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Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. Today, we're discussing collaborative management of atrial fibrillation in hematology patients. And in this panel today, we have Courtney Estes and Ellen Lazarre. They're both nurse practitioners with UAB Medicine. Ladies, I'm so glad to have you with us today. So, Ellen, I think I'm gonna start with you. I'd like you to kind of set the table for us. What kinds of issues does the hematology patient generally have? What are some of the issues you see with them every day? And what are we discussing here today?

Ellen Lazarre: Yeah, we see a wide range of hematology patients in our practice. They come in and can be acutely sick or even have chronic comorbidities. Some of the cardiac issues that we see might be like hypertension that might be controlled or uncontrolled. We also see, chronic heart failure. Sometimes the patients have that as a comorbidity, but sometimes that's picked up when we start working them up for their new disease, the hemotologic process. We also see patients with AFib that have had that long standing.

They might also have other cardiac tissues likeAa fluter or, they also sometimes can have pulmonary hypertension that we need help sometimes with cardio oncology to help us kind of manage that, get their medicines regulated, help with like fluid balance. And so we work really closely with cardio-oncology and Courtney and Dr. Linneman and all the team members. They're great to Get patients in quickly, because some of these patients, live far out and don't always have great primary care or, specialty, physicians.

And we see the patients in the clinic, but we also see patients in the hospital. And that team is also great cardio oncology to help manage those patients in the hospital as well.

Melanie Cole (Host): Well, thank you for that. So Courtney I'd like you to give us an atrial fibrillation overview. Tell us a little bit about the prevalence of AFib in these patients and a brief overview in general of AFib and what you see in the trends?

Courtney Estes: So atrial fibrillation is a type of like super ventricular arrhythmia that causes this irregular heartbeat. And as Ellen mentioned, a lot of the oncology patients may have had a chronic AFib issue or we discover it, and some of the medications or drugs they're needing for their treatments. And so it's just this arrhythmia that has these chaotic impulses from the top part of the heart. And sometimes it can be really fast. And so, we look ways to manage that, there's different types of AFib. It can come and go, it could be persistent or it could be permanent.

And so we really just weigh the risks and benefits with the patients on their therapies. And just, some oversight, there's a lot of risk for atrial fibrillation, risk factors of getting a atrial fibrillation. And so it's common really in the aging process, those at the age of 60 or older, typically one in 25, have a risk of getting atrial fibrillation. And that becomes, even a higher risk as we get even older in the 80 year old age, and older, demographics, one in 10 have a risk of getting atrial fibrillation. And so, with that being said, atrial fibrillation, because it's this erratic rhythm, there's a high risk of blood clots forming.

And then, we have to really be on high alert because then that poses a risk for stroke. And so we screen the patients, we use different formulas and try to really weigh the risk and benefit and how we're gonna manage the patient with atrial fibrillation. And so it's a process of just constant communication with the patient, talking to them about their quality of life and their desires while they're on the treatments for their cancer as well. And we really follow what we call a Chad's staff score. And typically, a score of one or less, we're just having conversations with the patient.

Depending on their lab counts depending on their other potential comorbidities, especially if they have cardiac comorbidities such as high blood pressure, heart failure and things like that, coronary disease, even they probably are already on a baby aspirin. But again, it depends because we're dealing with hematology patients. And so we really have to be mindful of their lab counts and make sure we reduce the risk of bleeding.

So if it's a Chads score that is greater than one, then that's where we get into those conversations of most likely, we're gonna be talking about a blood thinner. but we work really closely with the oncology team, as Ellen mentioned, just to make sure that we're not causing harm. But that we are co-managing the patient, and weighing the risk and benefits on the needed therapies, in the setting of a patient on these medications and new atrial fibrillation or how we're gonna control it. going forward with a new, leukemia diagnosis.

Melanie Cole (Host): Well, there certainly is so many issues at play here. It's a very complex situation. Now, Ellen, speak a little bit more and you can expand on what Courtney said on managing the atrial fibrillation in these patients who may be on some specific medications that can actually cause or exacerbate existing atrial fibrillation. Tell us about some of those medications that can do that, that they might be on for their hematology issues. And what are you doing to do that balance that Courtney was mentioning?

Ellen Lazarre: The evolution of CLL has changed with the new treatments and specifically with the development of the BTK inhibitors or the Brutin tyrosine kinase inhibitors. And we've seen like a shift from Traditional chemotherapy for CLL combined with immunotherapy now to this oral agents alone are sometimes paired with immunotherapy Those BTK inhibitors are widely used and highly effective in a variety of B cell malignancies. one of those drugs that we commonly see and is getting used, widely now as ibrutinib. That's a first line, BTK first generation inhibitor.

