Incidence and Outcomes of Atrial Arrhythmia with CDK4/6 Inhibitors in HR-Positive / HER2-Negative Breast Cancer

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Background: Cyclin-dependent kinase 4/6 (CDK4/6) inhibitors are increasingly used in hormone receptor-positive, HER2-negative (HR+/HER2-) breast cancer, yet emerging data suggest potential cardiotoxicity, including atrial arrhythmias (AA). Understanding the incidence and outcomes of AA in this population is essential as indications for CDK4/6 inhibitors expand. Objectives: To evaluate the incidence of new-onset AA and associated outcomes in patients with HR+/HER2- breast cancer treated with CDK4/6 inhibitors. Methods: We conducted a retrospective cohort study of patients treated at Mayo Clinic from 2015-2024 who received CDK4/6 inhibitors for HR+/HER2- breast cancer. The primary outcome was incidence of AA (atrial fibrillation, atrial flutter, or atrial tachycardia). Secondary outcomes included cerebrovascular events and all-cause mortality. Kaplan-Meier estimates and Cox regression models were used to assess outcomes and associated risk factors. Results: Among 2,782 patients, 59% received palbociclib, 28% abemaciclib, and 14% ribociclib. New-onset AA occurred in 45, with cumulative incidence at 5 years of 2.8%. No significant differences in AA incidence were observed between agents (p=0.44). Multivariate analysis identified age at treatment as the only independent predictor of AA (HR 1.073, p<0.001). Four patients with new-onset AA experienced cerebrovascular events. New-onset AA was associated with increased mortality (HR 1.56, p=0.012). Conclusions: CDK4/6 inhibitor therapy was associated with a low but clinically significant risk of new-onset AA, which in turn is associated with increased mortality. There was no significant difference in new-onset AA risk between different individual CDK4/6 inhibitor agents. Prospective studies are needed to define mechanisms and guide monitoring strategies.

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