Rare Presentation of Cardiotoxicity Related to 5-Fluorouracil

Abstract

5-Fluorouracil (5-FU) is a chemotherapeutic agent frequently used for the treatment of solid tumors. In a few cases, 5-FU can be associated with coronary vasospasm, cardiac ischemia, or life-threatening arrhythmias. Recognition of 5-FU cardiotoxicity is clinically important as after the rapid sensation of therapy, cardiotoxicity can be completely reversible, and on the other hand, readministration may lead to serious damage of the heart and even death. A 70-year-old male came to the emergency department (ED) with chest pain which started while receiving an infusion of 5-FU. The patient did not have a personal history or risk factors of coronary artery disease and his electrocardiogram (ECG) before starting chemotherapy was completely normal. In the ED, his ECG had ischemic changes, troponin was elevated, and echocardiogram showed anterior wall hypokinesis. However, emergent coronary angiogram did not reveal any acute coronary occlusion. 5-FU-induced cardiotoxicity was suspected; the patient was admitted to a progressive care unit for close monitoring and infusion of calcium channel blockers was initiated. The patient's symptoms and ECG findings gradually resolved, and two days later on discharge, patient was chest pain free and ECG was normal. This case supports the vasospastic hypothesis of 5-FU cardiac toxicity, describes its clinical course, and emphasizes the importance of better awareness and early recognition of the rare side effect as it may allow physicians to reduce the risk of life-threatening complications.

Figure 1

12-lead electrocardiogram (ECG) obtained at the time of arrival of the patient to the ED. ECG shows diffuse T wave inversions (blue arrows) and ST depressions in V3, V4, V5, and V6 (red arrows).

Figure 2

Patient's ECG three days before starting chemotherapy. ECG is normal with no ST segment or T wave abnormalities.

Figure 3

Patient's ECG after 2 hours from arrival to the ED. ECG shows new ST elevations on lead 1, V3, V4, and V5 (red arrows).

Figure 4

Pictures of emergent coronary angiogram after patient's arrival to the ED. Pictures show only mild focal left anterior descending artery disease.

Figure 5

Patient's ECG after 6 hours of hospitalization. ECG shows that T waves are normalized in most of the leads, but it still remains inverted in lead II, III, aVF (blue arrows).

Figure 6

Patient's ECG after 24 hours of hospitalization. CG shows that T waves are normalized in most of the leads and there are no ST segment abnormalities.

Figure 7

Patient's ECG on discharge ECG is normal with no T wave or ST segment abnormalities.