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How to deal with heart-wrenching chemotherapy drugs?
Written by | Su Xuhan
Recently, Medscape, a well-known medical website in the United States, published an article in the "Case Challenge Series", focusing on chemotherapy drug-related cardiotoxicity, which has attracted the attention and discussion of the medical community.
Readers and friends will first follow the small world to understand the details of the case.
Cases
■Patient cases
The patient, a 50-year-old man, presents to the emergency department with "chest pain for 3 days".
■History of present illness
- The patient had chest pain, the pain was located in the middle of the chest, it was a squeezing pain with a burning sensation, the pain and discomfort score was 7 points (out of 10), it could radiate to the left arm, the pain could be relieved after rest, the pain was relieved without taking medication, and it was not accompanied by shortness of breath, palpitations, dizziness, sweating, nausea, etc., and the patient denied a history of similar symptoms before.
■既往史
- History of gastroesophageal reflux disease. He was diagnosed with stage IIIB cecal adenocarcinoma 3 months ago, and planned radical surgery for right colon cancer, and started capecitabine + oxaliplatin chemotherapy regimen 3 days before the emergency department, but during this period, the reflux symptoms worsened, and he was started to take omeprazole acid suppression therapy.
- Occasional alcohol consumption, denial of smoking history, denial of illicit drug use. Denial of a history of viral illness.
■Physical examination
- T 36.8°C，P 94次/分，Bp 124/76mmHg，SpO2 95%。
- Conscious, mentally OK. Bilateral breathing movements are uniform and symmetrical. The heart rate was 94 beats per minute, the heart rhythm was uniform, and no pathological murmur or pericardial friction rub was heard in the auscultation area of each valve. No signs of heart failure were seen. No chest wall tenderness. There is no peripheral edema.
■Laboratory tests
- Complete blood count: normal
- 肌酐：1.3 mg/dL（参考范围，0.7-1.3 mg/dL）
- 高灵敏度肌钙蛋白水平:初始值为8 ng/L,1小时后复查为13 ng/L(参考范围:男性<22 ng/L)
- BNP：64 pg/mL（参考范围：<300 pg/mL）
- D-二聚体水平：1.32 μg/mL（参考范围：<0.50 μg/mL）
■Imaging tests
- Chest x-ray showed no abnormalities, and chest CT scan showed no pulmonary embolism.
- ECG: sinus rhythm with non-specific T wave abnormalities, see Figure 1;
Figure 1
- Stress echocardiography: after about 5 minutes of walking on the treadmill, the patient developed chest pain, electrocardiogram showed sinus rhythm, ST-segment elevation in the lower and sidewall leads, see Figure 2;
Figure 2
- Cardiac catheterization was performed immediately, and coronary angiography showed non-obstructive coronary artery disease, with 30%-40% mild lumen irregularity in the middle and distal end of the left anterior descending artery, and obvious tortuosity of the blood vessels, as shown in Figure 3.
Figure 3
Q1
Based on the above information, what do you think is the most likely diagnosis?
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Don't worry, read on!
Peel back the layers and make a clear diagnosis
How is the differential diagnosis made?
- Spontaneous coronary artery dissection and acute plaque rupture: both can be confirmed by cardiac catheterization and can be distinguished from this patient by angiography appearance.
- Coronary microvascular disease: most patients usually do not present with ECG changes, such as ST-segment elevation, and coronary angiography is normal, near-normal, with irregular walls, or less than 20% luminal stenosis. To confirm the diagnosis, additional tests are needed in addition to cardiac catheterization.
Depending on the degree and mechanism of cardiotoxicity, the clinical presentation varies from patient to patient. The most common symptom is chest pain, which can manifest as angina, pleuritic inflammation, or nonspecific chest pain, and other symptoms such as shortness of breath, palpitations, and malaise. Patients may be haemodynamically stable or may present with hypotension and/or tachycardia. A timely physical examination is required to determine the severity of the disease and to guide further ancillary investigations.
Evaluation of suspected chemotherapy-induced cardiotoxicity (particularly coronary vasospasm) should include a 12-lead ECG, cardiac biomarkers (including troponin, BNP), and a noninvasive and rapid echocardiography. Depending on the patient's clinical presentation and findings, invasive coronary angiography may be required to fully evaluate other potential causes of cardiac symptoms. It is safer and prudent to rule out other causes of the patient's symptoms before diagnosing chemotherapy-induced coronary vasospasm.
What chemotherapy drugs are easy to "break the heart"?
"Heartbreaking" here refers to cardiotoxicity caused by chemotherapy drugs, which in a broad sense means that the heart function is impaired, which can cause heart failure, cardiomyopathy, or arrhythmias.
Scan the QR code below or click "Read the original article" at the end of the article to view the top article and get a list of cardiotoxicity of chemotherapy drugs.
Prevention and treatment of chemotherapy-related cardiotoxicity
The European Society for Medical Oncology (ESMO) recommends continuous cardiac monitoring (eg, echocardiography, electrocardiogram, cardiac biomarker assays) (eg, TnI/TnT, BNP/NT pro-BNP) in patients with pre-existing left ventricular dysfunction, and prophylactic treatment with angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin II receptor antagonists (ARBs) for patients at high risk of cardiotoxicity [6].
In this case, the patient was eventually started with oral amlodia tablets 5 mg once a day, long-term backup nitroglycerin sublingual administration in case of chest pain, and 5-FU + oxaliplatin chemotherapy under hospital drug monitoring.
Clinical question quiz
1. A 52-year-old woman with a recent diagnosis of rectal cancer is receiving a chemotherapy regimen including capecitabine. She presented to the emergency department with chest pain, and after proper evaluation, she was diagnosed with chemotherapy-induced coronary vasospasm.
2. A 60-year-old male presents to the emergency department with an acute onset of chest pain while walking his dog 1 hour ago. He looked anxious and said he had recently been diagnosed with colon cancer and started chemotherapy yesterday.
Resources:
[1] Lenneman CG, Sawyer DB. Cardio-Oncology: An Update on Cardiotoxicity of Cancer-Related Treatment. Circ Res. 2016; 118(6):1008-1020.
[2] Narezkina A, Nasim K. Anthracycline Cardiotoxicity. Circ Heart Fail. 2019; 12(3):e005910.
[3] Copeland-Halperin RS, Liu JE, Yu AF. Cardiotoxicity of HER2-targeted therapies. Curr Opin Cardiol. 2019; 34(4):451-458.
[4] Pondé NF, Lambertini M, de Azambuja E. Twenty years of anti-HER2 therapy-associated cardiotoxicity. ESMO Open. 2016; 1(4):e000073.
[5] Chen X, Wang H, Zhang Z, et al. Case Report: Oxaliplatin-Induced Third-Degree Atrioventricular Block: First Discovery of an Important Side-Effect. Front Cardiovasc Med. 2022;9:900406.
[6] Curigliano G, Cardinale D, Suter T, et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. Ann Oncol. 2012; 23 Suppl 7:vii155-vii166.
Review of this article: Professor Xu Weiran Editor: Sheep
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