This has a higher rate of AFib is what we have seen. and. At times when patients do develop AFib, we're evaluating and considering, do we need a discontinued treatment? Or can we continue? One of the other side effects that we see with that drug can also be hypertension, that might require hypertensive management. We see that hypertension can get worse over time with that agent as well. So, we're always in consultation with cardio-oncology to help manage those patients.

Sometimes we'll just do a good baseline exam and send them to cardio-oncology to do a good workup before we start the ibrutinib, the new drug so that we can, detect changes quickly, and then they've already established care with cardio oncology. Some of the other side effects that we do see with the ibrutinib. It can be like neutropenia, thrombocytopenia, anemia, diarrhea, nausea, musculoskeletal pain, fatigue, bruising, and rashes.

But with the bleeding and the thrombocytopenia, that's where we also, consult with cardio oncology because sometimes we need their help about, management with the antiplatelets or anticoagulation therapies. But another drug that we also use is acalabrutinib and that's a second generation BTK inhibitor. And it's more selective, binding. So the side effects are not, as to severe at times as ibrutinib. it has a overall better safety profile and drug tolerance.

We do see some headache, sometimes GI symptom touches, nausea, diarrhea at times, and you can still have the anemia thrombocytopenia neutropenia. So we still with acalabrutinib work closely with cardio-oncology just for the management of bleeding complications, AFib, if it were to occur. But the good thing about ibrutinib and acalabrutinib is that if the patient does not respond to ibrutinib due to like significant side effects or comorbidities, we can switch the Calabrutinib and it is an effective management treatment option for patients. And typically has a better overall tolerance for patients.

Melanie Cole (Host): Well, thank you for that. So, Courtney, while we're speaking about this, how is hematology and oncology medical management with these comorbidities affecting those treatment decisions? Because there's a lot of cost and benefits that you're weighing with some of these medications that Ellen was discussing. So how does that affect the treatment decisions? and you can even highlight the importance of that collaboration between hematology and oncology when making those decisions.

Courtney Estes: Absolutely. Our motto is cancer doesn't wait. And so we are the, biggest cheerleaders for these patients and we want them to be able to get their treatments in a timely manner, but obviously, in a safe manner too, we don't wanna cause harm. And so, what Ellen was saying, there is a risk of atrial fibrillation with these BTK inhibitors, or commonly there's about 11% risk with the ibrutinib. And so that's when we do see often with patients coming in, we may see them and get a referral from the oncology team for a patient who has known AFib.

But this, drug treatment is, ideal and the best of choice. And so we go ahead and get them in. We follow them closely, do a basic workup. We probably are gonna get a baseline EKG, thyroid, and some labs just to check a few things as well as probably get them on a heart monitor because they may be, like I said earlier, persistent AFib, permanent AFib, or just paroxysmal in and out. And so it helps us to know with typically a 30 day monitor the burden of the atrial fibrillation.

And is the patient being managed appropriately or is this even a new AFib on these drugs, BTK inhibitor drugs, that we really need to step up the game? And so we have to kind of weigh again the risk and benefits one, on our end in cardiology, we've got to screen the patient for their other comorbidity risk. Some patients are not eligible for amiodarone a lot of these, antirrhythmic drugs can have drug interactions with their cancer treatments.

And so we really have to be careful on the drug choices that we choose. There's flucanod, there's sotalol, and you have to think about the risk of worsening, any possible coronary disease or heart failure. And so we go through that protocol and kind of make sure we're making the best approach for drug management. And then ideally, typically they're gonna be most likely on a rate controlled drug, such as Metopalol, maybe even corag. And earlier I mentioned sotalol, so we just screen the patient and make sure that we are providing the safest, but optimized care to protect them in the setting of having atrial fibrillation as well as their risks of potential stroke.

And so that's when we get into the discussions of possibly getting on the blood thinners, but, going back to ibrutinib, it's 11% risk of AFib. And in that case, which means a risk of possible stroke having that, abnormal rhythm. So let alone these drugs, ibrutinib, and then [inaudible]. They have risk of bleeding. And so we really have to weigh the benefits and risk with the patient and have those, patient centered discussions along with the oncology team. And again, our goal is to keep them on their drugs, for their overall benefit and response.

Sometimes there's a setting when these patients have severely low platelets thrombocytopenia, that we need to be thinking about other options such as is it a possibility for ablation? Or even a Watchman device, which is an implanted device that's placed in the left atrium that helps to really just steal that area up and prevent clots from forming? Of course, we have to be mindful that they may need, anticoagulation therapy a month or so after. And so we just really, really work closely with the oncology team and we're so grateful for them.

But we can quickly connect, get a plan for the patient. We have a general patient centered discussion on both sides. So we're all on the same page. We don't wanna skip a beat or delay any therapy. We're trying to just, keep in mind, the best approach for the patient, but the safest approach to have the best controlled atrial fibrillation, because we know it's a potential side effect of these drugs. But how can we keep them on these drugs, but yet have controlled atrial fibrillation and make sure they don't have symptoms with it?

