Multiple myeloma and al cardiac amyloidosis: the predictive role of HFA/ICOS risk score and other parameters

Background Anti-cancer drugs used to treat multiple myeloma (MM) can cause several cardiovascular toxic effects. HFA/ICOS risk score stratification is used to assess the baseline cardiovascular risk of cancer patients and its effectiveness has been demonstrated in breast cancer patients and some hematological malignancies but not in MM. In addition, patients with MM can have AL cardiac amyloidosis that can worsen the prognosis. Purpose to assess the effectiveness of HFA-ICOS risk score in predicting cardiovascular events in MM patients and the influence of cardiac amyloidosis and AL score on prognosis. Methods A prospective study was carried out enrolling 71 patients with MM (35 women and 36 men; mean age 68±10 years) treated with proteasome inhibitors with or without immunomodulators and daratumumab. Cardiological evaluation was performed before starting anti-cancer drugs and after a median period of 1 years. HFA/ICOS risk score and AL score were assessed in all patients at baseline. Cardiovascular events were assessed: cardiovascular death, heart failure hospitalization, arrhythmias, myocardial ischaemia, venous thromboembolism, new onset of arterial hypertension, cancer therapy-related cardiac dysfunction. Patients were divided into 2 groups: patients with HFA/ICOS risk core high and very high (A), patients with low and medium HFA/ICOS risk score (B). Results Group A included 26 patients, group B included 45 patients; 19 patients had AL cardiac amyloidosis and were included in group A. Cardiovascular adverse events were significantly higher in group A (65,38%) than group B (24,4%). In particular, cardiovascular death, hospitalization for heart failure and atrial fibrillation were significantly higher in group A, especially in patients with cardiac amyloidosis. Using logistic regression analysis, cardiovascular events were significantly associated with HFA/ICOS risk score high and very high, AL score ≥ 5, cardiac amyloidosis, heart failure, global longitudinal strain (GLS) and NT-pro BNP value at baseline, left ventricular mass at echocardiogram and left atrial volume indexed (p value < 0,05). At multiple regression analysis, only HFA/ICOS risk score, GLS and NT-pro BNP were independent predictors of cardiovascular events. A GLS value -10.5% and a NT-pro BNP value >164.50 mg/dl have been identified as the parameters capable of predicting events with the greatest sensitivity and specificity (AUC 1, p value < 0,0001). All patients with cardiac amyloidosis had CV events. Conclusion Our study confirms the effectiveness of HFA/ICOS risk score in patients with MM and the need to identify the presence of cardiac amyloidosis in these patients using AL score. Also AL score is associated with CV events and it is able to identify cardiac amyloidosis. NT-proBNP and GLS (included respectively in HFA/ICOS score and AL score) are independent predictors of CV events in MM patients and it should be assessed before starting treatment.