adult Survivorship Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Marcelo Di Carli
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Adult Survivorship Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA 02215, USA
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15
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Awadalla M, Mahmood SS, Groarke JD, Hassan MZO, Nohria A, Rokicki A, Murphy SP, Mercaldo ND, Zhang L, Zlotoff DA, Reynolds KL, Alvi RM, Banerji D, Liu S, Heinzerling LM, Jones-O'Connor M, Bakar RB, Cohen JV, Kirchberger MC, Sullivan RJ, Gupta D, Mulligan CP, Shah SP, Ganatra S, Rizvi MA, Sahni G, Tocchetti CG, Lawrence DP, Mahmoudi M, Devereux RB, Forrestal BJ, Mandawat A, Lyon AR, Chen CL, Barac A, Hung J, Thavendiranathan P, Picard MH, Thuny F, Ederhy S, Fradley MG, Neilan TG. Global Longitudinal Strain and Cardiac Events in Patients With Immune Checkpoint Inhibitor-Related Myocarditis. J Am Coll Cardiol 2020; 75:467-478. [PMID: 32029128 DOI: 10.1016/j.jacc.2019.11.049] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/03/2019] [Accepted: 11/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is a need for improved methods for detection and risk stratification of myocarditis associated with immune checkpoint inhibitors (ICIs). Global longitudinal strain (GLS) is a sensitive marker of cardiac toxicity among patients receiving standard chemotherapy. There are no data on the use of GLS in ICI myocarditis. OBJECTIVES This study sought to evaluate the role of GLS and assess its association with cardiac events among patients with ICI myocarditis. METHODS This study retrospectively compared echocardiographic GLS by speckle tracking at presentation with ICI myocarditis (cases, n = 101) to that from patients receiving an ICI who did not develop myocarditis (control subjects, n = 92). Where available, GLS was also measured pre-ICI in both groups. Major adverse cardiac events (MACE) were defined as a composite of cardiogenic shock, arrest, complete heart block, and cardiac death. RESULTS Cases and control subjects were similar in age, sex, and cancer type. At presentation with myocarditis, 61 cases (60%) had a normal ejection fraction (EF). Pre-ICI, GLS was similar between cases and control subjects (20.3 ± 2.6% vs. 20.6 ± 2.0%; p = 0.60). There was no change in GLS among control subjects on an ICI without myocarditis (pre-ICI vs. on ICI, 20.6 ± 2.0% vs. 20.5 ± 1.9%; p = 0.41); in contrast, among cases, GLS decreased to 14.1 ± 2.8% (p < 0.001). The GLS at presentation with myocarditis was lower among cases presenting with either a reduced (12.3 ± 2.7%) or preserved EF (15.3 ± 2.0%; p < 0.001). Over a median follow-up of 162 days, 51 (51%) experienced MACE. The risk of MACE was higher with a lower GLS among patients with either a reduced or preserved EF. After adjustment for EF, each percent reduction in GLS was associated with a 1.5-fold increase in MACE among patients with a reduced EF (hazard ratio: 1.5; 95% confidence interval: 1.2 to 1.8) and a 4.4-fold increase with a preserved EF (hazard ratio: 4.4; 95% confidence interval: 2.4 to 7.8). CONCLUSIONS GLS decreases with ICI myocarditis and, compared with control subjects, was lower among cases presenting with either a preserved or reduced EF. Lower GLS was strongly associated with MACE in ICI myocarditis presenting with either a preserved or reduced EF.
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Affiliation(s)
- Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adam Rokicki
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sean P Murphy
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nathaniel D Mercaldo
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lili Zhang
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Dahlia Banerji
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shiying Liu
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen and Nurnberg, Germany
| | - Maeve Jones-O'Connor
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Rula B Bakar
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen and Nurnberg, Germany
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Connor P Mulligan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Gagan Sahni
- Cardiovascular Institute, School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard B Devereux
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Brian J Forrestal
- Cardio-Oncology Program, Department of Cardiology, Medstar Washington Hospital Center, Medstar Heart and Vascular institute, Washington, DC
| | - Anant Mandawat
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Ana Barac
- Cardio-Oncology Program, Department of Cardiology, Medstar Washington Hospital Center, Medstar Heart and Vascular institute, Washington, DC
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Franck Thuny
- Cardiology Division, Cardiovascular Division, Department of Medicine, Aix-Marseille Universite, Marseille, France
| | - Stephane Ederhy
- UNICO-GRECO, Cardio-Oncology Program, Department of Cardiology, Assistance Publique-Hopitaux de Paris, Saint-Antoine Hospital, Paris, France
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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16
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Zhang L, Zlotoff DA, Awadalla M, Mahmood SS, Nohria A, Hassan MZO, Thuny F, Zubiri L, Chen CL, Sullivan RJ, Alvi RM, Rokicki A, Murphy SP, Jones-O'Connor M, Heinzerling LM, Barac A, Forrestal BJ, Yang EH, Gupta D, Kirchberger MC, Shah SP, Rizvi MA, Sahni G, Mandawat A, Mahmoudi M, Ganatra S, Ederhy S, Zatarain-Nicolas E, Groarke JD, Tocchetti CG, Lyon AR, Thavendiranathan P, Cohen JV, Reynolds KL, Fradley MG, Neilan TG. Major Adverse Cardiovascular Events and the Timing and Dose of Corticosteroids in Immune Checkpoint Inhibitor-Associated Myocarditis. Circulation 2020; 141:2031-2034. [PMID: 32539614 DOI: 10.1161/circulationaha.119.044703] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Lili Zhang
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Magid Awadalla
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center (S.S.M.)
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.N., J.D.G.)
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston
| | - Franck Thuny
- Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Department of Cardiology, Nord Hospital, Center for Cardiovascular and Nutrition Research, France (F.T.).,Mediterranean Group of Cardio-Oncology, Marseille, France (F.T.)
| | - Leyre Zubiri
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Carol L Chen
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York (C.LC., D.G.)
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Raza M Alvi
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston
| | - Adam Rokicki
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston
| | - Sean P Murphy
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Maeve Jones-O'Connor
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Germany (L.M.H., M.C.K.)
| | - Ana Barac
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC (A.B., B.J.F.)
| | - Brian J Forrestal
- Cardio-Oncology Program, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC (A.B., B.J.F.)
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles (E.H.Y.)
| | - Dipti Gupta
- Cardiology Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York (C.LC., D.G.)
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Germany (L.M.H., M.C.K.)
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital and Medical Center, Burlington, MA (S.P.S., S.G.)
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (M.A.R.)
| | | | - Anant Mandawat
- Cardio-Oncology Program, Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Emory University School of Medicine, Atlanta, GA (A.M.)
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, United Kingdom (M.M.)
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital and Medical Center, Burlington, MA (S.P.S., S.G.)
| | - Stephane Ederhy
- AP-HP, Saint-Antoine Hospital, Department of Cardiology, UNICO-GRECO Cardio-Oncology Program, Paris, France (S.E.)
| | | | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.N., J.D.G.)
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy (C.G.T.)
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, and Imperial College London, United Kingdom (A.R.L.)
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Ontario, Canada (P.T.)
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine (L. Zubiri, R.J.S., J.V.C., K.L.R.), Massachusetts General Hospital, Boston
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia (M.G.F.)
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center, Division of Cardiology and Department of Radiology (L. Zhang, M.A., M.Z.O.H., R.M.A., A.R., T.G.N.), Massachusetts General Hospital, Boston.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine (L. Zhang, D.A.Z., M.A., S.P.M., M.J.-O., T.G.N.), Massachusetts General Hospital, Boston
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17
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Affiliation(s)
- John D Groarke
- Cardio-Oncology Program, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan Cheng
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lee W Jones
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Javid Moslehi
- Cardio-Oncology Program, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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18
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Salem JE, Manouchehri A, Bretagne M, Lebrun-Vignes B, Groarke JD, Johnson DB, Yang T, Reddy NM, Funck-Brentano C, Brown JR, Roden DM, Moslehi JJ. Cardiovascular Toxicities Associated With Ibrutinib. J Am Coll Cardiol 2020; 74:1667-1678. [PMID: 31558250 DOI: 10.1016/j.jacc.2019.07.056] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ibrutinib has revolutionized treatment for several B-cell malignancies. However, a recent clinical trial where ibrutinib was used in a front-line setting showed increased mortality during treatment compared with conventional chemotherapy. Cardiovascular toxicities were suspected as the culprit but not directly assessed in the study. OBJECTIVES The purpose of this study was to identify and characterize cardiovascular adverse drug reactions (CV-ADR) associated with ibrutinib. METHODS This study utilized VigiBase (International pharmacovigilance database) and performed a disproportionality analysis using reporting odds ratios (ROR) and information component (IC) to determine whether CV-ADR and CV-ADR deaths were associated with ibrutinib. IC compares observed and expected values to find associations between drugs and adverse drug reactions using disproportionate Bayesian-reporting; IC025 (lower end of the IC 95% credibility interval) >0 is significant. RESULTS This study identified 303 ibrutinib-associated cardiovascular deaths. Ibrutinib was associated with higher reporting of supraventricular arrhythmias (SVAs) (ROR: 23.1; 95% confidence interval: 21.6 to 24.7; p < 0.0001; IC025: 3.97), central nervous system (CNS) hemorrhagic events (ROR: 3.7; 95% confidence interval: 3.4 to 4.1; p < 0.0001; IC025: 1.63), heart failure (ROR: 3.5; 95% confidence interval: 3.1 to 3.8; p < 0.0001; IC025: 1.46), ventricular arrhythmias (ROR: 4.7; 95% confidence interval: 3.7 to 5.9; p < 0.0001; IC025: 0.96), conduction disorders (ROR: 3.5; 95% confidence interval: 2.7 to 4.6; p < 0.0001; IC025: 0.76), CNS ischemic events (ROR: 2.2; 95% confidence interval: 2.0 to 2.5; p < 0.0001; IC025: 0.73), and hypertension (ROR: 1.7; 95% confidence interval: 1.5 to 1.9; p < 0.0001; IC025: 0.4). CV-ADR often occurred early after ibrutinib administration. Importantly, CV-ADR were associated with fatalities that ranged from ∼10% (SVAs and ventricular arrhythmias) to ∼20% (CNS events, heart failure, and conduction disorders). Ibrutinib-associated SVA portends poor prognosis when CNS events occur concomitantly, with 28.8% deaths (15 of 52 cases). CONCLUSIONS Severe and occasionally fatal cardiac events occur in patients exposed to ibrutinib. These events should be considered in patient care and in clinical trial designs. (Evaluation of Reporting of Cardio-vascular Adverse Events With Antineoplastic and Immunomodulating Agents [EROCA]; NCT03530215).
