The toxic tango: TKI and TCI cardiotoxicities.

BACKGROUND: Immune checkpoint inhibitors (ICI) and Tyrosine kinase inhibitors (TKI) are effective for several types of cancers, but they can have several cardiotoxicity sides effects. We present a case of TKI-ICI toxicity resulting in multiorgan inflammatory syndrome with myocarditis and thrombotic STEMI that were successfully treated with high-dose steroids and PCI. CASE PRESENTATION: Seventy-two year-old man patient treated with on pembrolizumab 200 mg IV every 3 weeks and Axitinib 5 mg PO q12h for the past 5 months complained of acute shortness of breath, altered mental status, and chronic diarrhea. Coronary angiography demonstrated a thrombotic lesion in the right coronary artery (RCA) that was treated successfully with percutaneous coronary intervention (PCI). Despite PCI he continued to complain of shortness of breath further workup with Cardiac MRI (CMR) was obtained showed an ejection fraction of 38%, small pericardial effusion, and delayed gadolinium enhancement (DGE) in the inferior wall suggestive of myocarditis. An empirical trial of high-dose steroids improved all patient symptoms and ejection fraction; therefore, the chemotherapy regimen was changed. CONCLUSION: This case report highlights the potential vasculogenic effects of Axitinib and immune-related myocarditis of pembrolizumab. Cardiologists and oncologists should be vigilant for the cardiotoxic effects of Axitinib and pembrolizumab.

A 59-Year-Old Woman With Shortness of Breath and Chest Pain.

CASE PRESENTATION: A 59-year-old woman presented to the ED with syncope. She had progressive shortness of breath with minimal activity and precordial resting chest pain for 1 month prior to presentation. She had a medical history of heart failure with preserved ejection fraction, severe OSA well controlled with CPAP of 11 cm H2O, and a history of DVT and pulmonary embolism, diagnosed 10 years ago for which she was maintained on warfarin. The patient also had chronic myeloid leukemia in the chronic phase; she had initially been treated with imatinib but was later switched to dasatinib about 4.5 years prior to presentation. The patient had achieved major molecular remission with dasatinib 140 mg daily. Her family history was noncontributory and specifically negative for pulmonary hypertension and heart failure. She had a history of smoking (50 pack years) but had quit 23 years ago.