Recently, a patient with advanced lung squamous cell carcinoma was received online. This patient used chemotherapy combined with immunotherapy in a local hospital for 21 cycles, and developed chest tightness and asthma, which made him struggling to walk. So I went to the hospital for examination and found a large amount of pericardial effusion . A month ago, there was no obvious pericardial effusion. Based on the medical history and some tests provided, I suspect that the patient's pericardial effusion is caused by immunotherapy drugs. It is recommended to place a cannula drainage, test the drainage of the effusion, and use hormones if necessary.
immune checkpoint inhibitors have been widely used in clinical practice for several years. To quote a senior from the tumor industry, the more they use these drugs, the more they feel, the more they feel, because they have suffered too much in clinical practice. In addition to the relatively common hypothyroidism, immune pneumonia, and immune hepatitis, in fact, immune-related cardiotoxicity cannot be ignored, because PD-1 and PD-L1 are also expressed in human cardiomyocytes. The use of PD-1/PDL-1 inhibitors may cause many adverse reactions to the cardiovascular system. The clinical manifestations of cardiotoxicity related to immunotherapy are mainly reflected in the following aspects:
immune myocarditis
immune myocarditis
immune myocarditis incidence is 0.06%-3.8%. Although the incidence rate is relatively low, the mortality rate is as high as 39.7%-50%. Once it occurs, nearly half of the people will be in danger of life. The symptoms may be atypical, mainly including chest pain, , shortness of breath, pulmonary edema, lower limb edema, arrhythmia , acute heart failure, cardiogenic shock, etc., and the occurrence time is mostly 15-30 days after the first medication. Among all cardiotoxicities, myocarditis is the main cause of lethality .
pericitis , pericardial effusion and pericardial filling
Immune checkpoint inhibitor-related pericardial diseases can manifest as chest pain, dyspnea , and in severe cases, it can rapidly develop into respiratory failure . Pericardial disease sometimes occurs simultaneously with immune myocarditis. In severe cases, the condition worsens rapidly, and even cardiac shock or cardiac arrest occurs.
Myocardial infarction
Patients using ICI may develop stable angina pectoris and acute coronary syndrome. Myocardial infarction is characterized by sudden chest pain, ischemia changes in the electrocardiogram (such as ST segment elevation, ST segment depression, or T wave inversion), and elevated troponin.
arrhythmia
Immunotherapy can cause cardiac conduction dysfunction , and arrhythmia, including atrial fibrillation, ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) and atrioventricular block (II or complete atrioventricular block). Among them, supraventricular arrhythmia has the highest incidence.
valve function impairment
immune checkpoint inhibitors can lead to valve dysfunction, such as moderate to severe aortic valve, mitral valve and tricuspid valve regurgitation . Heart valve lesions are usually accompanied by cardiomyopathy. How to prevent cardiotoxicity related to immunotherapy?
immunotherapy related cardiotoxicity is important to prevent it. Baseline electrocardiogram, myocardial enzyme and troponin tests should be routinely performed before using immunotherapy drugs. For high-risk patients (using excessively high-dose cardiotoxic drugs, having underlying heart diseases or having immune damage to other organs), cardiac color ultrasound should be performed in advance. Those with abnormalities should use immunotherapy drugs with caution.
In addition to the above examination, the inflammatory indicators (ESR, CRP and WBC counts) and BNP, NT pro-BNP and anti-stria antibody levels were checked in a timely manner in patients with suspected cardiotoxicity. In addition, cardiac 18F-FDG PET/CT also helps detect myocarditis.
