CARE™ CLL Discussion Series - Part 4

Hematology

20 Dec 2021

Introduction

In this segment, CARE™ Hematology Faculty member, Dr. Matthew Kang (Joseph Brant Hospital) is joined by cardiologist, Dr. Christian Constance (HMR) to discuss management of Cardiovascular AE’s associated with BTKi use in CLL.

Discussion Summary/Highlights

How do you typically screen for, diagnose, and grade atrial fibrillation (afib)?

  • In practice, we typically screen for afib based off patient history and self-reporting.
    • Regular electrocardiograms are not routinely ordered in patients with no symptoms or history to suggest an increased risk
  • For patients on BTKi therapy where afib is a concern additional screening efforts should be taken at every appointment
  • Cardiology perspective: for patients receiving BTKi treatment, EKGs are recommended at baseline and every few months in the first year as 50% of afib patients are asymptomatic making it easy to miss.

How to you approach referral for patients who develop atrial fibrillation? When should discussions on patient management be initiated with the cardiology team?

  • The earlier the cardiology team is consulted, the easier and quicker afib can be controlled

Recent clinical studies on BTKis has brought into focus the relevance of different grades of Afib. How should we be addressing different grades?

  • There is a large difference between patients with grade 1 or 2 and those with grade 3 or 4 (quite rare in 3-4% range)
    • Grade 1 and 2 can often be controlled quickly and in the outpatient setting
  • Major bleeds were a concern initially when considering whether anticoagulants can be used but this has subsided significantly given experience
    • Don’t worry about the afib and let it dictate what you use to treat your patients because the cardio teams can handle it easily in most cases. Well controlled, easily managed, many cardio’s have experience with oncology patient management.

What is your typical approach to managing atrial fibrillation in patients receiving BTKi therapy?

  • Hematologists should use a multilayered approach looking at:
    1. A. what type of anticoagulation required- referral to cardiologist for anticoagulation prescription is recommended
    2. B. Possible considerations for rate control- we will often ask the cardio team to try and avoid calcium channel blockers given drug-drug interactions with BTKi’s. This is where collaboration and communication between hematology and cardiology groups is essential.
  • Afib in the 60-70 year age group is as high as 4% in the general population so it is something the cardiologists are very comfortable managing.
    • Afib with BTKi use can be managed like any other case and many cardiologists now have experience in the cardio-oncology patient management given the use of these agents in recent years

If you have a patient who develops atrial fibrillation would you discontinue BTK inhibitor therapy or would you try to continue the therapy?

  • Approach is varied based on the individual patient scenario
    • If afib develops early with minor/no symptoms- it is generally OK to continue BTKi therapy with referral to local cardiologist
    • With grade 3-4 events where more intensive intervention is required (i.e. pacemaker or hospitalization)- Once cardiology is involved and afib is under control, we have the ability to determine what course of action is best for the patient whether it be dose reduction or discontinuation, or if treatment can be continued safely
  • Hypertension as a risk factor for afib- hypertension is usually picked up well by nurses, but is very important to watch for. If there is one risk factor for afib it is this and dose reductions/discontinuation may be avoided if caught early (grades 1 or 2)