SCOPING OUT CARDIOVASCULAR ASSESSMENT ON INITIATION AND SUBSEQUENT MONITORING DURING BTKI THERAPY, AN ERIC INITIATIVE

Background:BTK inhibitors (BTKi) have revolutionized the treatment landscape of chronic lymphocytic leukemia (CLL),leading to improved outcomes. However, BTKis are also associated with cardiovascular (CV) adverse eventsthat limit their use.Aims:We aimed to provide a snapshot of practices about the CV assessment on initiation and subsequentmonitoring during BTKi therapy.Methods:The survey was conducted by ERIC, the European Research Initiative on CLL. Hematologists (HM) responsiblefor managing patients with CLL answered questions regarding their clinical practice.Results:Overall, 84 HM from 32 countries responded. Forty-four (52.4%) are working in centers managing more than100 patients with CLL per year, and 16 (19%), 14 (16.6%) and 10 (12%) in centers managing 51-100, 21-50 andless than 20 patients, respectively. Most HM (51, 60%) mentioned changing their clinical practice in terms ofCV assessment for BTKis in the last 3 years.Most (79, 94%) were aware of CV risk estimation in all patients before initiating BTKi, while 72 (85.7%) routinelycarry out cancer therapy related-CV toxicity assessment (CTR-CVT) prior to initiating BTKis as suggested by theEuropean Society of Cardiology (ESC).For most, CTR-CVT includes taking CV history (66, 91.7%), considering the CV risk factors (61, 84.7%),performing physical examination (59, 81.9%), measuring vital signs (55, 76.4%) and taking a cancer treatmenthistory (50, 69.4%). Among those performing additional tests, 51 (69.9%) perform an electrocardiogram, 44(60.3%) a transthoracic echocardiogram, 41 (56.1%) calculate eGFR, 37 (50.7%) check the lipid profile, 33(45.2%) fasting glucose/HBA1c, 29 (39.7%)(NT-pro) BNP, and 19 (26%) troponin levels.Interestingly, 79 (94%) HM try to identify high-risk patients for CVT before initiating BTKi therapy. For 40 HM(50.6%), patients with a history of ventricular arrhythmia (VA) or severe hypertension (HT) or severe congestiveheart failure (CHF) are considered high risk, while 28 (35.4%) defined patients with HT or atrial fibrillation (AF)or CHF or history of myocardial infarction as high risk. Finally, 15 (20%) HM consider as high-risk patients withany CV risk factor.Only 49 (58.3%) HM were aware of ESC guidance on managing CV risk factors. However, 79 (94%) were willingto use specific guidance before initiating BTKis.Specific CV risk factors were considered a contraindication to BTKi for 46 (55.4%) HM. VA, CHF, severe HT, AFand family history of sudden cardiac death were considered contraindications for 27 (58.7%), 15 (32.6%), 10(21.7%), 6 (13%) and 6 (13%) HM, respectively.In terms of preference for a specific BTKi, 30 (35.7%) prefer second-generation BTKi in all patients with CV riskfactors, 20 (23.8%) avoid all BTKis in patients with high CV risk and prefer second-generation BTKi in all otherpatients, 15 (17.8%) prefer second-generation BTKis in all patients with high CV risk, 3 (3.6%) avoid BTKis in patients with any CV risk factors, and 15 (17.8%) do not have specific preferences (7/15 due to lack ofexperience with second-generation BTKi).During BTKi treatment, most (72, 85.7%) follow the ESC guidance on monitoring for HT. If HT is diagnosed,most HM (68, 81%) refer the patient to an HT specialist, 11 (13%) manage HT together with an HT specialist,and 5 (6%) manage HT alone.Summary/Conclusion:The importance of assessing the CVT risk before initiating BTKi is well recognized among HM. However, themanagement of CV risk differs significantly despite the existing recommendations. Close collaboration withcardiologists is crucial for tackling the nuances of managing the CV risk of BTKi.