Ko Jefferson, Wardill Thomas, Tan Sean, Ramkumar Satish
Department of Cardio-oncology, Victorian Heart Hospital, 631 Blackburn Road, Clayton, Melbourne, VIC 3168, Australia.
Department of Cardio-oncology, Victorian Heart Institute, 631 Blackburn Road, Clayton, Melbourne, VIC 3168, Australia.
Eur Heart J Case Rep. 2024 Nov 19;8(12):ytae620. doi: 10.1093/ehjcr/ytae620. eCollection 2024 Dec.
Immunotherapy has become a pillar of modern oncological management but is associated with significant immunotherapy-related adverse events (IRAEs). While myocarditis is a prominent IRAE which clinicians are increasingly aware of, immunotherapy-related coronary vasospasm is far less appreciated and can be especially difficult to elucidate in pre-existing coronary artery disease. This case demonstrates the approach to diagnosis and management of multiple cardiovascular and non-cardiovascular IRAEs.
A 57-year-old male with a history of metastatic melanoma on combined immunotherapy and ischaemic heart disease with multiple previous percutaneous coronary interventions presented with typical chest pain and troponin rise. Differential diagnoses for this presentation included a non-ST elevation myocardial infarction, myocarditis, and coronary vasospasm. Coronary angiogram did not reveal any new significant obstructive coronary artery disease while cardiac MRI did not reveal any radiological features consistent with myocarditis. However, empirical treatment for IRAEs resulted in both clinical and biochemical improvement and ability to discharge the patient on steroids and coronary vasodilators, having been GTN-infusion dependent as an inpatient.
Cardiovascular IRAEs are important to be aware of when managing patients on immunotherapy and more than one IRAE can occur concurrently. Given the caveats of non-invasive imaging and invasive nature of endomyocardial biopsy, the clinical history is key in establishing these crucial diagnoses which will significantly impact ongoing oncological management.
免疫疗法已成为现代肿瘤治疗的支柱，但与显著的免疫疗法相关不良事件（IRAEs）有关。虽然心肌炎是一种突出的IRAEs，临床医生对此的认识日益提高，但免疫疗法相关的冠状动脉痉挛却很少受到关注，在已有冠状动脉疾病的情况下尤其难以阐明。本病例展示了多种心血管和非心血管IRAEs的诊断和管理方法。
一名57岁男性，有转移性黑色素瘤病史，正在接受联合免疫治疗，并有缺血性心脏病史，曾多次接受经皮冠状动脉介入治疗，出现典型胸痛和肌钙蛋白升高。该表现的鉴别诊断包括非ST段抬高型心肌梗死、心肌炎和冠状动脉痉挛。冠状动脉造影未发现任何新的显著阻塞性冠状动脉疾病，而心脏磁共振成像未发现任何与心肌炎一致的影像学特征。然而，针对IRAEs的经验性治疗使临床和生化指标均得到改善，患者能够在出院时使用类固醇和冠状动脉扩张剂，住院期间一直依赖硝酸甘油输注。
在管理接受免疫治疗的患者时，了解心血管IRAEs很重要，并且可能同时发生不止一种IRAEs。鉴于非侵入性成像的局限性和心内膜心肌活检的侵入性，临床病史是确立这些关键诊断的关键，这些诊断将对正在进行的肿瘤治疗产生重大影响。
