Sivasubramanian, Barath Prashanth

Background: Acute heart failure affects ~9% of patients with hematological malignancies. This study aimed to evaluate the impact of acute heart failure on in-hospital mortality among patients with hematological malignancies and to identify independent predictors of mortality in this population. Methods: The National Inpatient Sample (2016–2021) was queried for adults (⩾18 years of age) with hematological malignancies and those who experienced in-hospital mortality. Among these, we identified patients who were hospitalized with a diagnosis of acute heart failure. Univariate analysis and multivariate regression were employed to analyze the mortality risk. A p ⩽ 0.05 was considered significant. Results: Among 40,246 patients with hematological malignancies who died in the hospital, the univariate analysis showed a higher in-hospital mortality in the acute heart failure cohort compared to the non-acute heart failure group (8.08% versus 4.52%, p < 0.001). However, after adjusting for sociodemographic factors and comorbidities, acute heart failure was associated with a lower risk of in-hospital mortality (OR 0.87, 95% CI 0.84–0.9, p < 0.001). Predictors of mortality in the acute heart failure cohort were age >60 years, hematopoietic stem cell transplant, severe sepsis, arrhythmias, infective endocarditis, bleeding from any source, acute respiratory failure, hepatic dysfunction, metabolic encephalopathy, and invasive ventilation (all p < 0.01). On subgroup analysis, acute myeloid leukemia, chronic myeloid leukemia, chronic lymphocytic leukemia, and multiple myeloma had a higher in-hospital mortality in the acute heart failure cohort compared to the non-acute heart failure group ( p < 0.001). Conclusion: Acute heart failure in patients with hematological malignancies was associated with poor outcomes in the presence of severe sepsis, organ dysfunction, and the need for mechanical ventilation. Close monitoring and a multidisciplinary team approach are recommended to optimize the treatment plan for this population.

Introduction: The incidence of cardiovascular events in the first 100 days post-HSCT was found to be 19%, with arrhythmia having the highest incidence of 12% (p&lt;0.0001). The incidence of cardiovascular events is 6.7% in patients with multiple myeloma treated with HSCT (HSCT-MM) [1]. However, the literature on arrhythmia in HSCT-MM patients is limited. Given the high risk of cardiac events in HSCT patients, we aimed to determine the impact of arrhythmia in patients with HSCT-MM. Methods: We conducted a retrospective analysis using the National Inpatient Sample Database (2018-2021). Adult patients with HSCT-MM who were primarily admitted for life-threatening arrhythmias were identified using ICD-10 codes [2]. We performed propensity matching and multivariate regression, considering a p-value of ≤0.05 as significant. Results: In 14,232 HSCT-MM patients, 168 (1.2%) had arrhythmia. The prevalence of arrhythmia in HSCT-MM patients was higher than in the remaining HSCT recipients (1.2% vs 0.9%, p&lt;0.01). In HSCT-MM, atrial fibrillation (69.6%) and atrial flutter (19%) were the common arrhythmias. Arrhythmia in HSCT-MM patients was more prevalent in those over the age of 60 years (84.5% vs 68.5%, p&lt;0.001), males (72.6% vs 58.2%, p&lt;0.001), and in the White race (84.8% vs 67.3%, p&lt;0.001) compared to those without arrhythmia. Arrhythmia was less common in those with bone marrow dysfunction compared to those with normocellular marrow (anemia 1% vs 1.5%, p&lt;0.01; thrombocytopenia 1% vs 1.2%, p&gt;0.05; neutropenia 0.7% vs 1.3%, p&lt;0.05; pancytopenia 0.9% vs 1.4%, p&lt;0.01). Among the HSCT-MM patients with arrhythmia, long-term anticoagulation was less frequently given than those without arrhythmia (44.6% vs 55.4%, p&lt;0.001). The arrhythmia cohort had less frequent acute kidney injury (19.1% vs 27.5%, p=0.01). The arrhythmia cohort required more vasopressors (2.4% vs 2.1%, p&gt;0.05) but had lower mortality (1.2% vs 4.5%, p&lt;0.05). Patients with arrhythmia had shorter hospital stays (Coefficient -3 days; 95% CI -3.8 to -2.3 days; p&lt;0.001) and lesser hospital charges (Coefficient $-41,200; CI $-55,700 to $-26,600; p&lt;0.001) compared to those without. However, the arrhythmia cohort had higher rates of acute heart failure (17.9% vs 9.1%, p&lt;0.001) and the risk of acute heart failure was also higher in those with arrhythmia (adjusted odds ratio 2.2; 95% CI 1.3 to 3.6; p&lt;0.01). In patients with acute heart failure and arrhythmia, atrial fibrillation was present in 76.7% and atrial flutter in 20%. In patients with acute heart failure and arrhythmia, bone marrow dysfunction was more common than normocellular bone marrow (anemia 22.2% vs 12.8%, p&gt;0.05; thrombocytopenia 38.7% vs 13.1%, p=0.001; neutropenia 18.2% vs 14.3%, p&gt;0.05; pancytopenia 8.7% vs 21.3%, p&gt;0.05). In the arrhythmia cohort, long-term anticoagulation was commonly given in those with acute heart failure compared to those without (53.3% vs 46.7%, p&gt;0.05), and acute kidney injury also occurred more frequently in those with heart failure (26.7% vs 17.4%, p&gt;0.05). Conclusion: Acute heart failure is a serious risk associated with arrhythmia in multiple myeloma patients treated with HSCT, with atrial fibrillation emerging as the most common arrhythmia. It is essential to prevent heart failure in those with arrhythmia, especially in patients with thrombocytopenia. Preventive measures could include more frequent follow-ups and having a multidisciplinary team to manage renal failure, monitor anticoagulation, and ensure rhythm control in these patients. References: Aghel N, Lui M, Wang V, et al.: Cardiovascular events among recipients of hematopoietic stem cell transplantation-A systematic review and meta-analysis. Bone Marrow Transplant. 2023, 58:478-90. 10.1038/s41409-023-01928-22021 ICD-10-CM. Accessed: July 14, 2024. https://www.cms.gov/medicare/coding-billing/icd-10-codes/2021-icd-10-cm.