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Affiliation(s)
- Joe-Elie Salem
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France; Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Ali Manouchehri
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie Bretagne
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - Bénédicte Lebrun-Vignes
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Douglas B Johnson
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tao Yang
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nishitha M Reddy
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christian Funck-Brentano
- Sorbonne Université, INSERM CIC-1421, AP-HP, Regional Pharmacovigilance Center, Pitié-Salpêtrière Hospital, UNICO-GRECO.6 Cardio-Oncology Program, Department of Pharmacology, Paris, France
| | - Jennifer R Brown
- CLL Center, Dana-Farber Cancer Institute; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Dan M Roden
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Javid J Moslehi
- Departments of Medicine and Pharmacology, Cardio-Oncology program, Vanderbilt University Medical Center, Nashville, Tennessee.
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19
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Zhang L, Awadalla M, Mahmood SS, Nohria A, Hassan MZO, Thuny F, Zlotoff DA, Murphy SP, Stone JR, Golden DLA, Alvi RM, Rokicki A, Jones-O’Connor M, Cohen JV, Heinzerling LM, Mulligan C, Armanious M, Barac A, Forrestal BJ, Sullivan RJ, Kwong RY, Yang EH, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Moslehi JJ, Coelho-Filho OR, Ganatra S, Rizvi MA, Sahni G, Tocchetti CG, Mercurio V, Mahmoudi M, Lawrence DP, Reynolds KL, Weinsaft JW, Baksi AJ, Ederhy S, Groarke JD, Lyon AR, Fradley MG, Thavendiranathan P, Neilan TG. Cardiovascular magnetic resonance in immune checkpoint inhibitor-associated myocarditis. Eur Heart J 2020; 41:1733-1743. [PMID: 32112560 PMCID: PMC7205467 DOI: 10.1093/eurheartj/ehaa051] [Citation(s) in RCA: 189] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/30/2019] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
AIMS Myocarditis is a potentially fatal complication of immune checkpoint inhibitors (ICI). Sparse data exist on the use of cardiovascular magnetic resonance (CMR) in ICI-associated myocarditis. In this study, the CMR characteristics and the association between CMR features and cardiovascular events among patients with ICI-associated myocarditis are presented. METHODS AND RESULTS From an international registry of patients with ICI-associated myocarditis, clinical, CMR, and histopathological findings were collected. Major adverse cardiovascular events (MACE) were a composite of cardiovascular death, cardiogenic shock, cardiac arrest, and complete heart block. In 103 patients diagnosed with ICI-associated myocarditis who had a CMR, the mean left ventricular ejection fraction (LVEF) was 50%, and 61% of patients had an LVEF ≥50%. Late gadolinium enhancement (LGE) was present in 48% overall, 55% of the reduced EF, and 43% of the preserved EF cohort. Elevated T2-weighted short tau inversion recovery (STIR) was present in 28% overall, 30% of the reduced EF, and 26% of the preserved EF cohort. The presence of LGE increased from 21.6%, when CMR was performed within 4 days of admission to 72.0% when CMR was performed on Day 4 of admission or later. Fifty-six patients had cardiac pathology. Late gadolinium enhancement was present in 35% of patients with pathological fibrosis and elevated T2-weighted STIR signal was present in 26% with a lymphocytic infiltration. Forty-one patients (40%) had MACE over a follow-up time of 5 months. The presence of LGE, LGE pattern, or elevated T2-weighted STIR were not associated with MACE. CONCLUSION These data suggest caution in reliance on LGE or a qualitative T2-STIR-only approach for the exclusion of ICI-associated myocarditis.
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Affiliation(s)
- Lili Zhang
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Syed S Mahmood
- Cardiology Division, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, 1300 York Avenue, New York, NY 10065, USA
| | - Anju Nohria
- Cardio-Oncology Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Franck Thuny
- Department of Cardiology, Aix-Marseille University, Assistance Publique–Hôpitaux de Marseille, Mediterranean university, Cardio-Oncology center (MEDI-CO center), Unit of Heart Failure and Valvular Heart Diseases, Hôpital Nord, Jardin du Pharo, 58 Boulevard Charles Livon 13007, Marseille, France
- Groupe Méditerranéen de Cardio-Oncologie (gMEDICO), AP-HM, Chemin des Bourrely, 13015, Marseille, France
- Aix-Marseille University, Center for CardioVascular and Nutrition research (C2VN), Inserm 1263, Inra 1260, 13385 Marseille, France
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Sean P Murphy
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Doll Lauren Alexandra Golden
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Adam Rokicki
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Maeve Jones-O’Connor
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schloßplatz 4, 91054 Erlangen, Germany
| | - Connor Mulligan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Merna Armanious
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Ana Barac
- Cardio-Oncology program, MedStar Heart and Vascular Institute, Georgetown University, 110 Irving St NW, Washington, DC 20010, USA
| | - Brian J Forrestal
- Cardio-Oncology program, MedStar Heart and Vascular Institute, Georgetown University, 110 Irving St NW, Washington, DC 20010, USA
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Schloßplatz 4, 91054 Erlangen, Germany
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, USA
| | - Otavio R Coelho-Filho
- Cardiology Division, State University of Campinas, Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas, São Paulo 13083-970, Brazil
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01805, USA
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, 1200 S Cedar Crest Blvd, Allentown, PA 18103, USA
| | - Gagan Sahni
- Cardiology Division, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, USA
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5, 80131 Naples, NA, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5, 80131 Naples, NA, Italy
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, University Road Southampton SO17 1BJ, UK
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | - Jonathan W Weinsaft
- Cardiology Division, Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, 1300 York Avenue, New York, NY 10065, USA
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA
| | - A John Baksi
- Cardiovascular Research Centre and Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney St, Chelsea, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, Kensington, London SW7 2DD, UK
| | - Stephane Ederhy
- UNICO-GRECO cardio-oncology program, sorbonne universite, Hopital Saint Antoine, 27 Rue de Chaligny, 75012 Paris, France
| | - John D Groarke
- Cardio-Oncology Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, Sydney St, Chelsea, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, Cale Street, Chelsea, London, SW3 6LY, United Kingdom
| | - Michael G Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Toronto General Hospital, Peter Munk Cardiac Center, University of Toronto, Toronto, ON, Canada
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Division of Cardiology, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
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Campia U, Moslehi JJ, Amiri-Kordestani L, Barac A, Beckman JA, Chism DD, Cohen P, Groarke JD, Herrmann J, Reilly CM, Weintraub NL. Cardio-Oncology: Vascular and Metabolic Perspectives: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e579-e602. [PMID: 30786722 DOI: 10.1161/cir.0000000000000641] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardio-oncology has organically developed as a new discipline within cardiovascular medicine as a result of the cardiac and vascular adverse sequelae of the major advances in cancer treatment. Patients with cancer and cancer survivors are at increased risk of vascular disease for a number of reasons. First, many new cancer therapies, including several targeted therapies, are associated with vascular and metabolic complications. Second, cancer itself serves as a risk factor for vascular disease, especially by increasing the risk for thromboembolic events. Finally, recent data suggest that common modifiable and genetic risk factors predispose to both malignancies and cardiovascular disease. Vascular complications in patients with cancer represent a new challenge for the clinician and a new frontier for research and investigation. Indeed, vascular sequelae of novel targeted therapies may provide insights into vascular signaling in humans. Clinically, emerging challenges are best addressed by a multidisciplinary approach in which cardiovascular medicine specialists and vascular biologists work closely with oncologists in the care of patients with cancer and cancer survivors. This novel approach realizes the goal of providing superior care through the creation of cardio-oncology consultative services and the training of a new generation of cardiovascular specialists with a broad understanding of cancer treatments.
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21
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Salem JE, Manouchehri A, arie Bretagne M, Lebrun Vignes B, Groarke JD, Johnson DB, Yang T, Reddy NM, Funck-Brentano C, Brown JR, Roden DM, Moslehi JJ. P1591Cardiovascular toxicity of ibrutinib: a pharmacovigilance study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Importance
Ibrutinib, a first in class Bruton tyrosine kinase inhibitor, has revolutionized treatment for several B-cell malignancies. However, early data suggested that ibrutinib was associated with supra-ventricular arrhythmias (SVA) and bleeding. Other types of cardiovascular adverse drug reactions (CV-ADR) induced by ibrutinib have been sporadically reported.
