Cardiovascular (CV) Mortality Among Adults Diagnosed with Leukemias: A Retrospective Cohort Study
Authors: Ayaz Ahsan , Naqvi Syed Arsalan , Farooq Saad , Sickora Kathryn , Wazir Muhammad Hisham , Hajj Mahmoud El , Lateef Tashifa S , Masood Adeel , Amin Saher , Rajkumar Christopher , Patel Mehul , Husnain Muhammad , Riaz Irbaz Bin , Mir Sajid Ahmad 
Published: December 2023

Background
CV mortality has been recognized as the preventable cause of death in most cancers. However, there is a scarcity of data exploring CV mortality in adults diagnosed with leukemia. Hence, understanding the timing, and quantifying the magnitude of CV mortality can facilitate strategies to reduce the burden of mortality in these patients.
Methods
Surveillance, Epidemiology, and End Results (SEER) database (2004-2018) was queried to obtain CV mortality (defined as deaths due to heart diseases, hypertension, cerebrovascular diseases, atherosclerosis, and aortic aneurysm and dissection) in adults (&gt;18 years of age) diagnosed with leukemias including acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myeloid leukemia (AML), and chronic myeloid leukemia (CML). Standardized mortality ratios (SMRs) were calculated. SMR was defined as the observed deaths from each category divided by the expected number of deaths in the age-matched US population for the same period. SMR &gt;1 indicated increased while &lt;1 indicated decreased mortality. SMR was presented by latency periods of &lt;2, 2-5, and &gt;5 years after the initial diagnosis of leukemias and stratified by age (&lt;50 years, 50-70 years, &gt;70 years), race (White, Black, Asian/Pacific Islander, Native American), ethnicity (Hispanic, Non-Hispanic), and marital status (married vs single/divorced/widowed).
Results
This analysis included 120,193 leukemia patients. Of which, 61,763 had lymphocytic leukemia and 58,430 were diagnosed with myeloid leukemia. In overall population, a significant increase in mortality was observed in adults diagnosed with leukemia (SMR: 1.34, 95% CI: 1.27-1.40). The risk of CV death was highest &lt;2 years of initial diagnosis (1.94, 1.87-2.01) as compared to the population who died 2-5 years (1.17, 1.11-1.23) and &gt;5 years (1.07, 1.01-1.14) after the initial diagnosis. In terms of different subgroups, patients aged &lt;50 years observed the highest risk of CV mortality within &lt; 2 years (9.35, 6.54-13.38) compared to patients aged 50-70 years (2.73, 2.45-3.04), and aged &gt;70 years (1.80, 1.73-1.88). Similarly, regarding race, Asians/Pacific islanders had the highest risk of CV mortality (4.41, 3.70-5.26) followed by Blacks (2.58, 2.26-2.94), and Whites (1.85, 1.78-1.92) within &lt;2 years of initial diagnosis. There was a significant increase in observed mortality in Hispanic (2.83, 2.47-3.23) as well as in non-Hispanic (1.90, 1.83-1.97) population within &lt;2 years of initial diagnosis. However, the magnitude was relatively higher in Hispanic as compared to non-Hispanics. The risk of CV death was observed to be higher in single/divorced/widowed patients (2.30, 2.00-2.20) compared to those who were married (1.81, 1.71-1.91). The CV mortality risk remained consistent for all subtypes of leukemias (ALL, CLL, AML and CML) in overall patient population and among subgroups of interest over different latency periods of &lt;2, 2-5, and &gt; 5years after the initial diagnosis. Small sample size in Native Americans precluded any meaningful statistics.
Conclusions:
Risk of CV mortality among adults with leukemia is observed to be highest among younger (&lt;50 years), Asians, Hispanics, and single/divorced/widowed patients, especially within 2 years of initial diagnosis. A risk-adapted approach may be warranted for cardiovascular care in these patients. Targeted cardio-oncological strategies should be aimed at improving CV mortality in patients who are at the highest risk of death.