Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis
Abstract Background Immune checkpoint inhibitor (ICI) myocarditis is associated with significant mortality risk. Electrocardiogram (ECG) changes in ICI myocarditis have strong prognostic value. However the impact of complete heart block (CHB) is not well defined. This study sought to evaluate the im...
| Main Authors: | , , , , , , , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
BMC
2023-09-01
|
| Series: | Cardio-Oncology |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s40959-023-00185-y |
| _version_ | 1797451309660504064 |
|---|---|
| author | Michael P. O’Shea Suganya Arunachalam Karikalan Ali Yusuf Timothy Barry Eiad Habib John O’Shea Michael Killian Eman Baqal Srishti Nayak Rajeev Masson Joerg Hermann Shimoli Shah Chadi Ayoub Hicham El Masry |
| author_facet | Michael P. O’Shea Suganya Arunachalam Karikalan Ali Yusuf Timothy Barry Eiad Habib John O’Shea Michael Killian Eman Baqal Srishti Nayak Rajeev Masson Joerg Hermann Shimoli Shah Chadi Ayoub Hicham El Masry |
| author_sort | Michael P. O’Shea |
| collection | DOAJ |
| description | Abstract Background Immune checkpoint inhibitor (ICI) myocarditis is associated with significant mortality risk. Electrocardiogram (ECG) changes in ICI myocarditis have strong prognostic value. However the impact of complete heart block (CHB) is not well defined. This study sought to evaluate the impact of CHB on mortality in ICI myocarditis, and to identify clinical predictors of mortality and CHB incidence. Methods We conducted a retrospective cohort study of patients with ICI myocarditis at three Mayo Clinic sites from 1st January 2010 to 31st September 2022 to evaluate mortality rates at 180 days. Clinical, laboratory, ECG, echocardiographic, and cardiac magnetic resonance imaging (CMR) characteristics were assessed. Cox and logistic regression were performed for associations with mortality and CHB respectively. Results Of 34 identified cases of ICI myocarditis, 7 (20.6%) had CHB. CHB was associated with higher mortality (HR 7.41, p = 0.03, attributable fraction 86.5%). Among those with CHB, troponin T (TnT) < 1000 ng/dL, low white blood cell count and high ventricular rate at admission were protective. There was trend towards increased survival among patients who underwent permanent pacemaker insertion (p = 0.051), although most experienced device lead complications. Factors associated with development of CHB included prolonged PR and QRS intervals and low Sokolow Lyon Index. Where these were normal and TnT was < 1000 ng/dL, no deaths occurred. Impaired myocardial longitudinal strain was sensitive for ICI myocarditis but was not prognostically significant. Conclusion There is a strong temporal association between CHB and early mortality in people with ICI myocarditis. Focusing on arrhythmogenic complications can be helpful in predicting outcomes for this group of critically ill individuals. |
| first_indexed | 2024-03-09T14:51:51Z |
| format | Article |
| id | doaj.art-0093e14df3a8402c981bc3367454cc67 |
| institution | Directory Open Access Journal |
| issn | 2057-3804 |
| language | English |
| last_indexed | 2024-03-09T14:51:51Z |
| publishDate | 2023-09-01 |
| publisher | BMC |
| record_format | Article |
| series | Cardio-Oncology |
| spelling | doaj.art-0093e14df3a8402c981bc3367454cc672023-11-26T14:22:36ZengBMCCardio-Oncology2057-38042023-09-019111010.1186/s40959-023-00185-yComplete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditisMichael P. O’Shea0Suganya Arunachalam Karikalan1Ali Yusuf2Timothy Barry3Eiad Habib4John O’Shea5Michael Killian6Eman Baqal7Srishti Nayak8Rajeev Masson9Joerg Hermann10Shimoli Shah11Chadi Ayoub12Hicham El Masry13Department of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicSaint James’s HospitalDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicMayo Clinic RochesterDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicDepartment of Cardiovascular Medicine, Mayo ClinicAbstract Background Immune checkpoint inhibitor (ICI) myocarditis is associated with significant mortality risk. Electrocardiogram (ECG) changes in ICI myocarditis have strong prognostic value. However the impact of complete heart block (CHB) is not well defined. This study sought to evaluate the impact of CHB on mortality in ICI myocarditis, and to identify clinical predictors of mortality and CHB incidence. Methods We conducted a retrospective cohort study of patients with ICI myocarditis at three Mayo Clinic sites from 1st January 2010 to 31st September 2022 to evaluate mortality rates at 180 days. Clinical, laboratory, ECG, echocardiographic, and cardiac magnetic resonance imaging (CMR) characteristics were assessed. Cox and logistic regression were performed for associations with mortality and CHB respectively. Results Of 34 identified cases of ICI myocarditis, 7 (20.6%) had CHB. CHB was associated with higher mortality (HR 7.41, p = 0.03, attributable fraction 86.5%). Among those with CHB, troponin T (TnT) < 1000 ng/dL, low white blood cell count and high ventricular rate at admission were protective. There was trend towards increased survival among patients who underwent permanent pacemaker insertion (p = 0.051), although most experienced device lead complications. Factors associated with development of CHB included prolonged PR and QRS intervals and low Sokolow Lyon Index. Where these were normal and TnT was < 1000 ng/dL, no deaths occurred. Impaired myocardial longitudinal strain was sensitive for ICI myocarditis but was not prognostically significant. Conclusion There is a strong temporal association between CHB and early mortality in people with ICI myocarditis. Focusing on arrhythmogenic complications can be helpful in predicting outcomes for this group of critically ill individuals.https://doi.org/10.1186/s40959-023-00185-yImmune checkpoint inhibitorsComplete heart blockMyocarditisPharmacoepidemiologyArrhythmias |
| spellingShingle | Michael P. O’Shea Suganya Arunachalam Karikalan Ali Yusuf Timothy Barry Eiad Habib John O’Shea Michael Killian Eman Baqal Srishti Nayak Rajeev Masson Joerg Hermann Shimoli Shah Chadi Ayoub Hicham El Masry Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis Cardio-Oncology Immune checkpoint inhibitors Complete heart block Myocarditis Pharmacoepidemiology Arrhythmias |
| title | Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis |
| title_full | Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis |
| title_fullStr | Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis |
| title_full_unstemmed | Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis |
| title_short | Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis |
| title_sort | complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis |
| topic | Immune checkpoint inhibitors Complete heart block Myocarditis Pharmacoepidemiology Arrhythmias |
| url | https://doi.org/10.1186/s40959-023-00185-y |
| work_keys_str_mv | AT michaelposhea completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT suganyaarunachalamkarikalan completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT aliyusuf completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT timothybarry completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT eiadhabib completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT johnoshea completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT michaelkillian completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT emanbaqal completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT srishtinayak completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT rajeevmasson completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT joerghermann completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT shimolishah completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT chadiayoub completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis AT hichamelmasry completeheartblockisasignificantpredictorofmortalityinimmunecheckpointinhibitormyocarditis |