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Non-Hodgkin lymphoma survivors with pre-existing cardiovascular conditions have increased heart failure risk
Pre-existing cardiovascular conditions appeared linked with increased risk for heart failure among survivors of non-Hodgkin lymphoma, study data showed.
Patients who have survived non-Hodgkin lymphoma are known to have a significantly higher risk for heart failure compared with the general population.
“By using a large, population-based cohort of contemporarily treated non-Hodgkin lymphoma survivors in Denmark, study investigators were able to study the contribution of hypertension, diabetes, and dyslipidemia to the later development of heart failure," Talya Salz, PhD, assistant attending outcomes research scientist in the department of epidemiology and biostatistics at Memorial Sloan Kettering Cancer Center,told HemOnc Today.
“An elevated risk of heart failure was evident among non-Hodgkin lymphoma survivors, compared with individuals without cancer, even within the first five years. And indeed, having more cardiovascular risk factors present at diagnosis was associated with an increased risk of later heart failure.”
The researchers reviewed Danish cancer registries to identify patients diagnosed with aggressive non-Hodgkin lymphoma from 2000 to 2010 (n = 2,508; 56% male; median age at diagnosis, 62 years). Researchers matched survivors by sex and age to controls from the general population (n = 7,399). Salz and colleagues evaluated heart failure beginning at 9 months after diagnosis through 2012 and used Cox regression analysis to assess the risk for heart failure in each group. Among cancer survivors, the researchers examined pre-existing cardiovascular factors and disease.
Non-Hodgkin lymphoma survivors had a 42% increased risk for heart failure compared with controls (HR = 1.42; 95% CI, 1.07-1.88).
A total of 115 survivors were diagnosed with heart failure during a median 2.5 years of follow-up. More than one-third (39%) of the survivors had at least one cardiovascular risk factor before cancer diagnosis, and nearly all (92%) underwent treatment with anthracycline-containing regimens.
Pre-existing heart disease before lymphoma diagnosis appeared associated with a greater risk for heart failure in survivors (HR = 2.71; 95% CI, 1.15-6.36). However, there was no association between pre-existing vascular disease and heart failure. Those with cardiovascular risk factors had an increased risk for heart failure compared with those who had no risk factors (for 1 vs. zero risk factors, HR = 1.63; 95% CI, 1.07-2.47; for ≥ 2 vs. zero risk factors, HR = 2.86; 95% CI, 1.56-5.23).
“For survivors of non-Hodgkin lymphoma, the presence of cardiovascular risk factors before the diagnosis of lymphoma in combination with anthracycline treatment should alert providers to heightened risk [for] heart failure even shortly after treatment,” the researchers wrote. “Clinicians should focus on preventive strategies among newly diagnosed patients with non-Hodgkin lymphoma with existing cardiovascular risk factors to avoid heart disease that can manifest in the early years of survivorship.” – by Andy Polhamus
Disclosures: The authors report no relevant financial disclosures.
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Pre-existing risk factors for cardiovascular disease and the presence of pre-existing nonvascular intrinsic heart disease were predictors of incident heart failure in surviving aggressive non-Hodgkin lymphoma patients treated between 2000 and 2010 and followed through 2012 in a study of Danish national health system data reported in Journal of Clinical Oncology on September 18, 2017. In this cohort of 2,508 survivors of non-Hodgkin lymphoma and 7,399 age- and sex-matched controls with mean follow-up of 2.5 years, non-Hodgkin lymphoma survivors demonstrated a 42% higher risk of heart failure than the controls. The presence of two or more pre-existing risk factors — hypertension, hyperlipidemia and diabetes — coupled with age and sex appeared associated with heart failure incidence of up to 46% after non-Hodgkin lymphoma treatment. Males aged 70 or over with two or three risk factors demonstrated the highest risks. Pre-existing intrinsic heart disease — defined as cardiomyopathy, myocardial, valvular or pericardial disease — appeared associated with a 2.71-fold increase in risk of incident heart failure among survivors (P = .02). Researchers found no significant increase in heart failure risk among survivors with vascular disease — defined as cardiac arrest, myocardial infarction, angina, coronary artery disease, Stroke, TIA, or Carotid Artery disease — or in those receiving chest radiation.
Researchers used ICD 10 codes to define populations of patients with diabetes, coronary and cerebrovascular disease and those defined as having intrinsic heart disease including cardiomyopathy, myocardial disease, valvular disease and pericardial disease. National drug databases were used to define risk factors for hypertension through the prescribing of Calcium Channel Blockers, Diuretics, Angiotensin Inhibitors, beta blockers or alpha blockers and Hyperlipidemia by the prescribing of statins. Heart failure was defined as an inpatient or outpatient event associated with one of 7 ICD 10 codes for heart failure.
No data were available regarding blood pressure, cholesterol or glucose readings or the percentage of hypertensive patients receiving beta blockers or angiotensin inhibitors that could be beneficial in heart failure or non-dihydropyridine antihypertensive that could be deleterious. Measures of myocardial performance such as ejection fraction were not reported.
Most of the non-Hodgkin lymphoma patients (92%) received anthracyclines with reduced use of anthracyclines in patients with cardiovascular risk factors and pre-existing vascular or intrinsic heart disease. The cumulative anthracycline dose appeared associated with an increase in risk of heart failure.
The strong relationship between modifiable risk factors for heart failure — such as hypertension, diabetes, valve disease and cardiomyopathy and incident heart failure — in survivors of non-Hodgkin lymphoma is clearly demonstrated in this study. With this high-risk population identified, consideration of efforts to optimize risk factors for heart failure using evidence-based therapies that are beneficial for the prevention and management of heart failure in high-risk patients may be a more effective strategy than the practice of withholding anthracyclines in higher-risk patients as suggested in this study.