Objective
To determine the full spectrum of CV-ADR associated with ibrutinib and provide data concerning their clinical characteristics.
Design
An observational, retrospective, pharmacovigilance study
Setting
VigiBase, the World Health Organization's pharmacovigilance database.
Main outcomes and measures
A disproportionality analysis using reporting odds-ratios (ROR) and information component (IC). IC compares observed and expected values to find associations between drugs and ADR using disproportionate Bayesian reporting; IC025 (lower end of the IC 95% credibility interval) >0 is considered statistically significant.
Exposures
Exposure to ibrutinib versus entire database.
Results
Ibrutinib was associated with higher reporting of supraventricular arrhythmias (SVA; ROR: 23.1 [21.6–24.7]; IC025:3.97), central nervous system (CNS) hemorrhagic events (ROR: 3.7 [3.4–4.1]; IC025:1.63), heart failure (HF; ROR: 3.5 [3.1–3.8]; IC025:1.46), ventricular arrhythmias (VA; ROR: 4.7 [3.7–5.9]; IC025:0.96), conduction disorders (CD; ROR: 3.5 [2.7–4.6]; IC025:0.76), CNS ischemic events (ROR: 2.2 [2.0–2.5]; IC025:0.73) and hypertension (ROR: 1.7 [1.5–1.9]; IC025:0.4). CV-ADR occurred early after ibrutinib administration, as soon as after the first dose, with a shorter median time to onset of 27.5 days (IQR: 1–138.5 days) for CD (p<0.01, Kruskal-Wallis), as compared to CNS ischemic events (51 days; IQR: 17.5–160 days, p: 0.05 vs. CD), CNS hemorrhagic events (53.5 days; IQR: 20.3–183.3 days, p: 0.03 vs. CD), HF (54 days; IQR: 20–142.8 days, p: 0.05 vs. CD), VA (70 days; IQR: 28.5–152.5 days, p: 0.03 vs. CD), SVA (74 days; (IQR: 29.5–196.5 days, p: 0.0004 vs. CD) and hypertension (164 days; IQR: 20–274 days, p: 0.04 vs. CD). CV-ADR were associated with fatalities, with rates ranging from ∼10% (SVA and VA) to ∼20% (CNS events, HF and CD). More deaths occurred when SVA cases were associated with CNS hemorrhagic and/or ischemic events compared to their absence (15/52, 28.8% vs. 88/907, 9.7%, p<0.0001, respectively).
Conclusions
Severe and occasionally fatal cardiac events related to cardiac SVA, VA, CD, HF, hypertension, CNS hemorrhagic and ischemic events occur in patients exposed to ibrutinib. These events should be considered in patient care and in clinical trial designs.
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Affiliation(s)
- J E Salem
- University Pierre & Marie Curie Paris VI, Paris, France
| | - A Manouchehri
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - M arie Bretagne
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - B Lebrun Vignes
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - J D Groarke
- Harvard Medical School, Cardiology, Boston, United States of America
| | - D B Johnson
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - T Yang
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - N M Reddy
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - C Funck-Brentano
- Hospital Pitie-Salpetriere, CIC-Paris Est, pharmacologie médicale, Paris, France
| | - J R Brown
- Harvard Medical School, Cardiology, Boston, United States of America
| | - D M Roden
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
| | - J J Moslehi
- Vanderbilt University, clinical pharmacology, Nashville, United States of America
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22
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Banerji D, Alvi RM, Afshar M, Tariq N, Rokicki A, Mulligan CP, Zhang L, Hassan MO, Awadalla M, Groarke JD, Neilan TG. Carvedilol Among Patients With Heart Failure With a Cocaine-Use Disorder. JACC Heart Fail 2019; 7:771-778. [PMID: 31466673 PMCID: PMC6719721 DOI: 10.1016/j.jchf.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study sought to assess the safety of carvedilol therapy among heart failure (HF) patients with a cocaine-use disorder (CUD). BACKGROUND Although carvedilol therapy is recommended among certain patients with HF, the safety and efficacy of carvedilol among HF patients with a CUD is unknown. METHODS This was a single-center study of hospitalized patients with HF. Cocaine use was self-reported or defined as having a positive urine toxicology. Patients were divided by carvedilol prescription. Subgroup analyses were performed by strata of ejection fraction (EF) ≤40%, 41% to 49%, or ≥50%. Major adverse cardiovascular events (MACE) were defined as cardiovascular mortality and 30-day HF readmission. RESULTS From a cohort of 2,578 patients hospitalized with HF in 2011, 503 patients with a CUD were identified, among whom 404 (80%) were prescribed carvedilol, and 99 (20%) were not. Both groups had similar characteristics; however, those prescribed carvedilol had a lower LVEF, heart rate, and N-terminal pro-B-type natriuretic peptide concentrations at admission and on discharge, and more coronary artery disease. Over a median follow-up of 19 months, there were 169 MACEs. The MACE rates were similar between the carvedilol and the non-carvedilol groups (32% vs. 38%, respectively; p = 0.16) and between those with a preserved EF (30% vs. 33%, respectively; p = 0.48) and were lower in patients with a reduced EF taking carvedilol (34% vs. 58%, respectively; p = 0.02). In a multivariate model, carvedilol therapy was associated with lower MACE among patients with HF with a CUD (hazard ratio: 0.67; 95% confidence interval; 0.481 to 0.863). CONCLUSIONS Our findings suggest that carvedilol therapy is safe for patients with HF with a CUD and may be effective among those with a reduced EF.
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Affiliation(s)
- Dahlia Banerji
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raza M Alvi
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Bronx-Lebanon Hospital Center of Icahn School of Medicine at Mount Sinai, Bronx, New York.
| | - Maryam Afshar
- Bronx-Lebanon Hospital Center of Icahn School of Medicine at Mount Sinai, Bronx, New York
| | - Noor Tariq
- Department of Medicine, Division of Cardiology, Yale New Haven Hospital of Yale University School of Medicine, New Haven, Connecticut
| | - Adam Rokicki
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Connor P Mulligan
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lili Zhang
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Malek O Hassan
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John D Groarke
- Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology, and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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23
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Gong J, Castro RR, Caron JP, Bay CP, Hainer J, Opotowsky AR, Mehra MR, Nohria A, Maron BA, Di Carli MF, Groarke JD. Predictive Prognostic Value of Ventilatory Inefficiency across the Spectrum of Heart Failure. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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24
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Zhang L, Jones-O'Connor M, Awadalla M, Zlotoff DA, Thavendiranathan P, Groarke JD, Villani AC, Lyon AR, Neilan TG. Cardiotoxicity of Immune Checkpoint Inhibitors. Curr Treat Options Cardiovasc Med 2019; 21:32. [PMID: 31175469 DOI: 10.1007/s11936-019-0731-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Immunotherapies, particularly immune checkpoint inhibitors (ICI), are revolutionary cancer therapies being increasingly applied to a broader range of cancers. Our understanding of the mechanism, epidemiology, diagnosis, and treatment of cardiotoxicity related to immunotherapies remains limited. We aim to synthesize the limited current literature on cardiotoxicity of ICIs and to share our opinions on the diagnosis and treatment of this condition. RECENT FINDINGS The incidence of ICI-associated myocarditis ranges from 0.1 to 1%. Patients with ICI-associated myocarditis often have a fulminant course with a case fatality rate of 25-50%. The diagnosis of this condition poses many challenges because independently a normal electrocardiogram, biomarkers, or a preserved left ventricular function do not rule out ICI-associated myocarditis. Endomyocardial biopsy should be pursued when clinical suspicion remains despite normal non-invasive tests. Data on optimal screening and surveillance tools are lacking. Cessation of ICIs, combined with high dose corticosteroids and other immunosuppressant approaches are the cornerstones of the treatment of ICI-associated myocarditis. This condition may recur when patients are re-challenged with these agents and the decision to resume ICIs should be made through a multidisciplinary discussion. Immunotherapies have changed the landscape of cancer treatment. Recognizing and managing cardiotoxicity related to ICIs is of critical importance. Our understanding of ICI-cardiotoxicity has improved, but large information gaps remain for further research. Due to the high case fatality rate, any type of cardiac symptoms or signs in a patient who has recently started an ICI should prompt consideration of ICI-cardiotoxicity.
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Affiliation(s)
- Lili Zhang
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Suite 400, 165 Cambridge Street, Boston, MA, 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Suite 400, 165 Cambridge Street, Boston, MA, 02114, USA
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital, London, UK
- Imperial College London, London, UK
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Suite 400, 165 Cambridge Street, Boston, MA, 02114, USA.