Background: Enterococci are the third most common cause of healthcare-associated infections in the United States, affecting 10-12% of all transplant recipients worldwide. Approximately 46% of patients with acute myeloid leukemia (AML) were found to be colonized with Enterococcus [1]. The risk of infection and its complications increases in patients treated with hematopoietic stem cell transplantation (HSCT). Given the high rates of Enterococcus colonization, we aimed to study the impact of Enterococcus infection in AML patients treated with HSCT. Methods: We conducted a retrospective analysis using the National Inpatient Sample Database (2018-2021). Adults over the age of 18 who were treated with HSCT for AML and had Enterococcus infections were identified using ICD-10 codes [2]. We performed the analysis using descriptive statistics and multivariate regression, with a p-value of less than 0.05 considered significant. Results: Of 40,462 HSCT patients, 1.3% (n=531) were admitted with Enterococcus infection. Among the HSCT recipients, Enterococcus infection was seen in 344 (1.4%) of 23,930 patients with all forms of Leukemia and in 134 (2.4%) of 5,693 patients with AML. There were no significant differences in sociodemographic factors such as age over 60 years, gender, or race between those with and without Enterococcus infection in the AML population (p&gt;0.5). The AML-Enterococcus cohort had longer hospital stays (20.8 vs. 9.5 days, p&lt;0.001) and higher total costs as compared to the AML-non-Enterococcus cohort ($373,619 vs. $147,075, p&lt;0.001). Additionally, the AML-Enterococcus cohort had a higher prevalence of urinary tract infections (28.4% vs. 5.2%, p&lt;0.001), fungal infections (13.4% vs. 8.6%, p&lt;0.05), and acute respiratory failure (26.1% vs. 15.5%, p&lt;0.001). Enterococcus infection was more common among patients with bone marrow dysfunction such as neutropenia (33.6% vs. 20.9%, p&lt;0.001), anemia (79.9% vs. 57.6%, p&lt;0.001), and pancytopenia (61.9% vs. 42.7%, p&lt;0.001). Enterococcus infection also was associated with higher rates of severe sepsis (22.4% vs. 9.4%, p&lt;0.001) and vasopressor usage (6.7% vs. 3%, p&lt;0.05). Crude analysis indicated a higher mortality rate in the AML-Enterococcus cohort compared to the AML-non-Enterococcus cohort (16.1% vs. 8.8%, p&lt;0.05). However, after adjusting for confounders, the mortality risk between the two cohorts was not significantly different (adjusted odds ratio 0.9, 95% CI 0.4-1.7, p&gt;0.05). Similarly, the utilization of palliative care services did not differ between the two cohorts (12.7% vs. 9.8%, p&gt;0.05). Conclusion: Enterococcus infection in the AML population who undergo HSCT poses a significant healthcare burden, resulting in longer hospital stays and higher healthcare costs. Patients with bone marrow dysfunction are at increased risk of Enterococcus infection and other opportunistic infections. For AML patients who have previously undergone transplantation and are hospitalized for sepsis, urinary tract infection, or respiratory failure, aggressive treatment with broad-spectrum antibiotics for Enterococcus is necessary. Due to the high crude mortality rate, it is essential to provide multidisciplinary care to reduce hemodynamic compromise and the potential need for vasopressor usage in these patients. It is important to consider Enterococcus as a differential diagnosis for any AML patient with HSCT presenting with a urinary tract infection or respiratory failure. Early recognition and treatment of Enterococcus infection could prevent lengthy hospital stays and reduce costs. References: Scheich S, Lindner S, Koenig R, et al.: Clinical impact of colonization with multidrug-resistant organisms on outcome after allogeneic stem cell transplantation in patients with acute myeloid leukemia. Cancer. 2018, 124:286-96. 10.1002/cncr.31045 2021 ICD-10-CM. Accessed: July 14, 2024. https://www.cms.gov/medicare/coding-billing/icd-10-codes/2021-icd-10-cm.