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Association of early electrical changes with cardiovascular outcomes in immune checkpoint inhibitor myocarditis

John R Power1, Joachim Alexandre2, Arrush Choudhary3

  • 1UC San Diego Health, San Diego, CA, 92103, USA.

Archives of Cardiovascular Diseases
|May 20, 2022
PubMed

Insights

Early electrocardiogram findings in immune-checkpoint inhibitor-associated myocarditis (ICI-myocarditis) predict mortality. Specific ECG abnormalities like heart block and Q waves indicate a higher risk of death and arrhythmias in ICI-myocarditis patients.

Area of Science:

  • Cardiology
  • Immunology
  • Oncology

Background:

  • Immune-checkpoint inhibitor-associated myocarditis (ICI-myocarditis) can cause arrhythmias, but the prognostic significance of early electrocardiogram (ECG) findings remains unclear.
  • While treatment strategies for ICI-myocarditis and acute cellular rejection (ACR) after cardiac transplantation are similar, their respective arrhythmia burdens are not well-defined.

Purpose of the Study:

  • To investigate the association between specific ECG findings in ICI-myocarditis and myocarditis-related mortality.
  • To evaluate the link between ECG abnormalities and life-threatening arrhythmias in ICI-myocarditis patients.
  • To compare the arrhythmia burden in ICI-myocarditis with that of ACR following cardiac transplantation.

Main Methods:

  • A retrospective analysis of 125 ICI-myocarditis cases from 49 hospitals worldwide.
  • Inclusion of 50 cases of grade 2R or 3R acute cellular rejection (ACR) as a comparator group.
  • ECG interpretations by two blinded cardiologists, followed by statistical analysis using adjusted hazard ratios (aHRs) to assess associations with mortality and arrhythmias.

Main Results:

  • Patients with complete heart block or life-threatening arrhythmias showed a significantly higher risk of myocarditis-related mortality (aHR(sh) 3.29 and 6.82, respectively).
  • Admission ECG findings of pathological Q waves, low QRS voltage, and Sokolow-Lyon index were independently associated with increased myocarditis-related mortality.
  • ICI-myocarditis exhibited a higher incidence of life-threatening arrhythmias (12.0% vs 2%) and third-degree heart block (15.2% vs 0%) compared to ACR.

Conclusions:

  • Specific ECG abnormalities in ICI-myocarditis, including ventricular tachycardias, heart block, low-voltage, and pathological Q waves, are significant predictors of myocarditis-related mortality and life-threatening arrhythmias.
  • The overall burden of arrhythmias in ICI-myocarditis is substantially greater than that observed in acute cellular rejection after heart transplantation.
Abstract

Keywords:
Cardio-oncologieCardio-oncologyElectrophysiologyImmunotherapyImmunothérapieMyocarditeMyocarditisÉlectrophysiologie

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