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Zhang L, Awadalla M, Mahmood SS, Groarke JD, Nohria A, Liu S, Hassan MZ, Cohen JV, Jones-O'Connor M, Murphy SP, Heinzerling LM, Sahni G, Chen CL, Gupta D, Moslehi JJ, Ganatra S, Ederhy S, Thuny F, Lyon AR, Tocchetti CG, Rizvi MA, Thavendiranathan P, Fradley MG, Neilan TG. LATE GADOLINIUM ENHANCEMENT IN PATIENTS WITH MYOCARDITIS FROM IMMUNE CHECKPOINT INHIBITORS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31283-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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26
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Awadalla M, Golden DLA, Mahmood SS, Alvi RM, Mercaldo ND, Hassan MZO, Banerji D, Rokicki A, Mulligan C, Murphy SPT, Jones-O'Connor M, Cohen JV, Heinzerling LM, Armanious M, Sullivan RJ, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Moslehi JJ, Shah SP, Ganatra S, Thavendiranathan P, Rizvi MA, Sahni G, Lyon AR, Tocchetti CG, Mercurio V, Thuny F, Ederhy S, Mahmoudi M, Lawrence DP, Groarke JD, Nohria A, Fradley MG, Reynolds KL, Neilan TG. Influenza vaccination and myocarditis among patients receiving immune checkpoint inhibitors. J Immunother Cancer 2019; 7:53. [PMID: 30795818 PMCID: PMC6387531 DOI: 10.1186/s40425-019-0535-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/13/2019] [Indexed: 12/18/2022] Open
Abstract
Background Influenza vaccination (FV) is recommended for patients with cancer. Recent data suggested that the administration of the FV was associated with an increase in immune-related adverse events (irAEs) among patients on immune checkpoint inhibitors (ICIs). Myocarditis is an uncommon but serious complication of ICIs and may also result from infection with influenza. There are no data testing the relationship between FV and the development of myocarditis on ICIs. Methods Patients on ICIs who developed myocarditis (n = 101) (cases) were compared to ICI-treated patients (n = 201) without myocarditis (controls). A patient was defined as having the FV if they were administered the FV from 6 months prior to start of ICI to anytime during ICI therapy. Alternate thresholds for FV status were also tested. The primary comparison of interest was the rate of FV between cases and controls. Patients with myocarditis were followed for major adverse cardiac events (MACE), defined as the composite of cardiogenic shock, cardiac arrest, hemodynamically significant complete heart block and cardiovascular death. Results The FV was administered to 25% of the myocarditis cases compared to 40% of the non-myocarditis ICI-treated controls (p = 0.01). Similar findings of lower rates of FV administration were noted among myocarditis cases when alternate thresholds were tested. Among the myocarditis cases, those who were vaccinated had 3-fold lower troponin levels when compared to unvaccinated cases (FV vs. No FV: 0.12 [0.02, 0.47] vs. 0.40 [0.11, 1.26] ng/ml, p = 0.02). Within myocarditis cases, those administered the FV also had a lower rate of other irAEs when compared to unvaccinated cases (36 vs. 55% p = 0.10) including lower rates of pneumonitis (12 vs. 36%, p = 0.03). During follow-up (175 [IQR 89, 363] days), 47% of myocarditis cases experienced a MACE. Myocarditis cases who received the FV were at a lower risk of cumulative MACE when compared to unvaccinated cases (24 vs. 59%, p = 0.002). Conclusion The rate of FV among ICI-related myocarditis cases was lower than controls on ICIs who did not develop myocarditis. In those who developed myocarditis related to an ICI, there was less myocardial injury and a lower risk of MACE among those who were administered the FV. Electronic supplementary material The online version of this article (10.1186/s40425-019-0535-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
| | - Doll Lauren Alexandra Golden
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Raza M Alvi
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Nathaniel D Mercaldo
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Malek Z O Hassan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Dahlia Banerji
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Adam Rokicki
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Connor Mulligan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Sean P T Murphy
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Maeve Jones-O'Connor
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen, Germany
| | - Merna Armanious
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, FL, USA
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, FL, USA
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen, Germany
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA, USA
| | | | | | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Franck Thuny
- Cardiovascular Division, Department of Medicine, Aix-Marseille Universite, Marseille, France
| | - Stephane Ederhy
- Cardio-Oncology Program, Division of Cardiology, Hopitaux Universitaires est Paris, Paris, France
| | - Michael Mahmoudi
- Division of Cardiology, Department of Medicine, Southampton General Hospital, Southampton, UK
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, FL, USA
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.,Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Affiliation(s)
- Anju Nohria
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
| | - John D Groarke
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
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28
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Ganatra S, Nohria A, Shah S, Groarke JD, Sharma A, Venesy D, Patten R, Gunturu K, Zarwan C, Neilan TG, Barac A, Hayek SS, Dani S, Solanki S, Mahmood SS, Lipshultz SE. Upfront dexrazoxane for the reduction of anthracycline-induced cardiotoxicity in adults with preexisting cardiomyopathy and cancer: a consecutive case series. Cardiooncology 2019; 5:1. [PMID: 32154008 PMCID: PMC7048095 DOI: 10.1186/s40959-019-0036-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/20/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiotoxicity associated with anthracycline-based chemotherapies has limited their use in patients with preexisting cardiomyopathy or heart failure. Dexrazoxane protects against the cardiotoxic effects of anthracyclines, but in the USA and some European countries, its use had been restricted to adults with advanced breast cancer receiving a cumulative doxorubicin (an anthracycline) dose > 300 mg/m2. We evaluated the off-label use of dexrazoxane as a cardioprotectant in adult patients with preexisting cardiomyopathy, undergoing anthracycline chemotherapy. METHODS Between July 2015 and June 2017, five consecutive patients, with preexisting, asymptomatic, systolic left ventricular (LV) dysfunction who required anthracycline-based chemotherapy, were concomitantly treated with off-label dexrazoxane, administered 30 min before each anthracycline dose, regardless of cancer type or stage. Demographic, cardiovascular, and cancer-related outcomes were compared to those of three consecutive patients with asymptomatic cardiomyopathy treated earlier at the same hospital without dexrazoxane. RESULTS Mean age of the five dexrazoxane-treated patients and three patients treated without dexrazoxane was 70.6 and 72.6 years, respectively. All five dexrazoxane-treated patients successfully completed their planned chemotherapy (doxorubicin, 280 to 300 mg/m2). With dexrazoxane therapy, changes in LV systolic function were minimal with mean left ventricular ejection fraction (LVEF) decreasing from 39% at baseline to 34% after chemotherapy. None of the dexrazoxane-treated patients experienced symptomatic heart failure or elevated biomarkers (cardiac troponin I or brain natriuretic peptide). Of the three patients treated without dexrazoxane, two received doxorubicin (mean dose, 210 mg/m2), and one received daunorubicin (540 mg/m2). Anthracycline therapy resulted in a marked reduction in LVEF from 42.5% at baseline to 18%. All three developed symptomatic heart failure requiring hospitalization and intravenous diuretic therapy. Two of them died from cardiogenic shock and multi-organ failure. CONCLUSION The concomitant administration of dexrazoxane in patients with preexisting cardiomyopathy permitted successful delivery of anthracycline-based chemotherapy without cardiac decompensation. Larger prospective trials are warranted to examine the use of dexrazoxane as a cardioprotectant in patients with preexisting cardiomyopathy who require anthracyclines.
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Affiliation(s)
- Sarju Ganatra
- Cardio-Oncology Program, Lahey Hospital and Medical Center, Burlington, MA USA
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Anju Nohria
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Sachin Shah
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
| | - John D. Groarke
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Ajay Sharma
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
| | - David Venesy
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
| | - Richard Patten
- Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, MA USA
| | - Krishna Gunturu
- Department of Hematology Oncology, Lahey Hospital and Medical Center, Burlington, MA USA
- Cancer Survivorship Program, Lahey Hospital and Medical Center, Burlington, MA USA
| | - Corrine Zarwan
- Department of Hematology Oncology, Lahey Hospital and Medical Center, Burlington, MA USA
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, MA USA
| | - Ana Barac
- Cardio-Oncology Program, Division of Cardiology, Medstar Washington Hospital Center, Washington, DC USA
| | - Salim S. Hayek
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI USA
| | - Sourbha Dani
- Division of Cardiovascular Medicine, Eastern Maine Medical Center, Bangor, ME USA
| | - Shantanu Solanki
- Department of Medicine, Westchester Medical Center, Valhalla, NY USA
| | - Syed Saad Mahmood
- Division of Cardiovascular Medicine, New-York Presbyterian Hospital/Weill Cornell Medical Center, New York City, NY USA
| | - Steven E. Lipshultz
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Oishei Children’s Hospital, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
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29
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Groarke JD, Mahmood SS, Payne D, Ganatra S, Hainer J, Neilan TG, Partridge AH, Di Carli MF, Jones LW, Mehra MR, Nohria A. Case-control study of heart rate abnormalities across the breast cancer survivorship continuum. Cancer Med 2018; 8:447-454. [PMID: 30578624 PMCID: PMC6346251 DOI: 10.1002/cam4.1916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/07/2022] Open
Abstract
Background Mechanisms underlying impaired exercise capacity and increased cardiovascular mortality observed in breast cancer (BC) patients remain unclear. The prevalence, functional, and prognostic significance of elevated resting heart rate (HR) and abnormal heart rate recovery (HRR) in breast cancer (BC) requires evaluation. Methods In a single‐center, retrospective, case‐control study of women referred for exercise treadmill testing (ETT), 448 BC patients (62.6 ± 10.0 years) were compared to 448 cancer‐free, age‐matched controls. Elevated resting HR was defined as HR ≥80 bpm at rest. Abnormal HRR at 1‐minute following exercise was defined as ≤12 bpm if active recovery or ≤18 bpm if passive recovery. Association of these parameters with exercise capacity and all‐cause mortality was evaluated. Results Elevated resting HR (23.7% vs 17.0%, P = 0.013) and abnormal HRR (25.9% vs 20.3%, P = 0.048) were more prevalent in BC cohort than controls. In adjusted analyses, BC patients with elevated resting HR (−0.9 METs (SE 0.3); P = 0.0003) or abnormal HRR (−1.3 METs (SE 0.3); P < 0.0001) had significant reductions in metabolic equivalents (METs) achieved during exercise. Elevated resting HR was not associated with mortality. There was a trend toward increased mortality in BC cohort with abnormal HRR (adjusted hazard ratio 2.06 (95% CI 0.95‐4.44, P = 0.07)). Conclusions Women across the BC survivorship continuum, referred for ETT, have an increased prevalence of elevated resting HR and abnormal HRR relative to cancer‐free, age‐matched female controls. These parameters were associated with decreased exercise capacity. Strategies to modulate these abnormalities may help improve functional capacity in this cohort.
