Elaine S. DeMeyer, RN, MSN, AOCN®, BMTCN®

Cancer Nursing Today nonprod

<p>Oncology nurses must know the potential cardiovascular (CV) complications related to graft-versus-host disease (GVHD). Although direct cardiac manifestations of GVHD are rare, CV side effects and comorbidities from drugs to manage GVHD after allogeneic stem cell transplant (SCT) are common.<h3>What Types of CV Toxicity Can Occur After Allogeneic SCT?</h3><p>Cardiac toxicity&mdash;or CV toxicity to include damage to the vascular system&mdash;may be described based on the time frame of occurrence after SCT. For example, life-threatening CV toxicity can present within the first few days of therapy to decades after SCT.</p><table style="width: 100%; border: 1px solid #000000; padding: 1px;">
<tbody>
<tr>
<td style="width: 20%; border: 1px solid #000000; padding: 1px; text-align: center;"><strong>Type of CV Toxicity</strong></td>
<td style="width: 30%; border: 1px solid #000000; padding: 1px; text-align: center;"><strong>Timing in Relation to SCT</strong></td>
<td style="width: 50%; border: 1px solid #000000; padding: 1px; text-align: center;"><strong>Common Manifestations</strong></td>
</tr>
<tr>
<td style="width: 20%; border: 1px solid #000000; padding: 1px; text-align: center;">Acute</td>
<td style="width: 30%; border: 1px solid #000000; padding: 1px; text-align: center;">Hours to days</td>
<td style="width: 50%; border: 1px solid #000000; padding: 1px; text-align: center;">Arrhythmias, especially bradycardia and<br>
QT prolongation</td>
</tr>
<tr>
<td style="width: 20%; border: 1px solid #000000; padding: 1px; text-align: center;">Early onset</td>
<td style="width: 30%; border: 1px solid #000000; padding: 1px; text-align: center;">Within 100 days</td>
<td style="width: 50%; border: 1px solid #000000; padding: 1px; text-align: center;">Often due to other conditions such as sepsis, transplant-associated thrombotic microangiopathy, sinusoidal obstruction syndrome (formerly called veno-occlusive disease), and GVHD</td>
</tr>
<tr>
<td style="width: 20%; border: 1px solid #000000; padding: 1px; text-align: center;">Late onset or chronic</td>
<td style="width: 30%; border: 1px solid #000000; padding: 1px; text-align: center;">&gt;3 months to decades</td>
<td style="width: 50%; border: 1px solid #000000; padding: 1px; text-align: center;">Cardiomyopathy, valvular disease, stroke, ischemic heart disease, or comorbid conditions (eg, diabetes, hypertension) with cardiac events</td>
</tr>
</tbody>
</table><p><a href="https://www.acc.org/latest-in-cardiology/articles/2021/02/13/15/28/acute-cv-complications-of-hematopoietic-stem-cell-transplantation" target="_blank" rel="noopener">Acute and early-onset CV toxicity</a> can include arrhythmias, acute heart failure, pericardial effusion or cardiac tamponade, and cardiac arrest. Cardiomyopathy, valvular disease, stroke, ischemic heart disease, or comorbid conditions (eg, diabetes, hypertension) with cardiac events are more common as late CV effects.</p><h3>What Are the Risk Factors for CV Toxicity?</h3><p>Many factors influence the development of CV toxicity, including patient-, disease-, and treatment-related risk factors. Older patients with preexisting CV comorbidities, arrhythmia, diabetes, or hypertension are at higher risk. During the pre-transplant evaluation, patients complete an echocardiogram and multigated acquisition (MUGA) scan to establish the baseline left ventricular ejection fraction (LVEF) critical for post-transplant comparison. High-risk patients may benefit from reduced-intensity regimens.</p><p>Patients with blood cancer are at risk for CV disease even before transplant conditioning regimens due to previous exposure to cardiotoxic agents, such as:</p><ul>
<li>Doxorubicin in hyperCVAD-based regimens for acute lymphoblastic leukemia (ALL)</li>
<li>Cytarabine and anthracycline (7 + 3) induction for acute myeloid leukemia (AML)</li>
<li>Specific tyrosine kinase inhibitors (TKIs) for chronic myeloid leukemia (CML)</li>
<li>Bruton&rsquo;s kinase inhibitors (BTKs) for chronic lymphocytic leukemia (CLL)</li>
</ul><p>High-dose cyclophosphamide in the conditioning regimen or given post transplant for GVHD prophylaxis and total body irradiation (TBI) can increase the risk of late CV toxicity. CV toxicity after allogeneic SCT has been reported in as many as <a href="https://ashpublications.org/bloodadvances/article/5/24/5599/477108/Cardiac-toxicity-after-matched-allogeneic" target="_blank" rel="noopener">43% of patients</a>.</p><h3>What Is the Relationship Between CV Toxicity and GVHD?</h3><ul>
<li>Vascular endothelial damage from GVHD can contribute to injury and inflammation, predisposing the patient to arterial damage. In addition, chronic GVHD can cause cardiac tissue autoimmune-type damage. Although target organs in chronic GVHD usually include the skin, liver, gut, lungs, joints, and eyes, the disease can target the heart directly (but this is rare).</li>
</ul><p>&nbsp;</p><ul>
<li>Studies show that patients with chronic GVHD can have diminished cardiac function with impaired left ventricular (LV) diastolic function. Compared with patients who did not develop chronic GVHD, those with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783135/" target="_blank" rel="noopener">chronic GVHD had LV wall thickness and mass</a>.</li>
<li>The cause of CV toxicity in GVHD is mainly from the drugs that manage it, particularly with long-term use in chronic GVHD. Patients with grade II or higher GVHD (beyond the skin) are at higher risk of developing CV risk factors. Comorbidities such as hypertension and diabetes likely are related to the side effects of calcineurin inhibitors (CNIs) and steroids. Both CNIs&mdash;tacrolimus and cyclosporin&mdash;can cause hypertension. In addition, tacrolimus can cause an enlarged heart, QT prolongation, chest pain, dyspnea, and peripheral edema. For grade II or higher, patients often receive systemic steroids, which can cause hyperglycemia.</li>
</ul><p>Oncology nurses have a critical role in monitoring for patient risk factors for CV toxicities, identifying toxicities early and promptly communicating them to the care team, observing the effectiveness of interventions, and discussing modifiable risk factors, such as smoking. The <a href="https://www.cancer.org/health-care-professionals/american-cancer-society-survivorship-guidelines/nupa-guidelines-for-cancer-survivors.html" target="_blank" rel="noopener">American Cancer Society</a> offers nutrition and physical activity guidelines for cancer survivors. High-risk patients or those with complications may benefit from a cardio-oncology program or cardio-oncologist, a unique blend of expertise of a cardiologist and oncologist to better monitor for long-term CV complications.</p><p>Oncology nurses must carefully assess for early symptoms of CV toxicity, particularly in patients with chronic GVHD. Teach patients to measure weight daily, self-monitor blood pressure, test glucose levels as needed, and keep a record of the findings. Collaborate with the provider to establish parameters for when nurses should report abnormal values. Remind patients who wear smartwatches that they can record their ECG at any time. Finally, review modifiable CV risk factors with patients, such as smoking cessation, increased activity, and dietary changes.</p><p><em>Read More </em><a href="https://cancernursingtoday.com/page/gvhd"><em>Recent Research on Graft-Versus-Host Disease</em></a></p></p>


GVHD Cardiovascular Complications

GVHD

Elaine DeMeyer, RN, MSN, describes cardiovascular toxicities related to GVHD after hematopoietic cell transplantation and what oncology nurses should look for to evaluate risk.