Managing Cardiac Issues in Patients Undergoing Bone Marrow Transplantation

Cardiovascular management is important throughout hematopoietic stem cell transplantation (HSCT), also known as bone marrow transplant, but comprehensive guidance has been limited to date. In early 2024, the American Heart Association (AHA) published guidelines that focus on incidence, risk stratification, and management throughout each stage of transplant to prevent cardiac complications.

The document, developed by the AHA Cardio-Oncology Committee of the Council on Clinical Cardiology, Council on Genomic and Precision Medicine, and the Council on Cardiovascular and Stroke Nursing, appears in Circulation.

Seth Rotz, MD, a pediatric hematologist/oncologist at Cleveland Clinic and one of the authors, says some cardiac issues occur more commonly than others.

Part of the challenge is that the literature has been siloed. “There are papers on short-and long-term cardiac complications, incidence in pediatrics, in adults, and in adults who are survivors of pediatric bone marrow transplant. But there hasn't been a single source that distills this information,” he explains.

Key recommendations

Cardiovascular assessment is essential across each stage of HSCT: pretransplant evaluation, peritransplant and survivorship. During the evaluation phase, a comprehensive workup of cardiovascular risk factors is recommended. Imaging studies should, ideally, include an echocardiogram (ECG).

The authors also recommend using a risk score, such as the Cardiovascular Registry on Bone Marrow Transplantation (CARE-BMT), to help stratify risk and determine if a more comprehensive evaluation and involvement of a cardiologist are needed.

“CARE-BMT is a way to really narrow down patients’ cardiac risk occurring during transplant,” notes Dr. Rotz. “This tool is used alongside the transplant comorbidity index,” he explains, “a global scale administered to any patient to assess the risk of toxicity before transplant.” However, it is worth noting that the tool is more tailored to adults, not children.

Dexrazoxane and more judicial use of anthracyclines may be used to reduce the degree of cardiac dysfunction in patients coming to transplantation, but risk stratification is still an important aim to optimize outcomes. Management during this phase should also focus on optimizing cardiovascular status in preparation for transplant, the authors note. This includes guideline-directed medical therapy and ensuring euvolemia.

Pediatric cardio-oncologist Shahnawaz Amdani, MD, adds, “When patients are in the hospital for their transplant, they often get lots of volume. If there is underlying heart dysfunction, this can quickly escalate, requiring respiratory support, intubation, heart support medication, or IV inotropic support. However, if they've been identified as high-risk, we can manage them better and stay on top of their diuresis better."

The authors of the statement found that in the first 100 days following transplant, the leading complications include atrial fibrillation/flutter (2%-10%) and heart failure (0.4%-2.2%). While other complications, such as myocardial infarction, shock, pericarditis/myocarditis, pericardial effusion, and cardiovascular death, have occurred, they are exceedingly rare.

Longer-term complications and management in survivorship

After the first 100 days of bone marrow transplant acute toxicities occur less frequently, and strategies for longer-term cardiovascular complications may be warranted. Atrial fibrillation/flutter and heart failure are again the top cardiovascular events, both with incidences around 10% or less. In lower-risk patients, monitoring is discretionary. For higher-risk patients, however, patients should undergo echocardiogram imaging three months following transplantation and then annually, the authors advise.

Emphasizing a survivorship perspective, Dr. Rotz adds, “A 10-year-old who has leukemia and has been cured by a bone marrow transplant may have 80 more years of life. The last thing you want is for them to develop a lethal heart disease in their 40s or 50s.”

Dedicated cardio-oncology care at Cleveland Clinic

Cleveland Clinic provides in-house cardio-oncology programs for both pediatric and adult patients. Dr. Amdani, who also leads the Pediatric Cardio-Oncology Center, says the center offers specialized cardiac care for patients who have or are receiving cancer treatment. A dedicated advanced practice provider and care coordinator also staff the center.

The center utilizes a myriad of specialized tests to evaluate risk. In addition to an echocardiogram, as recommended by the guideline, other diagnostic modalities are used to identify cardiac biomarkers, such as NT-proBNP and cardiac troponin, in addition to ambulatory rhythm monitors, exercise stress tests, and a cardiometabolic screening, which includes a hemoglobin A1C and lipid profile.

Drs. Rotz, Amdani and their colleagues work together to administer and monitor potentially cardiotoxic medications, which could adversely affect cardiac function, causing arrythmia, cardiomyopathy, and heart failure.

“We serially evaluate them with clinical exams and echocardiograms, as needed,” stresses Dr. Rotz.

The center also helps facilitate care for older pediatric patients or those being seen in survivorship whose care has been transitioned to adult specialists. Working in the same building enables a collaborative care environment, where providers frequently discuss complicated cases.

The relatively high volume of patients has also helped the team understand the unique challenges of this patient population. “After seeing a number of these patients, we have a sense of their trajectory and are adept at anticipating their needs,” says Dr. Amdani.

A look ahead

Questions in incidence and long-term management remain as experts continue to explore cardiovascular complications during and after bone marrow transplant. For example, the data for pediatric patients are more limited compared to adult patients, underscoring the need for more scientific evidence in a younger patient population.

Additionally, strategies to best manage cardiac complications, like cardiomyopathy, that develop later in life must be considered.

Dr. Rotz concludes, “I think it's important for the field going forward that we continue considering the implications of cardiac health and healthy lifestyles.”