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Affiliation(s)
- John D Groarke
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.,Adult Survivorship Program, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Syed S Mahmood
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts.,Cardio-Oncology Program, Massachusetts General Hospital, Boston, Massachusetts
| | - David Payne
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarju Ganatra
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas G Neilan
- Cardio-Oncology Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann H Partridge
- Adult Survivorship Program, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Marcelo F Di Carli
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anju Nohria
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts.,Adult Survivorship Program, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
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30
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Carnicelli AP, Thakkar A, Deicicchi DJ, Storm AC, Rimsans J, Connors JM, Mehra MR, Groarke JD, Givertz MM. Resource utilization and hospital readmission associated with gastrointestinal bleeding in patients with continuous-flow left ventricular assist devices. J Thromb Thrombolysis 2018; 47:375-383. [PMID: 30523584 DOI: 10.1007/s11239-018-1781-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Gastrointestinal bleeding (GIB) occurs in up to 40% of patients with continuous-flow (CF) left ventricular assist devices (LVADs). We sought to identify targets to improve hospital resource utilization and decrease readmissions after GIB. We performed a single-center, retrospective analysis of LVAD-associated GIB resulting in hospital admission between July 2011 and April 2014. Follow-up data were collected through March 2015. We analyzed 57 admissions for GIB in 23 patients. One or more diagnostic imaging study was performed in 47% of admissions, with a definite or probable source of GIB identified in 23%. A total of 76 endoscopies were performed (≥ 1 endoscopy in 79% of admissions, ≥ 2 in 42%). Definite or probable bleeding sources were identified in 25% and 12% of endoscopies, respectively. Patients who underwent multiple endoscopies were no more likely to have a bleeding source identified (OR 1.48; 95% CI 0.50-4.32; p = 0.59) and had longer hospital stays (11.1 vs. 7.8 days, p < 0.02). Readmission rates for GIB at 30 and 90 days were 33% and 53%, respectively. A decrease in antiplatelet regimen at discharge was associated with lower rate of readmission for GIB (OR 0.16; 95% CI 0.03-0.82; p = 0.03) or any cause (OR 0.21; 95% CI 0.05-0.85; p = 0.04) at 30 and 90 days. GIB in patients with CF-LVADs is associated with significant in-hospital resource utilization and high rates of readmission. Imaging and endoscopy are common, but have low diagnostic yield and infrequently result in successful intervention. Strategies to reduce resource utilization and prevent readmission are warranted.
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Affiliation(s)
- Anthony P Carnicelli
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Anjali Thakkar
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David J Deicicchi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew C Storm
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology and Hepatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Rimsans
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mandeep R Mehra
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael M Givertz
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Platz E, Merz A, Silverman M, Lewis E, Groarke JD, Waxman A, Systrom D. Association between lung ultrasound findings and invasive exercise haemodynamics in patients with undifferentiated dyspnoea. ESC Heart Fail 2018; 6:202-207. [PMID: 30474936 PMCID: PMC6352886 DOI: 10.1002/ehf2.12381] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/23/2018] [Indexed: 01/12/2023] Open
Abstract
Aims Dyspnoea is common in heart failure (HF) but non‐specific. Lung ultrasound (LUS) could represent a non‐invasive tool to detect subclinical pulmonary congestion in patients with undifferentiated dyspnoea. Methods and results We assessed the feasibility of an abbreviated LUS protocol (eight and two zones) in a prospective pilot study of 25 ambulatory patients with undifferentiated dyspnoea undergoing clinically indicated invasive cardiopulmonary exercise testing (iCPET) at rest (LUS 1) and after peak exercise (LUS 2). We also related LUS findings (B‐lines) to invasive haemodynamics stratified by supine pulmonary capillary wedge pressure (PCWP) (Congestion, >15 mmHg; Control, ≤15 mmHg). All enrolled patients (median age 68, 60% women, 32% prior HF, median ejection fraction 59%) had interpretable LUS 1 images in eight zones, and 20 (80%) had adequate LUS 2 images. LUS images were adequate in two posterior zones in 24 patients (96%) for LUS 1 and 18 (72%) for LUS 2. Although B‐line number was numerically higher in the Congestion group at rest and after peak exercise, this difference did not reach statistical significance. In the entire cohort, there was an association between B‐lines and rest systolic pulmonary artery pressure (r = 0.46, P = 0.02) and PCWP (r = 0.54, P = 0.005). There was an inverse relationship between B‐lines and peak VO2 (r = −0.65, P = 0.002). Conclusions Among ambulatory patients with undifferentiated dyspnoea, an abbreviated LUS protocol before and after iCPET is feasible in the majority of patients. B‐line number at rest was associated with invasively measured markers of haemodynamic congestion and was inversely related with peak VO2.
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Affiliation(s)
- Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Montane Silverman
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eldrin Lewis
- Harvard Medical School, Boston, MA, USA.,Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - John D Groarke
- Harvard Medical School, Boston, MA, USA.,Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron Waxman
- Harvard Medical School, Boston, MA, USA.,Pulmonary and Critical Care Medicine, Lung center; and Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - David Systrom
- Harvard Medical School, Boston, MA, USA.,Pulmonary and Critical Care Medicine, Lung center; and Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
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Groarke JD, Galazka PZ, Cirino AL, Lakdawala NK, Thune JJ, Bundgaard H, Orav EJ, Levine RA, Ho CY. Intrinsic mitral valve alterations in hypertrophic cardiomyopathy sarcomere mutation carriers. Eur Heart J Cardiovasc Imaging 2018; 19:1109-1116. [PMID: 30052928 PMCID: PMC6148328 DOI: 10.1093/ehjci/jey095] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/29/2018] [Accepted: 06/21/2018] [Indexed: 11/13/2022] Open
Abstract
Aims Mitral valve (MV) abnormalities are recognized features of hypertrophic cardiomyopathy (HCM), and there is preliminary evidence suggesting they are intrinsic phenotypic manifestations of sarcomere mutations, present in mutation carriers without left ventricular (LV) hypertrophy (subclinical HCM). However, further study is required to characterize the nature of these changes and their functional impact. Thus, we performed comprehensive echocardiographic analysis of MV structure and function on a genotyped population. Methods and results MV and papillary muscle echocardiographic parameters were measured in 192 genotyped individuals, including 50 overt HCM, 79 subclinical HCM, and 63 mutation-negative, healthy relatives as normal controls. Compared to controls, subclinical HCM subjects had elongated anterior MV leaflets relative to LV end-diastolic volume index (0.57 ± 0.02 vs. 0.51 ± 0.02 mm/mL/m2, P = 0.013) and anteriorly displaced papillary muscles [decreased papillary-septal separation (31.1 ± 0.7 vs. 34.2 ± 0.9 mm, P = 0.004) and relative antero-posterior position ratio of the papillary muscles (0.67 ± 0.01 vs. 0.71 ± 0.01, P = 0.011]. Similar findings were identified comparing overt HCM to controls. These MV changes were associated with an increased prevalence of systolic anterior motion (SAM) of the MV amongst subclinical HCM subjects. Conclusions Sarcomere mutations are associated with primary abnormalities of the MV apparatus, specifically excess anterior leaflet length relative to LV cavity size and anterior displacement of the papillary muscles; both features predisposing to SAM. These abnormalities appear to be early phenotypic consequences of sarcomere mutations, observed in mutation carriers with normal LV wall thickness.
