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Implementation of Cardiac Monitoring and Prevention Strategies Prior to CAR-T Cell Therapy to Prevent Cardiac Complications

Article Information

Anoshia Afzal1, Maria Kamal1, Nabeel Hussain2, Aimen Iqbal3, Ali Jaan4*

1Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, United States

2Department of Internal Medicine, Saba University School of Medicine, Saba

3Bahria University Medical and Dental College, Karachi, Pakistan

4Department of Internal Medicine, King Edward Medical University, Pakistan

*Corresponding author: Ali Jaan, Department of Internal Medicine, King Edward Medical University, Pakistan

Received: 22 February 2021; Accepted: 02 March 2021; Published: 04 March 2021

Citation: Anoshia Afzal, Maria Kamal, Nabeel Hussain, Aimen Iqbal, Ali Jaan. Implementation of Cardiac Monitoring and Prevention Strategies Prior to CAR-T Cell Therapy to Prevent Cardiac Complications. Archives of Internal Medicine Research 4 (2021): 046-047.

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Keywords

CAR-T-Cell Therapy

CAR-T-Cell Therapy articles

Article Details

Dear editor,

We would like to highlight some facts recently seen with Chimeric antigen receptor (CAR)-T-cell therapy and suggest a few recommendations in order to prevent significant mortality and morbidity due to cardiac complications after CAR T-cell therapy. CAR-T-cell therapy has been a relatively new and novel treatment for certain hematological and solid organ malignancies and has proven to be beneficial in treating some refractory malignancies. However, some concerning life threatening toxicities have been identified which need effective preventive strategies. Some of the reported complications include cytokine-release syndrome (CRS), which is the most frequently observed complication followed by CAR-T-cell-related encephalopathy syndrome (CRES) and rarely, fulminant hemophagocytic lymphohistiocytosis (HLH) and CAR-T-cell therapy mediated myocarditis [1-3]. The most common symptoms which point towards an impending life-threatening cardiac complication are reported to be mostly systemic and overlapping for CRS and myocarditis including hemodynamic instability (hypotension, hypoxia, tachycardia, arrhythmias), nausea, vomiting, pulmonary edema, and renal failure secondary to compromising circulation. Multiple treatment guidelines exist for the management of post-CAR T-cell therapy CRS such as treatment with antipyretic, antiemetics, steroids, IL-6 blocker (tocilizumab), and inotropic support, as CRS is a commonly reported complication [1, 2] but there are no recommendations for the prevention of myocarditis as only a few cases have been reported [3].

Proper guidelines should be established for cardiac monitoring before and after CAR T cell therapy to prevent myocarditis and sudden cardiac arrest. All patients should undergo checking for their basic cardiotoxicity profile prior to receiving any form of immunotherapy and certain prevention strategies should be designed to reduce the incidence of cardiac events and sudden cardiac deaths [3-5]. Serum biomarkers (troponins, NT-pro brain natriuretic peptide) can help in cardiac surveillance along with echocardiography and advanced cardiac imaging modalities like cardiac magnetic resonance (CMR) imaging might be useful while developing cardioprotective therapies [6]. Since most of the cardiac toxicity occurs quite rapidly after CAR T cell therapy, designed strategies should consider the timing of toxicity alongside the fact that there might be some delayed consequences that haven’t been reported yet, and more surveillance is required to assess those delayed complications. The highlight of this letter is to improve the overall cardiovascular outcome in patients who receive CAR T-cell therapy and it is only possible if there are effective strategies to tackle it [6, 7].

References

  1. Neelapu SS, Tummala S, Kebriaei P, et al. Chimeric antigen receptor T-cell therapy - assessment and management of toxicities. Nat Rev Clin Oncol 15 (2018): 47-62.
  2. Maude SL, Barrett D, Teachey DT, et al. Managing cytokine release syndrome associated with novel T cell-engaging therapies. Cancer J 20 (2014): 119-122.
  3. Afzal A, Farooque U, Gillies E, et al. T-cell Therapy-Mediated Myocarditis Secondary to Cytokine Release Syndrome. Cureus 12 (2020): e10022.
  4. Ghosh AK, Chen DH, Guha A, et al. CAR T cell therapy-related cardiovascular outcomes and management: systemic disease or direct cardiotoxicity?. J Am Coll Cardiol 2 (2020): 97-109.
  5. Brudno JN, Kochenderfer JN. Toxicities of chimeric antigen receptor T cells: recognition and management. Blood 127 (2016): 3321-3330.
  6. Ghosh AK, Chen DH, Guha A, et al. CAR T cell therapy–related cardiovascular outcomes and management. JACC Cardio Oncol 2 (2020): 97-109.
  7. Seraphim A, Westwood M, Bhuva AN, et al. Advanced imaging modalities to monitor for cardiotoxicity. Curr Treat Options Oncol 20 (2019): 73.

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