Incidence of cardiovascular events in patients treated with immune checkpoint inhibitors

Background

In rare cases, immune checkpoint inhibitors (ICIs) cause immune-mediated myocarditis. However, the true incidence of other major adverse cardiovascular events (MACE) following ICI treatment remains unknown, mainly because late occurring side effects are rarely reported in prospective clinical trials.

Purpose

To identify the incidence and risk factors of MACE in a real-life ICI-treated cancer cohort and to compare the incidence with non-ICI-treated cancer patients and population controls.

Methods

In total, 672 ICI-treated patients were included. The primary endpoint was MACE, a composite of acute coronary syndrome, heart failure, stroke and transient ischemic attack. Secondary outcomes were acute coronary syndrome and heart failure separately. Incidence rates were compared between groups after matching according to age, sex, cardiovascular history and cancer type.

Results

Incidence of MACE was 10.3% during a median time of follow-up of 13 months (IQR 6 to 22). In multivariable analysis, a history of heart failure (hazard ratio (HR): 2.27; 95% confidence interval (CI): 1.03 to 5.04; p=0.043) and valvular heart disease (HR 3.01; 95% CI: 1.05 to 8.66; p=0.041) remained significantly associated with MACE.

Cumulative incidence rates were significantly higher in the matched ICI group (rate at full range of follow-up (rate): 8.51; 95% CI: 6.18 to 11.4) compared with the cancer cohort not exposed to ICI (rate: 5.20; 95% CI: 3.56 to 7.35; p=0.032) and the population controls (rate: 2.55; 95% CI: 2.16 to 2.99; p<0.001) mainly driven by a higher risk of heart failure events (Figure 1).

Conclusions

Cardiovascular events during and after ICI treatment are more common than currently appreciated. Patients at risk are those with a history of cardiovascular disease. Compared with matched cancer and population controls, MACE incidence rates are significantly higher, suggesting a potential harmful effect of ICI treatment besides the underlying risk.

Funding Acknowledgement

Type of funding sources: None.

Heart failure hospitalization in adult patients with congenital heart disease: risk factors for repeated admissions

Background

Heart failure hospitalizations in adult patients with congenital heart disease (ACHD) are increasing and are associated with higher healthcare-related costs. We aimed to evaluate factors that are associated with repeated heart failure hospitalizations and whether heart failure hospitalizations are related to adverse outcome in ACHD patients with heart failure (ACHD-HF).

Methods

Out of 3995 patients under active follow-up in our institution (last visit >2010), 256 patients (mean age 49.5±16.7 years) had ACHD-HF and were included in the study. Medical records were reviewed, including heart failure hospitalization prior and after study inclusion. A combined endpoint of death, ventricular assist device and transplantation was defined.

Results

Overall, 136 ACHD-HF patients (53%) had a prior heart failure hospitalization. Over a mean follow-up of 2.5±2.3 years, 44 patients (17%) had repeated heart failure hospitalizations. Of these, 31 patients (12%) had 1; 9 patients (4%) 2 and 4 patients (2%) 3 repeated heart failure hospitalizations. Patients with repeated heart failure hospitalizations had higher NYHA class (p=0.031), were more likely to have end-organ dysfunction (p=0.025) and more likely to have a prior heart failure hospitalization (p<0.001). In multivariable Cox regression analysis, only end-organ dysfunction (HR 2.431 95% CI 1.516–43.896 p<0.001) was related to repeated hospitalization. Seventy patients (27%) reached the combined endpoint of death, VAD or transplantation (event-rate 11% per year). Repeated heart failure hospitalizations was not related to the combined endpoint in Cox regression analysis.

Conclusions

Heart failure hospitalizations are frequent in ACHD-HF. End-organ dysfunction appears to be a strong determinant of repeated heart failure hospitalizations. Event-rate is high in patients with ACHD-HF, but repeated heart failure hospitalizations were not related to outcome in this short-term follow-up study.

Funding Acknowledgement

Type of funding sources: None. Table 1.1Table 1.2

Short-term prognostic value of heart failure diagnosis in a contemporary cohort of patients with ACHD

Background

Heart failure (HF) is one of the primary causes of premature death in patients with adult congenital heart disease (ACHD), yet population-specific data remains scarce. This study aims at assessing the short-term value of prognostic value of a heart failure diagnosis in patients with adult congenital heart disease, and its relation to ACHD classification systems such as the Bethesda disease complexity classification and the physiological severity classification.

