Cardiac Risk Stratification Before Stem Cell Transplantation Assessed in New Review

Patients undergoing hematopoietic stem cell transplantation (HSCT) face measurable cardiovascular risks both shortly after the procedure and years into survival, and a new narrative review published in Cardio-Oncology lays out how clinicians can stratify that risk before transplant and monitor it afterward. The review, authored by Preetinder Singh Manshahia, Aditya Sanjeevi, Maryam Maqsood, Abel Tessema, Keshav Patel and Amit Bansal, was published on 21 October 2026 as an open-access article.

The authors focused on short-term and long-term cardiovascular complications after HSCT, on pre-transplant cardiac risk assessment and optimization, and on post-transplant cardiovascular screening and long-term surveillance. Their synthesis divides HSCT-related cardiovascular complications into two broad categories. By 100 days after transplant, the incidence of cardiovascular complications is reported at 4 to 5.5 percent. Over five years, the cumulative incidence rises to 14 percent, underscoring that the cardiovascular burden does not end once the early recovery period passes.

Among these complications, atrial fibrillation and atrial flutter emerge as the most common. The review reports an incidence of 2.6 percent at 100 days, rising to 6.8 percent at five years. Heart failure follows, with an incidence of 1.1 percent at 100 days and 5.4 percent at five years. These figures frame the scale of the problem: cardiovascular complications are described by the authors as a major cause of non-relapse mortality and morbidity after HSCT, meaning that for some patients the heart, rather than the underlying cancer, becomes the limiting threat to long-term health.

The risk factors for early and late complications are not identical. Short-term cardiovascular risk is associated with older age and with reduced pre-transplant left ventricular ejection fraction, specifically values below 50 percent. Long-term risk, by contrast, is associated with a wider set of factors: older age, hypertension, diabetes, smoking, chronic kidney disease, coronary artery disease, obesity, and reduced pre-transplant left ventricular ejection fraction. This distinction matters because it suggests that the two windows of vulnerability draw on partly different aspects of a patient’s baseline health.

For heart failure specifically after transplant, the review identifies additional influences: allogeneic HSCT, graft-versus-host disease, cumulative anthracycline exposure, and chest radiation. Transplant type also appears to shape long-term outcomes. Allogeneic HSCT recipients have a higher long-term cumulative incidence of cardiovascular complications than autologous HSCT recipients, although early complication rates appear similar between the two groups. The authors also note that prior cancer-related treatment exposures should be weighed alongside traditional cardiometabolic comorbidities when assessing risk.

A central practical contribution of the review is its endorsement of a transplant-specific risk tool. The Cardiovascular Registry in Bone Marrow Transplantation, or CARE-BMT, score can be used for pre-HSCT cardiac risk stratification covering both short-term and long-term cardiovascular events.

On the surveillance side, the review proposes a structured, risk-adapted approach. Post-transplant monitoring should include periodic assessment of cardiovascular risk factors, electrocardiograms, and echocardiography in high-risk patients.

Management recommendations in the review center on modifiable risk. High-risk patients should receive guideline-directed optimization of modifiable cardiovascular risk factors and treatment of established cardiovascular disease. Given the elevated long-term cardiovascular risk in HSCT survivors, the authors argue that proactive monitoring and aggressive management of modifiable risk factors, through lifestyle modifications and pharmacotherapy, is critical. They frame this within a structured approach that accounts for transplant type, prior cancer treatment exposures, and cardiometabolic comorbidities to guide pre-transplant optimization, cardio-oncology referral, and longitudinal follow-up.

As a narrative review of existing literature rather than a new clinical trial, the article synthesizes published evidence rather than generating new patient-level data, and its incidence figures reflect the studies it surveys. Even so, its message is direct: cardiovascular complications after HSCT are common enough, and their risk factors identifiable enough, that systematic pre-transplant cardiac assessment and long-term cardio-oncology follow-up deserve a defined place in transplant care.

Subject of Research: Cardiac risk stratification and cardiovascular complication surveillance in hematopoietic stem cell transplantation

Article Title: Cardiac risk stratification for patients undergoing hematopoietic stem cell transplantation and associated cardiovascular complications

Article References: Manshahia, P. S., Sanjeevi, A., Maqsood, M., Tessema, A., Patel, K., & Bansal, A. (2026). Cardiac risk stratification for patients undergoing hematopoietic stem cell transplantation and associated cardiovascular complications. Cardio-Oncology. https://doi.org/10.1186/s40959-026-00585-w

Image Credits: AI Generated

DOI: 10.1186/s40959-026-00585-w

Keywords: hematopoietic stem cell transplantation, cardio-oncology, cardiac risk stratification, CARE-BMT score, atrial fibrillation, heart failure, left ventricular ejection fraction, coronary artery calcium, global longitudinal strain, non-relapse mortality, cardiovascular surveillance, anthracycline exposure