November 2023

Lara C. Pullen, PhD

A new study reports on the long-term risk for coronary heart disease (CHD) in blood or marrow transplant (BMT) recipients and identifies individuals who are at high risk for CHD. Risk factors in this population include older age at BMT; male sex; a history of smoking, diabetes, hypertension, or arrhythmia; and pre-BMT chest radiation. Radhika Gangaraju, MD, MSPH, assistant professor at the Institute for Cancer Outcomes and Survivorship at the University of Alabama in Birmingham, and colleagues published their findings in JACC: CardioOncology and highlight the need for targeted screening and aggressive control of the risk factors.

The investigators evaluated a cohort of 6,677 BMT recipients who had been transplanted at City of Hope, University of Minnesota, or University of Alabama at Birmingham and who had survived at least two years. They followed the patients for a median length of 6.9 years from BMT and found that the 20-year cumulative incidence of CHD was 5.5%. The findings indicate that BMT survivors are 61% more likely to develop CHD as compared with sibling controls. The authors acknowledged that because the study relied on self-reporting, they could not capture complete details regarding clinical presentation and laboratory abnormalities among those who developed CHD.

Dr. Gangaraju explained that while a previous study found the risk of cardiovascular disease (CVD) was higher after allogeneic BMT than autologous BMT (15-year cumulative incidence of 7.5% vs. 2.3%), she and her colleagues found a higher 20-year cumulative incidence of CHD after autologous BMT (6.44 ± 0.63%) than after allogeneic BMT (4.61 ± 0.51%). She suspects the difference in findings may be because patients in her study who were receiving autologous BMT were older than patients in the previous study. Moreover, the previous study included other cardiovascular outcomes, such as congestive heart failure, stroke, and peripheral vascular disease, as opposed to the current study that restricted its analysis to CHD.

The Center for International BMT Research and the European Group for BMT Late Effects Working Group guidelines provide consensus recommendations for screening and management of cardiovascular risk factors and CVD in BMT recipients and recommend a similar approach for CHD assessment in BMT recipients as in the general population. Dr. Gangaraju believes, however, that such recommendations are not sufficient and that all BMT survivors should be advised of their increased risk for CHD and counseled to take preventive care, such as following a healthy diet and performing regular exercise. She also believes that patients who have undergone BMT should receive more intensive screening and management of cardiovascular risk factors than the general population.

Although clinicians in the transplant community recognize the risk of cardiovascular events in BMT recipients, Dr. Gangaraju said there are “no validated tools that can be used in clinic.” She and her colleagues thus created a nomogram, which, once validated, can serve as a simple individual CHD risk analysis tool that can be used to educate patients at the time of BMT. The team also hopes to develop a simple online tool that incorporates the same information found in the nomogram.

Dr. Gangaraju explained that although BMT recipients are followed intensively in the first year post-transplant, after five years their follow-up appointments are spaced farther apart, and the patients transition to primary care. CHD, however, tends to develop five or more years post-BMT. “These patients should be followed closely,” Dr. Gangaraju said, “but they don’t necessarily have to be followed in a transplant center.” She thus calls for increased education of primary care physicians who will be following BMT recipients long term, and she hopes her team’s nomogram can help with patient management. She believes that the need for such specific information about cancer survivors will only grow as primary care physicians treat an increasing number of patients who have received transplants.

Reference

Gangaraju R, Chen Y, Hageman L, et al. Prediction of coronary heart disease events in blood or marrow transplantation recipients. JACC: CardioOncol. 2023;5(4):504-517.