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Cited by 165Cancer Immunotherapy and BiomarkersViral Infections and Immunology ResearchChemotherapy-induced cardiotoxicity and mitigation

Cardiomuscular Biomarkers in the Diagnosis and Prognostication of Immune Checkpoint Inhibitor Myocarditis

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Lehmann, Lorenz H., Heckmann, Markus B., Bailly, Guillaume, Finke, Daniel, Procureur, Adrien, Power, John R., Stein, Frederic, Bretagne, Marie +55 more·2023·Circulation
DOI 10.1161/circulationaha.123.062405PMC PMC10527069
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Abstract

BACKGROUND: Immune checkpoint inhibitors (ICIs) are approved for multiple cancers but can result in ICI-associated myocarditis, an infrequent but life-threatening condition. Elevations in cardiac biomarkers, specifically troponin-I (cTnI), troponin-T (cTnT), and creatine kinase (CK), are used for diagnosis. However, the association between temporal elevations of these biomarkers with disease trajectory and outcomes has not been established. METHODS: We analyzed the diagnostic accuracy and prognostic performances of cTnI, cTnT, and CK in patients with ICI myocarditis (n=60) through 1-year follow-up in 2 cardio-oncology units (APHP Sorbonne, Paris, France and Heidelberg, Germany). A total of 1751 (1 cTnT assay type), 920 (4 cTnI assay types), and 1191 CK sampling time points were available. Major adverse cardiomyotoxic events (MACE) were defined as heart failure, ventricular arrhythmia, atrioventricular or sinus block requiring pacemaker, respiratory muscle failure requiring mechanical ventilation, and sudden cardiac death. Diagnostic performance of cTnI and cTnT was also assessed in an international ICI myocarditis registry. RESULTS: Within 72 hours of admission, cTnT, cTnI, and CK were increased compared with upper reference limits (URLs) in 56 of 57 (98%), 37 of 42 ([88%] P =0.03 versus cTnT), and 43 of 57 ([75%] P <0.001 versus cTnT), respectively. This increased rate of positivity for cTnT (93%) versus cTnI ([64%] P <0.001) on admission was confirmed in 87 independent cases from an international registry. In the Franco–German cohort, 24 of 60 (40%) patients developed ≥1 MACE (total, 52; median time to first MACE, 5 [interquartile range, 2–16] days). The highest value of cTnT:URL within the first 72 hours of admission performed best in terms of association with MACE within 90 days (area under the curve, 0.84) than CK:URL (area under the curve, 0.70). A cTnT:URL ≥32 within 72 hours of admission was the best cut-off associated with MACE within 90 days (hazard ratio, 11.1 [95% CI, 3.2–38.0]; P <0.001), after adjustment for age and sex. cTnT was increased in all patients within 72 hours of the first MACE (23 of 23 [100%]), whereas cTnI and CK values were less than the URL in 2 of 19 (11%) and 6 of 22 (27%) of patients ( P <0.001), respectively. CONCLUSIONS: cTnT is associated with MACE and is sensitive for diagnosis and surveillance in patients with ICI myocarditis. A cTnT:URL ratio <32 within 72 hours of diagnosis is associated with a subgroup at low risk for MACE. Potential differences in diagnostic and prognostic performances between cTnT and cTnI as a function of the assays used deserve further evaluation in ICI myocarditis.

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  • In ICI myocarditis, troponin T is specifically associated with adverse outcomes.

    “In ICI myocarditis, troponin T is specifically associated with adverse outcomes”

    From Autoimmune Myocarditis, Old Dogs and New Tricks. (2024) · cites this paper as [235]

  • Troponin T is more sensitive for surveillance in patients with ICI myocarditis.

    “and is more sensitive for surveillance in patients.”

    From Autoimmune Myocarditis, Old Dogs and New Tricks. (2024) · cites this paper as [235]

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Cited by

Sorted by citations

Authors
Lehmann, L. H., Heckmann, M. B., Bailly, G., Finke, D., Procureur, A., Power, J. R., Stein, F., Bretagne, M., Ederhy, S., Fenioux, C., Hamwy, O., Funck-Brentano, E., Romano, E., Pieroni, L., Münster, J. P., Allenbach, Y., Anquetil, C., Leonard-Louis, S., Palaskas, N. L., Hayek, S. S., Katus, H. A., Giannitsis, E., Frey, N., Kaya, Z., Moslehi, J., Prifti, E., Salem, J.-E., Thuny, F., Crusz, S., Asnani, A., Karlstaedt, A., Rocher, F., Paven, E., Obeid, M., Chan, W. T., Flint, D. L., Arangalage, D., Courand, P.-Y., Nicol, M., Cariou, E., Tamura, Y., Florido, R., Francis, S., Leong, D., Piriou, N., Akhter, N., Shahneen, S., Itzhaki Ben Zadok, O., Habib, M., Vachhani, P., Peretto, G., Zhu, H., Laufer Perl, M., Aras, M., Alexandre, J., Lenneman, C., Levenson, J., Deswal, A., Zaha, V. G., Gaughan, E. M., Ewer, S., Johnson, D., & Baldassarre, L. A.
Affiliations
  • German Cancer Research Center (DE)
  • University Hospital Heidelberg (DE)
  • Inserm (FR)
  • University of California San Diego (US)
  • Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Department of Cardiology, UNICO-GRECO Cardio-oncology program, Saint-Antoine Hospital, Paris, France (S.E.).
  • Hopital Ambroise-Paré, Neuilly Sur Seine, France (E.F-B.).
  • Université Paris Sciences et Lettres (FR)
  • Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Biochimie- Hormonologie, Hôpital Tenon, Paris, France (L.P.).
  • University of California, San Francisco (US)
  • Neuropathology (S.L-L.), Sorbonne Université, Assistance Publique-Hôpitaux de Paris, INSERM, Hôpital Pitié-Salpêtrière, France.
  • The University of Texas MD Anderson Cancer Center (US)
  • University of Michigan (US)
  • Assistance Publique – Hôpitaux de Paris (FR)
Corresponding author
  • Lehmann, Lorenz H.
  • Salem, Joe-Elie
ORCID
Venue
Circulation
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2023-08-08
Volume
148
Issue
6
Pages
473-486
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
DOI
10.1161/circulationaha.123.062405
PMC
PMC10527069
OpenAlex
W4380729801
Cited by
165
References
2
Citations by year
2026: 55 · 2025: 58 · 2024: 42 · 2023: 10
FWCI
20.04
Type
journal article
Language
en
Open access
Locations
  • Circulation (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • HAL (submittedVersion, other-oa)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • Deutsche Forschungsgemeinschaft
  • Bundesministerium für Bildung und Forschung
  • National Institutes of Health (4r00hl141702-04)
  • National Heart, Lung, and Blood Institute (R00-HL-141702, R01HL141466, R01HL160688, R01HL156021, R01HL155990)
  • National Cancer Institute (P01CA261669)
Topics
  • Health Sciences › Medicine › Oncology › Cancer Immunotherapy and Biomarkers
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Viral Infections and Immunology Research
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Chemotherapy-induced cardiotoxicity and mitigation
Keywords
immune checkpoint inhibitor-associated myocarditis, cardiac troponin I, cardiac troponin T, creatine kinase, cardiac biomarkers, prognostic factors, diagnostic accuracy, cardio-oncology, sudden cardiac death, heart failure, ventricular arrhythmias, atrioventricular block
MeSH terms
Immune Checkpoint Inhibitors, Creatine Kinase, Humans, Myocarditis, Prognosis, Biomarkers, Troponin T

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