Hypertension in hematologic malignancies and hematopoietic cell transplantation: An emerging issue with the introduction of novel treatments

Abstract

Blood pressure levels are directly associated with cardiovascular and cerebrovascular morbidity and mortality, rendering arterial hypertension a major public health problem affecting almost 1 billion people worldwide. Several models have been used for cardiovascular risk prediction based on traditional cardiovascular risk factors. Among them, hypertension represents a factor that may be triggered by distinct pathogenetic mechanisms in specific disease populations. Accumulating evidence points towards an increased incidence of hypertension in patients with hematologic malignancies and recipients of hematopoietic cell transplantation. However, the role of hypertension in these entities remains under-reported in the relevant literature. In the complex setting of life-threatening conditions that need immediate and aggressive treatment, conditions that are common and easy to diagnose such as hypertension, may be neglected by treating physicians. However, hypertension may represent a key diagnostic and prognostic clinical finding in acute syndromes, such as thrombotic microangiopathy. Furthermore, hypertension may arise as a late effect of long-term survivors leading to increased morbidity and mortality across all age groups. Our concise review focuses on incidence, pathophysiology and management of hypertension in patients following hematopoietic cell transplantation and treatment for hematologic malignancies.

Introduction

Hypertension is a public health challenge of global proportions. Despite the continuing development of numerous effective and well-tolerated pharmacological treatments, high blood pressure continues to represent a leading cause of cardiovascular morbidity and mortality worldwide [1]. Hypertension affects almost one billion people worldwide [2] and is accompanied by tremendous health care costs in the long-term, as it typically predates the development of coronary artery disease, heart failure, atrial fibrillation and stroke. Since its detrimental effects on the vasculature, the heart and other target organs progress gradually without any alarming or apparent symptoms, the designation “silent killer” has been ascribed to hypertension. Hence, early identification and prompt treatment of high blood pressure emerges as extremely important to lower the risk for cardiovascular disease, especially in certain patient populations with increased cardiovascular risk [3,4].

Continuing progress in hematologic therapeutics has remarkably improved long-term survival rates over the past decades for patients with hematologic malignancies and recipients of hematopoietic cell transplantation (HCT). In the complex setting of life-threatening syndromes that need immediate and aggressive treatment, conditions such as hypertension, which are common but contribute importantly to increased cardiovascular risk, may be underestimated by treating physicians. However, hypertension may not only be a key diagnostic and prognostic clinical finding in acute syndromes, such as thrombotic microangiopathy, but also a common clinical characteristic in long-term survivors. Recently, acute and delayed toxicities related to the primary disease and the applied therapeutics have emerged during the long-term follow-up of these patients. Accumulating evidence points towards an increased incidence of hypertension in survivors of hematological malignancies and HCT [5]. Cardiovascular toxicities, including hypertension, may have a detrimental effect on their quality of life and represent a major contributor to early mortality [6,7]. Hence, hypertension in the management and long-term follow-up of these patients should not be regarded as an innocent bystander, but rather as a hazardous epiphenomenon.

Our concise review focuses on incidence, pathophysiology and management of hypertension in patients following HCT and treatment for hematologic malignancies. For this purpose, a PubMed search was performed using the following keywords: hypertension, cardiovascular risk, hematological malignancy, hematopoietic cell transplantation. Data presentation has been organized according to different clinical conditions and hematology treatment modalities.