Outcomes of Acute Myeloid Leukemia patients undergoing hematopoietic stem cell transplantation with and without pre-existing heart failure: A national inpatient analysis

Abstract Background: Hematopoietic stem cell transplantation (HSCT) offers curative potential for patients with acute myeloid leukemia (AML), yet its intensive nature poses significant risks for patients with cardiovascular comorbidities. Heart failure (HF), in particular, may predispose patients to a cascade of transplant-related complications. However, data evaluating the inpatient risks associated with HF in AML patients undergoing HSCT remain limited. Methods: We performed a weighted retrospective analysis using the National Inpatient Sample from 2016 to 2022 to identify adult patients hospitalized for HSCT with a diagnosis of AML. Patients were stratified by history of heart failure. The primary objective was to evaluate the association between HF and post-transplant complications using multivariable logistic regression, adjusting for demographics and hospital characteristics. Complications of interest included arrhythmias, respiratory failure, renal injury, and thromboembolic events. Results were reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs), and significance was defined as p < 0.05. Results: Among 8,205 weighted hospitalizations for AML receiving HSCT, 475 patients (5.8%) had a documented history of heart failure. The overall cohort had a mean age of 48.5 years, with HF patients significantly older than those without HF (54.3 vs. 48.2 years). Males comprised 53.6% of the study population, and the majority identified as White (67.6%), followed by Black (9.3%) and other racial groups (23.1%). Compared to non-HF patients, those with HF were more likely to experience a broad spectrum of severe complications. HF was independently associated with a more than twofold increase in atrial fibrillation (aOR 2.15, 95% CI: 1.09–4.23, p = 0.027) and nearly a fourfold increase in ventricular tachycardia (aOR 3.84, 95% CI: 1.37–10.75, p = 0.010). Respiratory support needs were markedly elevated, with greater odds of requiring non-invasive ventilation (aOR 3.63, p = 0.014) and mechanical ventilation (aOR 4.83, p < 0.001) in the HF group. The risk of cardiogenic shock was dramatically increased (aOR 33.13, 95% CI: 3.99–274.87, p = 0.001). HF was also significantly associated with higher odds of pericardial effusion (aOR 4.53, p = 0.004), acute kidney injury (aOR 2.76, p < 0.001), and pulmonary embolism (aOR 43.52, p = 0.005), though the latter was characterized by a wide confidence interval. Deep vein thrombosis was not significantly different between groups (aOR 2.81, p = 0.277).Conclusion: Pre-existing heart failure in AML patients undergoing HSCT is a powerful predictor of adverse inpatient outcomes, including significant cardiopulmonary, renal, and thromboembolic complications. These findings underscore the need for vigilant cardiovascular risk assessment and pre-transplant optimization in this vulnerable population. As HSCT becomes increasingly accessible to older and medically complex patients, integrating cardiologic evaluation into transplant planning may be essential to improving clinical trajectories.