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Affiliation(s)
- John D Groarke
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
| | - Patrycja Z Galazka
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
| | - Allison L Cirino
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
| | - Neal K Lakdawala
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
| | - Jens J Thune
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Bispebjerg Bakke 23, Denmark
| | - Henning Bundgaard
- The Unit for Inherited Cardiac Diseases, The Heart Center, Rigshospitalet, Copenhagen Health Science Partners, Copenhagen University, Blegdamsvej 9, Denmark
| | - E John Orav
- Division of General Medicine, Brigham and Women’s Hospital, Boston, 75 Francis Street, MA USA
| | - Robert A Levine
- Cardiology Division, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, USA
| | - Carolyn Y Ho
- Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, USA
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Luk A, Groarke JD, Desai AS, Mahmood SS, Gopal DM, Joyce E, Shah SP, Lindenfeld J, Stevenson L, Lakdawala NK. First spot urine sodium after initial diuretic identifies patients at high risk for adverse outcome after heart failure hospitalization. Am Heart J 2018; 203:95-100. [PMID: 29907406 DOI: 10.1016/j.ahj.2018.01.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 01/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Relief of congestion is the primary goal of initial therapy for acute decompensated heart failure (ADHF). Early measurement of urine sodium concentration (UNa) may be useful to identify patients with diminished response to diuretics. The aim of this study was to determine if the first spot UNa after diuretic initiation could select patients likely to require more intensive therapy during hospitalization. METHODS At the time of admission, 103 patients with ADHF were identified prospectively, and UNa was measured after the first dose of intravenous diuretic. Clinical outcomes were compared for patients with UNa >60 mmol/L and UNa of ≤60 mmol/L, with the primary outcome of a composite of death at 90 days, mechanical circulatory support during admission, and requirement of inotropic support at discharge. RESULTS Patients with UNa ≤60 had lower admission blood pressure, had less chronic neurohormonal antagonist prior to admission, and were more than twice as likely to experience the primary end point (hazard ratio 2.40, 95% CI 1.02-5.66, P = .045), which was marginally significant after adjusting for renal function and baseline home loop diuretic. Worsening renal function was significantly more common in patients with UNa <60 (23.6% vs 6.5%, P = .05). Although the initial assessment of congestion was similar at admission, patients with low early UNa had a longer length of stay (11 vs 6 days, P < .006) than patients with UNa >60. CONCLUSIONS Assessment of spot UNa after initial intravenous loop diuretic administration may facilitate identification and triage of a population of HF patients at increased risk for adverse events and prolonged hospitalization.
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Affiliation(s)
- Adriana Luk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Syed Saad Mahmood
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | | | - Sachin P Shah
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Lahey Hospital and Medical Center, Burlington, MA
| | | | - Lynne Stevenson
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Vanderbilt University Medical Center, Nashville, TN
| | - Neal K Lakdawala
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
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Ganatra S, Sharma A, Shah S, Chaudhry GM, Martin DT, Neilan TG, Mahmood SS, Barac A, Groarke JD, Hayek SS, Dani S, Venesy D, Patten R, Nohria A. Ibrutinib-Associated Atrial Fibrillation. JACC Clin Electrophysiol 2018; 4:1491-1500. [PMID: 30573111 DOI: 10.1016/j.jacep.2018.06.004] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 11/28/2022]
Abstract
Ibrutinib, a novel and potent Bruton tyrosine kinase inhibitor, is an effective and well-tolerated treatment for a variety of B-cell lymphomas. However, its use is associated with an increased incidence of atrial fibrillation (AF), ranging from 4% to 16%. We reviewed the original clinical trials that led to the approval of ibrutinib, as well as several other prospective and retrospective studies, to better appreciate the incidence of ibrutinib-associated AF. Based on 16 studies included in our analysis, the incidence of ibrutinib-associated AF was 5.77 per 100 person-years, which is much higher than rates previously reported with ibrutinib and compared with the general adult population. New onset AF in cancer patients is associated with a significantly higher risk of heart failure and thromboembolism, even after adjusting for known risk factors. In addition, ibrutinib poses unique challenges due to its interactions with many medications that are commonly used to manage AF. Ibrutinib also inhibits platelet activation and decisions regarding anticoagulation have to be carefully weighed against this increased risk of bleeding. Ibrutinib's interaction with calcium channel blockers, digoxin, amiodarone, and direct oral anticoagulants can result in either ibrutinib or other drug-related toxicity and careful selection and dose adjustment may be needed. Ibrutinib-associated AF can be a therapy-limiting side effect and physicians should be familiar with the special management considerations imposed by this agent. We review the potential mechanisms and incidence of ibrutinib-associated AF and propose an algorithm for its management.
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Affiliation(s)
- Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts.
| | - Ajay Sharma
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Sachin Shah
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Ghulam M Chaudhry
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - David T Martin
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Syed Saad Mahmood
- Division of Cardiovascular Medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Ana Barac
- Cardio-Oncology Program, Division of Cardiology, Medstar Washington Hospital Center, Washington, DC
| | - John D Groarke
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Cardio-Oncology Program, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Salim S Hayek
- Division of Cardiology, Emory University, Atlanta, Georgia
| | - Saurbha Dani
- Division of Cardiovascular Medicine, Eastern Maine Medical Center, Bangor, Maine
| | - David Venesy
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Richard Patten
- Division of Cardiovascular Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Anju Nohria
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Cardio-Oncology Program, Dana-Farber Cancer Institute, Boston, Massachusetts
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Nadruz W, West E, Sengeløv M, Grove GL, Santos M, Groarke JD, Forman DE, Claggett B, Skali H, Nohria A, Shah AM. Cardiovascular phenotype and prognosis of patients with heart failure induced by cancer therapy. Heart 2018; 105:34-41. [PMID: 29764969 DOI: 10.1136/heartjnl-2018-313234] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/10/2018] [Accepted: 04/23/2018] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE This study compared the clinical features, cardiac structure and function evaluated by echocardiography, cardiopulmonary response to exercise and long-term clinical outcomes between patients with heart failure (HF) induced by cancer therapy (CTHF) and heart failure not induced by cancer therapy (NCTHF). METHODS We evaluated 75 patients with CTHF and 894 with NCTHF who underwent clinically indicated cardiopulmonary exercise testing, and followed these individuals for a median of 4.5 (3.0-5.8) years, during which 187 deaths and 256 composite events (death, heart transplantation and left ventricular (LV) assistant device implantation) occurred. RESULTS Compared with NCTHF, patients with CTHF were younger, with lower prevalence of cardiovascular comorbidities, higher LV ejection fraction (LVEF), but similar global longitudinal strain. LV diastolic function (higher E/e' ratio) and compliance (higher end-diastolic pressure/LV end-diastolic volume index ratio) were worse in CTHF and were both associated with adverse outcomes. Despite a favourable clinical profile, peak VO2 and VE/VCO2 slope were similarly impaired in CTHF and NCTHF. In multivariable Cox regression analysis including clinical characteristics, cardiopulmonary exercise testing variables and LVEF, CTHF was associated with a significantly higher risk of death (HR 2.64; 95% CI 1.53 to 4.55; p=0.001) and composite events (HR 1.79; 95% CI 1.10 to 2.91; p=0.019) compared with NCTHF. CONCLUSIONS CTHF is characterised by a distinct clinical profile, better LVEF but worse LV diastolic properties, and similarly impaired global longitudinal strain, functional capacity and ventilatory efficiency. Accounting for differences in clinical characteristics, CTHF was associated with worse long-term prognosis than NCTHF.
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Affiliation(s)
- Wilson Nadruz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Internal Medicine, University of Campinas, Campinas, Brazil
| | - Erin West
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Morten Sengeløv
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gabriela L Grove
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mário Santos
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel E Forman
- Department of Cardiology, University of Pittsburgh Medical Center and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
Take home figureModifiers of the association of childhood cancer therapies and excess CV risk observed in adult survivors, together with promising strategies for risk reduction and inherent barriers to achieving reduction in CV risk. CV, cardiovascular; GLS, global longitudinal strain; RT, radiation therapy.
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Affiliation(s)
- John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Boston, MA, USA
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Mahmood SS, Fradley MG, Cohen JV, Nohria A, Reynolds KL, Heinzerling LM, Sullivan RJ, Damrongwatanasuk R, Chen CL, Gupta D, Kirchberger MC, Awadalla M, Hassan MZO, Moslehi JJ, Shah SP, Ganatra S, Thavendiranathan P, Lawrence DP, Groarke JD, Neilan TG. Myocarditis in Patients Treated With Immune Checkpoint Inhibitors. J Am Coll Cardiol 2018; 71:1755-1764. [PMID: 29567210 DOI: 10.1016/j.jacc.2018.02.037] [Citation(s) in RCA: 861] [Impact Index Per Article: 143.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Myocarditis is an uncommon, but potentially fatal, toxicity of immune checkpoint inhibitors (ICI). Myocarditis after ICI has not been well characterized. OBJECTIVES The authors sought to understand the presentation and clinical course of ICI-associated myocarditis. METHODS After observation of sporadic ICI-associated myocarditis cases, the authors created a multicenter registry with 8 sites. From November 2013 to July 2017, there were 35 patients with ICI-associated myocarditis, who were compared to a random sample of 105 ICI-treated patients without myocarditis. Covariates of interest were extracted from medical records including the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiovascular death, cardiogenic shock, cardiac arrest, and hemodynamically significant complete heart block. RESULTS The prevalence of myocarditis was 1.14% with a median time of onset of 34 days after starting ICI (interquartile range: 21 to 75 days). Cases were 65 ± 13 years of age, 29% were female, and 54% had no other immune-related side effects. Relative to controls, combination ICI (34% vs. 2%; p < 0.001) and diabetes (34% vs. 13%; p = 0.01) were more common in cases. Over 102 days (interquartile range: 62 to 214 days) of median follow-up, 16 (46%) developed MACE; 38% of MACE occurred with normal ejection fraction. There was a 4-fold increased risk of MACE with troponin T of ≥1.5 ng/ml (hazard ratio: 4.0; 95% confidence interval: 1.5 to 10.9; p = 0.003). Steroids were administered in 89%, and lower steroids doses were associated with higher residual troponin and higher MACE rates. CONCLUSIONS Myocarditis after ICI therapy may be more common than appreciated, occurs early after starting treatment, has a malignant course, and responds to higher steroid doses.
