Cardiac Assessment Before Hematopoietic Stem Cell Transplantation: How to Manage Cardiac Risk


A 54-year-old man with a recent diagnosis of intermediate risk was referred to the cardio-oncology clinic for cardiac assessment. He was due to receive consolidation with a regimen potentially including anthracyclines and, if suitable, allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen–identical sibling donor. He had already completed induction therapy with idarubicin, cytarabine (classical 3+7), and midostaurin, achieving hematological complete remission.

His medical history includes hypertension, hypercholesterolemia, and coronary artery disease (CAD). His only coronary event was a non–ST-segment elevation myocardial infarction 15 years earlier that required percutaneous coronary intervention of the proximal right coronary artery (no other coronary lesions were present). His left ventricular ejection fraction (LVEF) at his most recent (6 months earlier) follow-up appointment was 55%, and exercise stress test findings at that time were clinically and electrically negative.

Cardiac Assessment and Investigations

His current medications include omeprazole 20 mg OID, enalapril 20 mg BID, aspirin 100 mg OID, carvedilol 12.5 mg BID, rosuvastatin 20 mg OID, and acyclovir 400 mg BID. He is physically active, free of symptoms from a cardiac viewpoint, and capable of performing activities equivalent to >4 METs per day, globally self-reporting himself in New York Heart Association (NYHA) class I and Canadian Cardiovascular Society (CCS) class I.

Physical examination findings are unremarkable, including blood pressure (BP) 110/76 mm Hg and heart rate 65 bpm. An electrocardiogram (ECG) shows sinus rhythm with a normal P-R interval, a narrow QRS complex, Q waves in leads V1 and V2, and inversion of the T wave in leads V1, V2, and aVL with other repolarization abnormalities (Figure 1). Laboratory tests include kidney function test values and electrolyte levels within the reference ranges, total cholesterol level 240 mg/dL, low-density lipoprotein cholesterol level 70 mg/dL, fasting plasma glucose level 97 mg/dL, hemoglobin A1c (HbA1c) concentration 5.6%, hemoglobin level 12 g/dL, and iron and thyroid profiles within the reference ranges. Cardiac biomarker levels have not been assessed recently.

Figure 1

Figure 1

Which one of the following approaches to minimize cardiac risk with HSCT is most in line with the current available evidence?

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