Cardiopulmonary complications of DIC in AML: A nationwide inpatient study Free

Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults, accounting for approximately 80% of adult cases [1]. Despite major advancements in the treatment and supportive care of AML, early mortality remains markedly elevated, often driven by complications such as disseminated intravascular coagulation (DIC). DIC is a severe coagulopathy commonly seen in AML and is associated with a spectrum of clinical complications, predominantly affecting the cardiopulmonary system. To reduce mortality in AML, it is essential to better understand DIC and its associated complications, particularly their contribution to adverse clinical outcomes. While existing database studies have provided insight into cardiac complications linked to DIC, a significant gap persists in our understanding of pulmonary complications in this context. Our study focuses on addressing this knowledge gap with a goal of informing future risk modification strategies.

Information regarding adult (AGE>18) patients admitted with AML between 2020-2022 was procured from National Inpatient Sample (NIS), using ICD-10-DM codes. The abstracted data was stratified into two groups based on presence and absence of DIC. STATA was employed to perform 1:1 propensity score matching of the two cohorts in respect to age, gender, and comorbidities. Pre and post matching univariate and multivariate logistic and regression analysis was performed to obtain results in the form of odds ratio (OR) with 95% confidence interval (CI).

Out of a total of 66,735 AML patients, 965 had coexisting DIC. When compared to those without DIC, these patients had a higher cerebrovascular accidents.Post-matching, DIC was found to be associated with significantly higher rate of cardiogenic shock (5.18% vs 0.52%; OR=10.49; P=0.013), cardiac arrest (5.18% vs 0.52%; OR=10.49; P=0.029), mortality (44.56% vs 5.70%, OR=13.30; P<0.001), acute respiratory distress syndrome (3.63% vs 0.52%; OR=7.23; P=0.003), pneumonia (26.42% vs 13.99%; OR=2.21, P=0.004), sepsis (44.04% vs 12.95%; OR=5.29; P<0.001), need for inotropic support (12.44% vs 2.59%; OR=5.34; P=0.002), and need for mechanical ventilation (21.76% vs 0.52%; OR=53.40; P<0.001). However, there was no significant difference in incidence of acute MI (3.63% vs 1.04%;OR=3.59; P=0.104), acute HF (4.14% vs 4.14%; OR=1.00; P=1.0), acute pulmonary edema (3.63% vs 1.55%; OR=2.38; P=0.211), pulmonary embolism (3.11% vs 1.55%; OR=2.03; P=0.344), arrhythmias (18.65% vs 16.58%; OR=1.0; P=1.0), bradycardia and AV blocks (1.55% vs 1.55%; OR=1.0; P=01.0), and pericardial effusion (7.25% vs 2.07%; OR=3.69; P=1.0).

The presence of DIC was significantly associated with increased in-hospital mortality. After adjusting for age, sex, and comorbidities through propensity score matching, the odds of death were more than thirteen times higher in AML patients with DIC than without.. DIC was linked with adverse cardiopulmonary outcomes, including, ARDS, pneumonia, sepsis,cardiogenic shock, and cardiac arrest. This may be due to a multifactorial etiology of leukemic cells expressing procoagulant factors and promoting cytokine release, alongside stimulation of proinflammatory cytokines and endothelial dysfunction. The final result is widespread microvascular thrombosis, ischemia and bleeding. By contrast, outcomes like myocardial infarction, pulmonary edema, and acute respiratory distress syndrome were not statistically significant after matching. This may be explained by potential confounding factors or reflect the multifactorial nature of critical illness in this population. Our findings underscore DIC as a critical turning point in AML patients. Recognizing and addressing the associated cardiopulmonary complications early and proactively can significantly improve patient outcomes, offering a more hopeful prognosis.

1.Ten Cate H, Leader A. Management of Disseminated Intravascular Coagulation in Acute Leukemias. Hamostaseologie. 2021 Apr;41(2):120–6. Review indicates a DIC prevalence of 8.5–25% in non-APL AM