Table 3.

Cardiovascular Preventative and Supportive Care Interventions for CAR T-Cell Therapy

Pre T cell Infusion

1. Comprehensive assessment that includes a detailed cardiovascular (CV) history and physical examination including estimation of exercise tolerance, screening for CV disease risk factors (hypertension, diabetes, hyperlipidemia, obesity, smoking) and baseline 12 lead electrocardiography (ECG), analogous to assessment prior to cardiotoxic treatment. Cardio-oncology consult for further evaluation and risk stratification as per Figure 1

2. Baseline echocardiogram to evaluate cardiac structure and function especially in older patients, those with impaired exercise tolerance, known structural heart disease, abnormal baseline ECGs, suggestive symptoms or multiple CV risk factors

3. Consider evaluation for ischemia in patients with poor exercise tolerance or any exertional symptoms

4. Consider tapering antihypertensive medications prior to infusion

During Therapy

1. Continue low dose aspirin in patients with known coronary artery disease / percutaneous coronary intervention until platelets <30,000(35)

2. Monitor vital signs every 4 hours with attention to fevers, hypotension and tachycardia; every 2 hours in patients with fever and tachycardia. Telemetry monitoring for patients found to have persistent tachycardia or arrhythmia

3. Maintenance of adequate hydration. Initiate replacement IV fluids for patients with poor oral intake or high insensible losses to maintain euvolemia

4. Initiate volume resuscitation with IV fluid for sustained hypotension

5. Consider intensive care monitoring if hypotension recurs after 1st fluid bolus or HR persistently >125 bpm.

6. ECG, troponin, and echocardiogram for persistent hypotension not responsive to intravenous fluid boluses. Consider intensive care unit transfer for hemodynamic management

7. Initiate vasopressor support if BP unresponsive to 1st fluid resuscitation. Discuss with CAR-T team regarding the use of tocilizumab.

8. Consider invasive hemodynamic monitoring for patients with shock who have reduced LV systolic function and/or refractory to low dose vasopressor.