Melanie Cole (Host): So interesting and such a comprehensive approach. I'd like to give you each a chance for a brief, last word. Ellen, I'd like you just to speak about some of the targeted therapies we didn't mention like TKIs for leukemia patients and where those are fitting in as far as this collaborative management and looking at the comorbid conditions, some of which we know are actually exacerbated, made worse, or even caused by the medications and therapies themselves. But are necessary to keep under control, whether it's hypertension or AFib or any of those comorbid conditions.

Ellen Lazarre: The cardio-oncology team is wonderful with TKI treatments as well. So we use those drug classes with some of our chronic myeloid leukemias, or even sometimes our acute, lymphocytic leukemias patients. And those patients are typically on treatment long term, as long as they're responding to it and not developing any resistance, or lack of response to that drug. There's a couple drugs that, we automatically consult cardio-oncology for, one of them is called to Cisigna or norlotinib.

It's a great drug. That's a second generation, TKI. But we have seen as more data continues to come out over the years that it can have a lot of cardiac side effects. So, cardio-oncology is essential. They will do a baseline exam typically on the patient and make sure the blood pressure is well controlled, help us with lipid levels. Make sure those are well controlled to help decrease any stroke risk. They also help us with, Sprycel or dasatinib. That one, we typically see plural effusions at times that has even led at times to pulmonary hypertension.

And cardio oncology is wonderful to help us manage with that because the patient can be very symptomatic with shortness of breath or chest tightness. And so sometimes helping just with Lasix management, and ways to help make the patient comfortable and sometimes repeating echos and EKGs. And they are typically following those patients, routinely at least every six months. The wonderful thing about them is even if we're seeing a patient in clinic and they're having more cardiac symptoms, we can reach out and they're very open and quick to help us adjust the medicines.

And they might do a televisit. They might just reach out to the patient. But they're really great about establishing rapport with the patients and the patients always love going to see them because they're helping them with their immediate symptoms, but they're also helping them, long term. Just prevention wise, helping them monitor their blood pressure. They talk to them about exercise and I mean, that exercise, can be hard sometimes for our patients because they do feel very fatigued, especially if they have any issues with their blood counts or anemia.

But they help encourage staying active, which helps the patient do well overall. So it is been a great collaboration, having cardio-oncology, helps see our patients and has really expanded the care for our patients and just really, added a lot of value to their lives.

Melanie Cole (Host): And Courtney last word to you and what a great topic. You're both so knowledgeable and I can hear how well you work with your patients and the compassion involved. For referring physicians, Courtney, please let them know about when you feel it's important to refer to this collaborative team of hematology, oncology, and even cardiology and how you're all working together for this very important multidisciplinary approach?

Courtney Estes: So I think for us, we have an open door policy. I mean, if there is a question, our doors always open ,phone call away, a text, page, because you just never know some of these symptoms like mentioned, patients have fatigue, low energy, low counts, but a lot of times that can kind of mimic possible typical, coronary syndrome. And so we just, wanna have an open door policy to make sure that we're readily available, especially with these vulnerable patients. They're already, I'm sure under high stress, worried, a lot of anxiety, depression, just sometimes not knowing the trajectory of the cancer.

but we highly rely on the oncology team to co-manage. And like Ellen said, we'll be able to go see the patient in infusion or sometimes try to pop over to the oncology clinic. as far as the referral, I think it's just when in doubt refer, and I think you can never have enough team members on your side for the betterment of the patient and their care, especially a patient with cancer. Because like I said, cancer, doesn't wait and it just takes a lot of hands on deck sometimes to, co-manage their symptom burden or, some of their comorbidities.

So we have a cardiology pool within UAB, that we can request physicians to refer to us, that we check through a message pool frequently. Sometimes patients are rocking on and they've had cancer. They've been on treatments and their medications may not have any indication of a possible cardiotoxic effect but then their treatment plan changes. Perhaps maybe they've progressed or something's changed along the way, and they need a different drug therapy that may cause cardiotoxic effects.

A drug therapy mentioned earlier was immunotherapy. And so, we recommend patients being referred to us if there's a treatment plan change, especially knowing if there's possible cardiac side effects. Such as hypertension risk of, atrial fibrillation, risk of heart attack, heart failure. And so we really rely on depends on especially the oncology team, just to give us a heads up. And they're always so willing to help and work with us very efficiently, to make sure that we keep the focus on the patient. So they don't miss a beat in their treatment.

Melanie Cole (Host): Thank you both so much for joining us today, a physician can refer a patient to UAB medicine by calling the missed line at 1-800-UAB-MIST. Or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.