Methods

This study included 3995 patients under active follow-up at our institution. We used a standardized definition of ACHD-HF. Predictors of the composite primary outcome: death, transplant or ventricular assist device (VAD) were identified using uni- and multivariable Cox proportional hazard models.

Results

Mean age was 35.7±13.3 years. According to the Bethesda disease complexity classification 33.5% of patients had simple defects, 55.6% moderate defects, and 10.9% severe defects. Based on the physiological severity classification, 18.0% of patients were in physiological stage A, 35.6% in physiological stage B, 42.2% in physiological stage C, and 4.2% in physiological stage D. The overall prevalence of ACHD-HF was 6.4%. During a median follow up of 1.8 (IQR 1.3–2.9) years, patients with ACHD-HF had a worse outcome with 27.3% reaching the composite primary endpoint of death, heart transplant or VAD implantation, compared to 1.4% of ACHD patients without HF. Event-free survival was 91.1%, 72.0% and 46.1% at 2, 4 and 6 years in patients with ACHD-HF, compared to 99.5%, 98.7% and 95.1% in ACHD patients without HF. In multivariable analysis the presence of heart failure (HR 4.6; 95% CI 2.9–7.2; p<0.001) and the physiological severity classification (HR 3.1; 95% CI 2.3–4.1; p<0.001) were independently associated with the composite primary outcome, whereas the Bethesda disease complexity classification was not (HR 0.9; 95% CI 0.7–1.3; p=0.701).

Conclusion

The risk of mortality, transplant and VAD is substantially increased in ACHD-HF patients. Our data provides insight into the short term prognostic value of a HF diagnosis in ACHD patients, helping physicians to gauge the prognosis in ACHD-HF and thereby guide management decisions. In addition to the physiological severity classification, the presence of HF proves to be a valuable prognostic marker in patients with ACHD.

Funding Acknowledgement

Type of funding sources: None. Kaplan–Meier analysesUni- and multivariable Cox regression

Adverse remodeling of the subpulmonary left ventricle in patient with systemic right ventricle is associated with clinical outcome

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This research received project funding by KU Leuven

Background – Early recognition of adverse remodeling is important since outcome is unfavorable once patients with a systemic right ventricle (sRV) become symptomatic. We aimed assessing prognostic markers linked to short-term clinical evolution in this population. 

Purpose - We aimed assessing short-term clinical evolution and early prognostic markers of cardiac complications in adults with sRV (atrial switch repair for D-transposition of the great arteries (D-TGA) and congenitally corrected transposition of the great arteries (ccTGA)) based on detailed phenotyping. 

Methods– Thirty-three patients with sRV underwent detailed phenotyping including exercise CMR. Adverse outcome was a composite of heart failure episode and tachyarrhythmia. Descriptive statistics and univariate cox regression analyses were performed. 

Results - Thirty-three patients (76% male) with sRV were followed over mean follow-up time of 3 years. Mean age was 40 ± 8 (range 26-57) years at latest follow-up. When compared to baseline, (I) most patients remained in NYHA functional class I (76%),  (II) the degree of severity of the SAVV regurgitation rose and (III) more electrical instability was documented at latest follow-up. Six (18%) of a total of nine events were counted as first cardiovascular events (9% heart failure, 9% arrhythmia). NTproBNP (HR 11.02 (95%CI 1.296-93.662), p= 0.028), oxygen pulse (HR 1.202 (95% CI 1.012-1.428), p = 0.037), left ventricle end diastolic volume index (LVEDVi) in rest (HR 1.046 (95% CI 1.002-1.092), p = 0.041) and during exercise (HR 1.035 (95% CI 1.002-1.069), p = 0.038), stroke volume index (SVi) of the subpulmonary left ventricle (LV) in rest (HR 1.154 (95% CI 1.005-1.322), p = 0.038) and at peak exercise (HR 1.065 (95% CI 1.007-1.125), p = 0.026) were significantly associated with the first cardiovascular event (Figure 1A and B). 

Conclusion – NTproBNP was by far the best prognostic marker for clinical outcome. Adverse remodelling with increase of LVEDVi and SVi of the subpulmonary LV at rest and during exercise were associated with worse clinical outcome. We theorize that remodeling of the subpulmonary ventricle might be an early sign of a failing sRV circulation (Figure 2).