Immune check point inhibitors (ICI) are increasingly used in management of cancers.Their ultra-modern bene? ts are often over- shadowed by adverse events collectively termed as ‘Immune- related Adverse Events’ .The incidence of ICI-Induced cardiotoxicity is immensely under-reported and the most common presentation is Acute Myocarditis in up-to 2.4% patients. Other manifestations include Takotsubo cardiomyopathy, VTE, Plaque rupture etc. We present a case of Pembrolizumab (ICI) induced Symptomaticstable Myocarditis.
48 year old Gentleman with Metastatic Melanoma managed with Immunotherapy admitted to CCU from oncology day unit with cardiac chest pain over three days. Initial investigations revealed non-speci?c changes on ECG,Troponin-T of 474 and CRP of 14.
Chest X-ray showed mild congestion whilst Echo demonstrated normal EF and CTPA excluded PE. An IP-Coronary Angiogram showed normal coronary arteries. Finally, Cardiac-MRI showed edema and non speci?c in?ammatory reaction.This patient was managed as Myocarditis with IV steroids.
Mechanism of ICI- induced Myocarditis :
Although Mechanism is not entirely clear.The most widely accepted hypothesis is based on suppression of immune inhibitory receptors (overly expressed in cardiac tissue ) by these novel agents. Certain mice models have suggested that this leads to unregulated activation of T-cells and in?ltration of myocardium.
Diagnosis and Management of ICI-induced Myocarditis:
ICI- induced myocarditis presents with non speci?c symptoms like chest pain and SOB posing diagnostic challenges. Almost 100% patients present with rise in troponin. ECG, Echo and Angiogram helps exclude ACS. Cardiac MR remains imaging modality of choice based on Lake-Louise criteria whilst the gold standard is Endomyocardial biopsy.
Management is based on grades of severity and involves use of steroids and immunosuppressive therapies. Grades encompass subclinical and symptomatic (Stable,Unstable or Decompensated) myocarditis.
ICI’s, although cutting-edge pose multi-system challenges that merit further research. Concerns looming around diagnostic uncertainty with exact timings of tests to be done needs further randomized control trials.
What will audience learn from your presentation?
• Acute cardio-oncology and cardio-immunology disease manifestations have always
been underreported due to dearth of solid case based evidence. Whilst
Immunotherapies have revolutionized the management of various cancers, their
systemic side e?ects still remain unexplored.
• This topic provides rare insights into the acute cardiac presentation of a drug which is
now widely used in the management of various cancers.
• The audience of this conference who will be aspiring cardiologists and acute medics will
be able to broaden their di?erential horizon when dealing with acute cardiac chest pain.
• This presentation will also be able to initiate discussion on how immune system
modi?cation refashions various organ systems response including cardiovascular
• This case presentation will bene?t audience in a way that it will act as a ground breaking
idea for future observational and analytical studies.