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Affiliation(s)
- Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York; Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Germany
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rongras Damrongwatanasuk
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Germany
| | - Magid Awadalla
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Malek Z O Hassan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Javid J Moslehi
- Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Taqueti VR, Solomon SD, Shah AM, Desai AS, Groarke JD, Osborne MT, Hainer J, Bibbo CF, Dorbala S, Blankstein R, Di Carli MF. Coronary microvascular dysfunction and future risk of heart failure with preserved ejection fraction. Eur Heart J 2018; 39:840-849. [PMID: 29293969 PMCID: PMC5939665 DOI: 10.1093/eurheartj/ehx721] [Citation(s) in RCA: 348] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/08/2017] [Accepted: 12/04/2017] [Indexed: 01/09/2023] Open
Abstract
Aims Coronary microvascular ischaemia, cardiomyocyte injury and stiffness may play an important role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). To date, the relationship between coronary flow reserve (CFR), myocardial injury, diastolic dysfunction, and future HFpEF risk is unknown. Methods and results Consecutive patients (n = 201) undergoing evaluation for suspected coronary artery disease (CAD) with stress myocardial perfusion positron emission tomography, serum troponin, and transthoracic echocardiography who did not have flow-limiting CAD or reduced left ventricular ejection fraction were identified. Patients were followed up (median 4.1 years) for cardiovascular death and hospitalization for non-fatal myocardial infarction or heart failure. Coronary flow reserve was quantified as stress/rest myocardial blood flow. Early diastolic flow (E) and relaxation (e') velocities were obtained via transmitral and tissue Doppler, respectively. Patients with impaired CFR (<2, n = 108) demonstrated linearly decreasing e' and increasing E/e' consistent with worsening diastolic function (P for trend <0.0001). A detectable troponin was associated with diastolic dysfunction only in the presence of impaired CFR (interaction P = 0.002). In adjusted analyses, impaired CFR was independently associated with diastolic dysfunction (E/e'septal > 15, adjusted OR 2.58, 95%CI 1.22-5.48) and composite cardiovascular outcomes or HFpEF hospitalization alone (adjusted HR 2.47, 95%CI 1.09-5.62). Patients with both impaired CFR and diastolic dysfunction demonstrated >five-fold increased risk of HFpEF hospitalization (P < 0.001). Conclusion In symptomatic patients without overt CAD, impaired CFR was independently associated with diastolic dysfunction and adverse events, especially HFpEF hospitalization. The presence of both coronary microvascular and diastolic dysfunctions was associated with a markedly increased risk of HFpEF events.
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Affiliation(s)
- Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amil M Shah
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Center for Advanced Heart Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - John D Groarke
- Center for Advanced Heart Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael T Osborne
- Cardiac MR/PET/CT Program, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Mahmood S, Fradley MG, Cohen JV, Nohria A, Reynolds KL, Heinzerling LM, Sullivan RJ, Damrongwatanasuk R, Chen C, Gupta D, Kirchberger MC, Moslehi J, Shah S, Ganatra S, Thavendiranathan P, Lawrence DP, Groarke JD, Neilan TG. MYOCARDITIS IN PATIENTS TREATED WITH IMMUNE CHECKPOINT INHIBITORS. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31240-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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41
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Groarke JD, Payne DL, Claggett B, Mehra M, Gong J, Caron J, Mahmood S, Hainer J, Neilan T, Partridge AH, Di Carli M, Jones LW, Nohria A. PROGNOSTIC IMPORTANCE OF POOR CARDIORESPIRATORY FITNESS IN PATIENTS WITH CANCER REFERRED FOR EXERCISE TREADMILL TESTING. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32046-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Joyce E, Lala A, Stevens SR, Cooper LB, AbouEzzeddine OF, Groarke JD, Grodin JL, Braunwald E, Anstrom KJ, Redfield MM, Stevenson LW. Prevalence, Profile, and Prognosis of Severe Obesity in Contemporary Hospitalized Heart Failure Trial Populations. JACC Heart Fail 2017; 4:923-931. [PMID: 27908391 DOI: 10.1016/j.jchf.2016.09.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This study evaluated the prevalence, profile, and prognosis of severe obesity in a large contemporary acute heart failure (AHF) population. BACKGROUND Better prognosis has been reported for obese heart failure (HF) patients than nonobese HF patients, but in other cardiovascular populations, this effect has not been demonstrated for severely obese patients. METHODS A cohort of 795 participants with body mass index (BMI) measured at time of admission and complete follow-up were identified from enrollment in 3 contemporary AHF trials (DOSE [Diuretic Strategies Optimization Evaluation], CARRESS-HF [Cardiorenal Rescue Study in Acute Decompensated Heart Failure], and ROSE [Renal Optimization Strategies Evaluation in Acute Heart Failure]). Patients were divided into 4 BMI categories according to standard World Health Organization criteria, as follows: normal weight: 18.5 to 25 kg/m2 [n = 128]; overweight: 25 to 29.9 kg/m2 [n = 209]; mild-to-moderate obese: 30 to 39.9 kg/m2 [n = 301]; and severely obese: ≥40 kg/m2 [n = 157]). The relationship between BMI and 60-day composite outcome (death, rehospitalization, or unscheduled provider visit) was investigated. RESULTS Patients with severe obesity (19.7%) were younger, more often female, hypertensive, diabetic, and more likely to have higher blood pressures and left ventricular ejection fraction, and lower N-terminal pro-B-type natriuretic peptide and troponin I levels than other BMI category patients. Following admission for AHF, patients with normal weight showed the highest risk of 60-day composite outcome, followed by patients who were severely obese. Overweight and mild-moderately obese patients showed lowest risk. CONCLUSIONS Nearly one-fifth of AHF patients enrolled in contemporary randomized clinical trials are severely obese. A U-shaped curve for short-term prognosis according to BMI is seen in AHF. These findings may help to better inform both HF clinical care and future clinical trial planning.
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Affiliation(s)
- Emer Joyce
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York
| | | | - Lauren B Cooper
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Omar F AbouEzzeddine
- Department of Medicine, Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - John D Groarke
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin L Grodin
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Margaret M Redfield
- Department of Medicine, Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Lynne W Stevenson
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Nadruz W, West E, Sengeløv M, Santos M, Groarke JD, Forman DE, Claggett B, Skali H, Shah AM. Prognostic Value of Cardiopulmonary Exercise Testing in Heart Failure With Reduced, Midrange, and Preserved Ejection Fraction. J Am Heart Assoc 2017; 6:JAHA.117.006000. [PMID: 29089342 PMCID: PMC5721737 DOI: 10.1161/jaha.117.006000] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background This study aimed to compare the independent and incremental prognostic value of peak oxygen consumption (VO2) and minute ventilation/carbon dioxide production (VE/VCO2) in heart failure (HF) with preserved (HFpEF), midrange (HFmEF), and reduced (HFrEF) ejection fraction (LVEF). Methods and Results In 195 HFpEF (LVEF ≥50%), 144 HFmEF (LVEF 40–49%), and 630 HFrEF (LVEF <40%) patients, we assessed the association of cardiopulmonary exercise testing variables with the composite outcome of death, left ventricular assist device implantation, or heart transplantation (256 events; median follow‐up of 4.2 years), and 2‐year incident HF hospitalization (244 events). In multivariable Cox regression analysis, greater association with outcomes in HFpEF than HFrEF were noted with peak VO2 (HR [95% confidence interval]: 0.76 [0.67–0.87] versus 0.87 [0.83–0.90] for the composite outcome, Pinteraction=0.052; 0.77 [0.69–0.86] versus 0.92 [0.88–0.95], respectively for HF hospitalization, Pinteraction=0.003) and VE/VCO2 slope (1.11 [1.06–1.17] versus 1.04 [1.03–1.06], respectively for the composite outcome, Pinteraction=0.012; 1.10 [1.05–1.15] versus 1.04 [1.03–1.06], respectively for HF hospitalization, Pinteraction=0.019). In HFmEF, peak VO2 and VE/VCO2 slope were associated with the composite outcome (0.79 [0.70–0.90] and 1.12 [1.05–1.19], respectively), while only peak VO2 was related to HF hospitalization (0.81 [0.72–0.92]). In HFpEF and HFrEF, peak VO2 and VE/VCO2 slope provided incremental prognostic value beyond clinical variables based on the C‐statistic, net reclassification improvement, and integrated diagnostic improvement, with models containing both measures demonstrating the greatest incremental value. Conclusions Both peak VO2 and VE/VCO2 slope provided incremental value beyond clinical characteristics and LVEF for predicting outcomes in HFpEF. Cardiopulmonary exercise testing variables provided greater risk discrimination in HFpEF than HFrEF.
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Affiliation(s)
- Wilson Nadruz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA.,Department of Internal Medicine, University of Campinas, Brazil
| | - Erin West
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Morten Sengeløv
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mário Santos
- Faculty of Medicine of University of Porto, Portugal
| | - John D Groarke
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Daniel E Forman
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA.,VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
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Fradley MG, Groarke JD, Laubach J, Alsina M, Lenihan DJ, Cornell RF, Maglio M, Shain KH, Richardson PG, Moslehi J. Recurrent cardiotoxicity potentiated by the interaction of proteasome inhibitor and immunomodulatory therapy for the treatment of multiple myeloma. Br J Haematol 2017; 180:271-275. [PMID: 29048105 DOI: 10.1111/bjh.14970] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/14/2017] [Indexed: 02/02/2023]
Abstract
Patients with multiple myeloma (MM) have improved treatment options, including immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs). Despite their efficacy, increased rates of cardiovascular (CV) complications occur in patients exposed to some of these therapies. While previous research has focused on identifying the toxicities inherent to each specific agent, the CV side effects may be potentiated by the combination of PIs and IMiDs plus dexamethasone. We present a patient with MM with recurrent cardiotoxicity only when exposed to combination PI and IMiD-based therapy. We also review the literature in this context, and propose a potential algorithm for cardiotoxicity prevention in this population.
