Preexisting heart failure associated with lower use of anthracyclines and chemotherapy

1. In this longitudinal cohort study of 30 728 patients with diffuse large-B-cell lymphoma, preexisting heart failure at lymphoma diagnosis was present in 4266 patients and associated with lower anthracyclines use.

2. At one year, lymphoma mortality was 41.8% in patients with preexisting heart failure and 29.6% in patients without preexisting heart failure. 

Evidence Rating Level: 2 (Cohort)

Study Rundown: Anthracycline-based chemotherapy is a highly effective, first-line treatment for diffuse large B-cell lymphoma (DLBCL). While this treatment is effective, it may also contribute to cardiac injury and subsequently an increased risk of clinical heart failure (HF). This study aimed to assess the prevalence of HF in older patients at the time of DLBCL diagnosis and the association of preexisting HF with the use of anthracycline-based chemotherapy. Individuals aged 65 years and older with newly diagnosed DLBCL from 2000 to 2015 were included. The primary exposure was preexisting HF in the year prior to DLBCL diagnosis. The primary outcome was anthracycline-based chemotherapy treatment. Secondary outcomes included cardioprotective medications and cause-specific mortality. A total of 30 728 patients with DLBCL were included in this study, of which 4266 patients had preexisting HF at lymphoma diagnosis. Patients with preexisting HF were found to be less likely to receive anthracycline treatment. At one year, lymphoma mortality was 41.8% in patients with preexisting HF and 29.6% without preexisting HF. After adjusting for baseline and time-varying treatment, preexisting HF was associated with higher lymphoma mortality. A major strength of this study was its large sample size. However, due to the use of claims data and a lack of access to clinical data such as left ventricular ejection fraction, symptom burden, and biomarkers, a limitation of this study was that HF was not categorized into HF with reduced or preserved ejection fraction.

Click to read the study in JAMA Cardiology

Click to read an accompanying invited commentary in JAMA Cardiology

Relevant Reading: Upfront dexrazoxane for the reduction of anthracycline-induced cardiotoxicity in adults with preexisting cardiomyopathy and cancer: a consecutive case series

In-Depth [retrospective cohort]: This study assessed the prevalence of preexisting HF in older patients with DLBCL and its association with treatment patterns and outcomes. Data was obtained from the Surveillance, Epidemiology, and End Results (SEER) Medicare registry from 1999 to 2016. Individuals included in this study were 65 years and older with newly diagnosed DLBCL from 2000 to 2015. The primary exposure was preexisting HF in the year prior to DLBCL diagnosis. The primary outcome was anthracycline-based treatment. Secondary outcomes included cardioprotective medications and cause-specific mortality. The associations between preexisting HF and anthracycline-based treatment were estimated using multivariable logistic regression. The associations between preexisting HF and cause-specific mortality were evaluated using cause-specific Cox proportional hazards models with adjustment for comorbidities and type of cancer treatment. A total of 30 728 patients with DLBCL (mean age [SD], 77.8 [7.2] years; 15 474 [50.4%] female) were included in this study. Preexisting HF at lymphoma diagnosis was present in 4266 patients (13.9%). Patients with preexisting HF were found to be less likely to receive anthracycline treatment (odds ratio [OR], 0.55; 95% CI, 0.49-0.61). The one-year lymphoma mortality was 41.8% (95% CI, 40.5-43.2) with preexisting HF and 29.6% (95% CI, 29.0% – 30.1%) without preexisting HF. After adjusting for baseline and time-varying treatment, preexisting HF was associated with higher lymphoma mortality (hazard ratio, 1.24; 95% CI, 1.18 – 1.31). Preexisting HF was associated with lower odds of receiving any chemotherapy (OR, 0.89; 95% CI, 0.82-0.96) and lower odds of receiving anthracyclines in the first year after diagnosis (OR, 0.55; 95% CI, 0.49 – 0.61). Preexisting HF was also associated with higher cardiovascular mortality in models adjusted for clinical, social determinants of health, and hospital-level variables (HR, 1.82; 95%CI, 1.65-2.00) compared with patients without preexisting HF.

Image: PD

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