Cardiac risk stratification for patients undergoing hematopoietic stem cell transplantation and associated cardiovascular complications

Our review focuses on short-term and long-term cardiovascular complications (CVC) after hematopoietic stem cell transplant (HSCT); pre-HSCT cardiac risk assessment and optimization; and post-HSCT cardiovascular screening and long-term surveillance. We conducted a narrative review of existing literature on CVC pertaining to HSCT, with emphasis on pre-transplant risk assessment tools and post HSCT cardiac surveillance and optimization. HSCT related CVC are divided into short-term and long-term, with an incidence of 4–5.5% by 100 days and 14% by 5 years respectively. Atrial fibrillation/flutter is the most common CVC, with incidence of 2.6% at 100 days and 6.8% at 5 years, followed by heart failure at 1.1% and 5.4%, respectively. Short-term CVC risk is associated with older age and reduced pre-transplant left ventricular ejection fraction (LVEF) (< 50%), whereas long-term risk is associated with older age, hypertension, diabetes, smoking, chronic kidney disease, coronary artery disease, obesity, and reduced pre-HSCT LVEF. Post-transplant heart failure risk is further influenced by allogeneic HSCT, graft-versus-host disease, cumulative anthracycline exposure, and chest radiation. Allogeneic HSCT recipients have higher long-term cumulative CVC incidence than autologous HSCT recipients, although early CVC rates appear similar. The Cardiovascular Registry in Bone Marrow Transplantation (CARE-BMT) score can be used for pre-HSCT cardiac risk stratification for short- and long-term cardiovascular events which can guide management and timely cardio-oncology referrals. Post-HSCT surveillance should include periodic assessment of cardiovascular risk factors, electrocardiogram, and echocardiography monitoring in high-risk patients, with emerging roles for coronary artery calcium (CAC) assessment and global longitudinal strain (GLS). High-risk patients should receive guideline-directed optimization of modifiable risk factors and treatment of established cardiovascular disease (CVD). CVC arise as a major cause of non-relapse mortality (NRM) and morbidity after HSCT. Validated HSCT specific CARE-BMT score helps with cardiac risk assessment. A structured, risk-adapted approach should be followed, taking into consideration transplant and prior cancer related treatment exposures, traditional cardiometabolic comorbidities and targeted testing to guide pre-transplant optimization, cardio-oncology referral and longitudinal follow up. Given the elevated long-term cardiovascular (CV) risk in HSCT survivors, proactive monitoring and aggressive management of modifiable CV risk factors through lifestyle modifications and pharmacotherapy is critical. Other emerging strategies include incorporation of CAC scoring, and GLS to further individualize risk assessment and surveillance.