Atrial fibrillation during hematopoietic stem cell transplantation: how often, why, and how we manage it - data from the ARCA-TPH registry
I Gamez Guijarro, A Luna De Abia, N Fernandez Arias, J Ducay Rico, P Remior Perez, A Pardo Sanz, A Chinea Rodriguez, A Sanchez-Tornero De La Cruz, P Herrera Puente, F J Lopez Jimenez, J L Zamorano Gomez, P Agudo QuilezAbstract
Background
Atrial fibrillation (AF) is the most frequent cardiovascular (CV) complication during hematopoietic stem cell transplantation (HSCT), but data on its management in modern HSCT practice remain limited.
Objectives
To evaluate the incidence, risk factors, and management strategies of AF during hospitalization for HSCT and early post-discharge.
Methods
This single-centre, observational cohort study included 394 consecutive patients undergoing autologous or allogeneic HSCT between 2018 and 2022. Demographic, clinical, echocardiographic, and biochemical data were collected.
Results
AF or atrial flutter occurred in 18 patients (4.6%), with similar incidence in autologous (5%) and allogeneic (3.9%) HSCT. No significant differences were observed in baseline clinical or echocardiographic characteristics between patients with and without AF. Mean follow-up of patients developing AF was 3.4 years (SD 1.5 years). During hospitalization, AF was related to CV events such as heart failure (9 (50%) vs 19 (5.1%) patients; p<0.001) and non-CV complications notably acute lung disease (4 (22.2%) vs 16 (4.3%); p=0.009). Inpatient management was heterogeneous: among the 18 patients (4.6%) who developed AF, most (16 (88.9%)) were diagnosed in the first 12 hours from AF onset. Frequency control was the initial in-hospital strategy in 8 patients (44.4%) and rhythm control was preferred initially in 10 patients (55.6%). Anticoagulation decision at discharge was individualized due to comorbidities including thrombocytopenia, with 46.7% anticoagulated upon leaving the hospital. AF recurrence after discharge was uncommon (6.7%) and there were no cardioembolic complications. Among patients discharged without anticoagulation, no thromboembolic events occurred during follow-up, both in low-risk (CHA2DS2-VASc <2) and higher-risk groups. At discharge, all patients were in sinus rhythm, AF recurrence was low (6.7%), and antithrombotic strategies during follow-up were heterogeneous, with no adverse events observed (Figure 1).
Conclusions
AF represents a clinically significant early CV complication during HSCT hospitalization. Rhythm and antithrombotic strategies are heterogeneous. Rhythm control was not preferred initially in half of the patients due to the risk/limitations of anticoagulation in HSCT context, but no cardioembolic events after the episode occurred in either rhythm or frequency control in this registry. There is need for standardized, evidence-based protocols to optimize rhythm control and anticoagulation strategies in HSCT population.