Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA.
Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston
Oncologist. 2018 Aug;23(8):879-886. doi: 10.1634/theoncologist.2018-0130. Epub 2018 May 25.
Immune checkpoint inhibitors (ICIs) are approved for a wide range of malignancies. They work by priming the immune system response to cancer and have changed the landscape of available cancer treatments. As anticipated, modulation of the regulatory controls in the immune system with ICIs results in diverse immune-related adverse events, targeting any organ or gland. These toxicities are rarely fatal and generally regress after treatment discontinuation and/or prescription of corticosteroids. Recently, several cases of ICI-related cardiotoxicity have been reported with complications ranging from cardiogenic shock to sudden death. The true incidence of ICI-associated myocarditis is likely underestimated, due to a combination of factors including the lack of specificity in the clinical presentation, the potential of overlap with other cardiovascular and general medical illnesses, the challenges in the diagnosis, and a general lack of awareness of this condition. Currently, there are no clear guidelines for surveillance, diagnosis, or management of this entity. There are multiple unresolved issues including, but not limited to, identifying those at risk of this uncommon toxicity, elucidating the pathophysiology, determining if and what type of surveillance is appropriate, optimal work-up of suspected patients, and methods for resolution of myocarditis. Here we describe a clinical vignette and discuss the salient features and management strategies of ICI-associated myocarditis.
The incidence of immune checkpoint inhibitor (ICI)-associated myocarditis is unclear and has been reported to range from 0.06% to 1% of patients prescribed an ICI.Myocarditis may be difficult to diagnose.The risk factors for ICI-associated myocarditis are not well understood but may include underlying autoimmune disease and diabetes mellitus.The prevalence of myocarditis has been reported to be higher with combination immune therapies.Myocarditis with ICI's typically occurs early, with an elevated troponin, may present with an normal left ventricular ejection fraction and may have a fulminant course.The optimal management of myocarditis associated with ICI's is unclear but most cases are treated with high-dose steroids.
免疫检查点抑制剂 (ICI) 已获准用于广泛的恶性肿瘤。它们通过启动免疫系统对癌症的反应，改变了可用癌症治疗的格局。正如预期的那样，ICI 对免疫系统的调节控制会导致各种免疫相关的不良反应，针对任何器官或腺体。这些毒性很少致命，通常在停止治疗和/或使用皮质类固醇后会消退。最近，有报道称几种与 ICI 相关的心脏毒性病例，其并发症从心源性休克到猝死不等。由于多种因素的综合作用，包括临床表现缺乏特异性、与其他心血管和一般内科疾病的重叠可能性、诊断方面的挑战以及对这种疾病的普遍认识不足，ICI 相关心肌炎的真实发病率可能被低估。目前，尚无针对该疾病的监测、诊断或管理的明确指南。仍存在多个未解决的问题，包括但不限于确定易患这种罕见毒性的人群、阐明病理生理学、确定是否以及何种类型的监测是合适的、疑似患者的最佳检查、以及心肌炎的解决方法。在这里，我们描述了一个临床病例，并讨论了 ICI 相关心肌炎的显著特征和管理策略。
免疫检查点抑制剂（ICI）相关心肌炎的发病率尚不清楚，据报道，接受 ICI 治疗的患者中有 0.06%至 1%发生心肌炎。心肌炎可能难以诊断。ICI 相关心肌炎的危险因素尚不清楚，但可能包括潜在的自身免疫性疾病和糖尿病。联合免疫疗法的心肌炎患病率较高。ICI 相关心肌炎通常发生较早，肌钙蛋白升高，左心室射血分数可能正常，且可能呈暴发性病程。ICI 相关心肌炎的最佳治疗方法尚不清楚，但大多数情况下采用大剂量类固醇治疗。
