https://openworks.mdanderson.org/sumexp21/1209/thumbnail.jp

Daher, Marilyne, MD

Deswal, Anita, MD MPH

Iliescu, Cezar, MD

Kabani, Samat, MD

Oderinde, Praise A

Palaskas, Nicolas, MD

English

OpenWorks @ MD Anderson

Background• Despite promising cancer results from immune checkpoint inhibitors (ICI) several immune related adverse events (irAE) have been observed, including myocarditis. • Though it has a  low incidence, 0.5 to 1%, ICI myocarditis is the most fatal irAE with a reported mortality of 25 to 50%. • ICI myocarditis diagnosis depends on a combination of clinical presentation: biomarkers, cardiac imaging, and endomyocardial biopsy.• The clinical presentation of myocarditis is often equated with heart failure despite most patients presenting with normal left ventricular ejection fraction (LVEF). • Current practice guidelines suggest to first rule coronary artery disease (CAD) prior to making a diagnosis of myocarditis. Methods • A single center retrospective cohort study of all patients who had endomyocardial biopsy for suspected ICI myocarditis between January 2018 and January 2020 was performed.• Manual electronic medical record review was performed to collect demographics, oncologic history, laboratory values, catheterization data, and cardiac imaging data. • Pulmonary capillary wedge pressure (PWCP) ≥12mmHg indicates heart failure and PCWP<12mmHg indicates no heart failure. • Clinical parameters and right heart hemodynamics were compared using Chi-square test. Results con’t• 47% presented with dyspnea but presenting symptoms of dyspnea and elevated PCWP were not associated (p=0.09). • Of the 8 patients presenting with dyspnea but with normal PCWP, 3 (38%) had concomitant myositis, myasthenia gravis, or guillian barre irAEs. • Significant CAD was found on left heart cath in 26% of patients presenting with myocarditis but the presence of CAD was not associated with having elevated PCWP (p=0.14). Conclusions• ICI myocarditis has varied clinical presentations including heart failure • Only half may actually have heart failure this may be present in those with both normal and depressed LVEF.• With patients presenting with dyspnea but have normal filling pressures on echocardiogram, concomitant muscular/neuromuscular junction irAEs should be considered. • Cancer and CAD have shared risk factors and up to a quarter of patients presenting with myocarditis may have concomitant CAD • The presence of CAD should not rule out myocarditis.  ReferencesLili Zhang, Kerry L. Reynolds, Alexander R. Lyon, Nicolas Palaskas, Tomas G. Neilan,The Evolving Immunotherapy Landscape and the Epidemiology, Diagnosis, and Management of Cardiotoxicity: JACC: CardioOncology Primer,JACC: CardioOncology, Volume 3, Issue 1, 2021, Pages 35-47, ISSN 2666-0873, https://doi.org/10.1016/j.jaccao.2020.11.012. (https://www.sciencedirect.com/science/article/pii/S2666087320303331)Palaskas N, Lopez-Mattei J, Durand JB, Iliescu C, Deswal A. Immune Checkpoint Inhibitor Myocarditis: Pathophysiological Characteristics, Diagnosis, and Treatment. J Am Heart Assoc. 2020 Jan 21; 9(2):e013757. doi: 10.1161/JAHA.119.013757. Epub 2020 Jan 21. PMID: 31960755; PMCID: PMC7033840.Title of the Poster Presentation Goes HereAuthors of the Poster Presentation Goes HereInstitutional and/or Graduate School of Biomedical Sciences Affiliation Goes Here Objective To establish that the presentation of heart failure may not always indicate ICI myocarditis.Immune Checkpoint Inhibitor Myocarditis: Concomitant Coronary Artery Disease and Heart FailurePraise Oderindea,d, Samat Kabani MDb, Marilyne Daher MDc, Cezar Iliescu MDa, Anita Deswal MD MPHa, Nicolas L. Palaskas MdaaUniversity of Texas MD Anderson Cancer Center, Houston, Texas bUniversity of Texas Health Science Center, Houston, Texas cBaylor College of Medicine, Houston, Texas dUniversity of Houston- Downtown. Results • 52 patients had endomyocardial biopsy for suspicion of ICI myocarditis. • The mean age was 68 years and the majority were male (75%).• 42 (81%) patients had definite, probable, or possible myocarditis and the remaining were considered negative for myocarditis. Right/Left Heart Catheterization Data Definite MyocarditisProbableMyocarditisPossible Myocarditis Negative for MyocarditisP-valueMedian (IQR)n=26 n=7 n=9 n=11RangeRight atrial mean pressure 9 (7-11) 7 (4-9) 5 (5-12) 8 (8-9) 0.440-10 0-21 44271Pulmonary artery systolic pressure 32 (26-36) 26 (25 -36) 35 (28-43) 33 (29-40) 0.619-46 21-57 24-58 23-54Pulmonary artery mean pressure 20 (18-24) 22 (14-24) 27 (17-32) 22 (19-29) 0.6513455 14946 13-42 15-35Pulmonary capillary wedge pressure mean 12 (9-15) 11 (8-13) 16 (7-22) 13 (10-16) 0.7944278 44313 12479 44461Left ventricular end-diastolic pressure 20 (12-22) 17 (14-19) 22 (11-26) 18 (15-19) 0.7512451 11810 12236 14-20Cardiac index- Fick 2.8 (2.2-3.1) 2.3 (2.1-2.4) 2.1 (1.8-2.2) 3.1 (2.8-3.2) 0.07L/min/m2 1.4-3.8 2.1-2.5 1.3-2.3 2.2-3.3Arterial aortic systolic blood pressure 128 (114-144) 138 (122-150) 114 (105-122) 128 (117-132) 0.3788-169 102-154 89-163 114-164Demographics & Definite Probable Possible Negative for P-valueClinical Parameters Myocarditis Myocarditis Myocarditis MyocarditisRange n=26 n=7 n=9 n=11Age, Median (IQR) 74 (66-77) 62 (58-73) 65 (63-69) 69 (66-76) 0.54Gender % (M/F) 73/27 71/29 89/11 73/27 0.79Race % 0.4White 73 57 67 27Black 8 14 0 0Other 21 28 32 73• Of those with myocarditis, LVEF <50% was observed in 47% of patients and pulmonary capillary wedge pressure (PCWP) >12 mmHg was observed in 47% of patients • Elevated PCWP and LVEF <50% were not correlated (p=0.78).Table 1-Baseline Demographics Table 2-Right and Left Heart Catheterization Data at Time of Biopsy

Immune Checkpoint Inhibitor Myocarditis: Concomitant Coronary Artery Disease and Heart Failure

https://openworks.mdanderson.org/cgi/viewcontent.cgi?article=1209&context=sumexp21

Immune Checkpoint Inhibitor Myocarditis: Concomitant Coronary Artery Disease and Heart Failure

Abstract

Similar works

Full text

Available Versions

OpenWorks @ MD Anderson