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Affiliation(s)
- Michael G Fradley
- Cardio-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
| | - John D Groarke
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Jacob Laubach
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Melissa Alsina
- H. Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Daniel J Lenihan
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Cardio-Oncology Program, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert F Cornell
- Cardio-Oncology Program, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Hematology-Oncology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michelle Maglio
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kenneth H Shain
- H. Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Javid Moslehi
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Cardio-Oncology Program, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Hematology-Oncology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Barghash MH, De Castro RRT, Motiwala SR, Nayor M, Gopal D, Luk A, Brinkley DM, Joyce E, Chaudhry S, Groarke JD, Lakdawala N, Givertz MM, Desai A, Nohria A, Stevenson LW. Most Admissions to HF Service are Preceded by a Provider Interaction That Did Not Prevent Hospitalization. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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46
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Vader JM, LaRue SJ, Stevens SR, Mentz RJ, DeVore AD, Lala A, Groarke JD, AbouEzzeddine OF, Dunlay SM, Grodin JL, Dávila-Román VG, de Las Fuentes L. Timing and Causes of Readmission After Acute Heart Failure Hospitalization-Insights From the Heart Failure Network Trials. J Card Fail 2016; 22:875-883. [PMID: 27133201 PMCID: PMC5085925 DOI: 10.1016/j.cardfail.2016.04.014] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Readmission or death after heart failure (HF) hospitalization is a consequential and closely scrutinized outcome, but risk factors may vary by population. We characterized the risk factors for post-discharge readmission/death in subjects treated for acute heart failure (AHF). METHODS AND RESULTS A post hoc analysis was performed on data from 744 subjects enrolled in 3 AHF trials conducted within the Heart Failure Network (HFN): Diuretic Optimization Strategies Evaluation in Acute Heart Failure (DOSE-AHF), Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF), and Renal Optimization Strategies Evaluation in Acute Heart Failure (ROSE-AHF). All-cause readmission/death occurred in 26% and 38% of subjects within 30 and 60 days of discharge, respectively. Non-HF cardiovascular causes of readmission were more common in the ≤30-day timeframe than in the 31-60-day timeframe (23% vs 10%, P = .016). In a Cox proportional hazards model adjusting a priori for left ventricular ejection fraction <50% and trial, the risk factors for all-cause readmission/death included: elevated baseline blood urea nitrogen, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) non-use, lower baseline sodium, non-white race, elevated baseline bicarbonate, lower systolic blood pressure at discharge or day 7, depression, increased length of stay, and male sex. CONCLUSIONS In an AHF population with prominent congestion and prevalent renal dysfunction, early readmissions were more likely to be due to non-HF cardiovascular causes compared with later readmissions. The association between use of ACEI/ARB and lower all-cause readmission/death in Cox proportional hazards model suggests a role for these drugs to improve post-discharge outcomes in AHF.
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Affiliation(s)
- Justin M Vader
- Washington University School of Medicine, St. Louis, Missouri.
| | - Shane J LaRue
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina
| | - Anuradha Lala
- Mount Sinai Hospital, New York, New York; Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - John D Groarke
- Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
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Nadruz W, West E, Santos M, Skali H, Groarke JD, Forman DE, Shah AM. Heart Failure and Midrange Ejection Fraction: Implications of Recovered Ejection Fraction for Exercise Tolerance and Outcomes. Circ Heart Fail 2016; 9:e002826. [PMID: 27009553 DOI: 10.1161/circheartfailure.115.002826] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 02/18/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Evidence-based therapies for heart failure (HF) differ significantly according to left ventricular ejection fraction (LVEF). However, few data are available on the phenotype and prognosis of patients with HF with midrange LVEF of 40% to 55%, and the impact of recovered systolic function on the clinical features, functional capacity, and outcomes of this population is not known. METHODS AND RESULTS We studied 944 patients with HF who underwent clinically indicated cardiopulmonary exercise testing. The study population was categorized according to LVEF as follows: HF with reduced LVEF (HFrEF; LVEF<40%; n=620); HF with midrange ejection fraction and no recovered ejection fraction (LVEF was consistent between 40% and 55%; n=107); HF with recovered midrange ejection fraction (LVEF, 40%-55% but previous LVEF<40%; n=170); and HF with preserved LVEF (HFpEF; LVEF>55%; n=47). HF with midrange ejection fraction and no recovered ejection fraction and HF with recovered midrange ejection fraction had similar clinical characteristics, which were intermediate between those of HFrEF and HFpEF, and comparable values of predicted peak oxygen consumption and minute-ventilation/carbon dioxide production slope, which were better than HFrEF and similar to HFpEF. After a median of 4.4 (2.9-5.7) years, there were 253 composite events (death, left ventricular assistant device implantation, or transplantation). In multivariable Cox-regression analysis, HF with recovered midrange ejection fraction had lower risk of composite events than HFrEF (hazard ratio, 0.25; 95% confidence interval, 0.13-0.47) and HF with midrange ejection fraction and no recovered ejection fraction (hazard ratio, 0.31; 95% confidence interval, 0.15-0.67), and similar prognosis when compared with HFpEF. In contrast, HF with midrange ejection fraction and no recovered ejection fraction tended to show intermediate risk of outcomes in comparison with HFpEF and HFrEF, albeit not reaching statistical significance in fully adjusted analyses. CONCLUSIONS Patients with HF with midrange LVEF demonstrate a distinct clinical profile from HFpEF and HFrEF patients, with objective measures of functional capacity similar to HFpEF. Within the midrange LVEF HF population, recovered systolic function is a marker of more favorable prognosis.
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Affiliation(s)
- Wilson Nadruz
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.)
| | - Erin West
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.)
| | - Mário Santos
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.)
| | - Hicham Skali
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.)
| | - John D Groarke
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.)
| | - Daniel E Forman
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.)
| | - Amil M Shah
- From the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (W.N., E.W., H.S., J.D.G., A.M.S.); Department of Internal Medicine, University of Campinas, Campinas, Brazil (W.N.); Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of University of Porto, Porto, Portugal (M.S.); and Department of Medicine, Section of Geriatric Cardiology, University of Pittsburgh Medical Center, PA (D.E.F.).
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Grodin JL, Lala A, Stevens SR, DeVore AD, Cooper LB, AbouEzzeddine OF, Mentz RJ, Groarke JD, Joyce E, Rosenthal JL, Vader JM, Tang WHW. Clinical Implications of Serum Albumin Levels in Acute Heart Failure: Insights From DOSE-AHF and ROSE-AHF. J Card Fail 2016; 22:884-890. [PMID: 26844764 DOI: 10.1016/j.cardfail.2016.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/19/2016] [Accepted: 01/28/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypoalbuminemia is common in patients with chronic heart failure and, as a marker of disease severity, is associated with an adverse prognosis. Whether hypoalbuminemia contributes to (or is associated with) worse outcomes in acute heart failure (AHF) is unclear. We sought to determine the implications of low serum albumin in patients receiving decongestive therapies for AHF. METHODS AND RESULTS Baseline serum albumin levels were measured in 456 AHF subjects randomized in the DOSE-AHF and ROSE-AHF trials. We assessed the relationship between admission albumin levels (both as a continuous variable and stratified by median albumin [≥3.5 g/dL]) and worsening renal function (WRF), worsening heart failure (WHF), and clinical decongestion by 72 hours; 7-day cardiorenal biomarkers; and post-discharge outcomes. The mean baseline albumin level was 3.5 ± 0.5 g/dL. Albumin was not associated with WRF, WHF, or clinical decongestion by 72 hours. Furthermore, there was no association between continuous albumin levels and symptom change according to visual analog scale or weight change by 72 hours. Albumin was not associated with 60-day mortality, rehospitalization, or unscheduled emergency room visits. CONCLUSIONS Baseline serum albumin levels were not associated with short-term clinical outcomes for AHF patients undergoing decongestive therapies. These data suggest that serum albumin may not be a helpful tool to guide decongestion strategies.
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Affiliation(s)
- Justin L Grodin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anuradha Lala
- Department of Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts; Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lauren B Cooper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Omar F AbouEzzeddine
- Department of Medicine, Division of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - John D Groarke
- Department of Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emer Joyce
- Department of Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julie L Rosenthal
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin M Vader
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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Joyce E, Gopal DM, Luk A, Groarke JD, Shah SP, Stewart GC, Givertz MM, Mehra MR. Grip Strength Assessment and Early Outcomes in Hospitalized Acute Decompensated Heart Failure: A Prospective Study. J Card Fail 2015. [DOI: 10.1016/j.cardfail.2015.06.336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Gopal DM, Groarke JD, Luk A, Joyce E, Shah SP, Lewis EF, Lakdawala NK, Nohria A. Bedside Hemodynamic Profiles in Acute Decompensated Heart Failure: Clinical Uncertainty May Identify Higher Risk. J Card Fail 2015. [DOI: 10.1016/j.cardfail.2015.06.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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