A CASE OF GEMCITABINE-INDUCED CARDIOMYOPATHY

Abstract

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Gemcitabine is a nucleoside analog and pyrimidine antimetabolite that inhibits RNA synthesis and is currently approved to treat a variety of cancers. It is considered relatively safe and is generally well tolerated. The most common side effects include myelosuppression and gastrointestinal side effects. Cardiac side effects from this medication are rare. A prior meta-analysis involving gemcitabine showed incidence estimates of ~1% for overall cardiovascular adverse events which includes myocardial ischemia, supraventricular arrythmias, heart failure and pericardial disease. Of all the possible cardiac toxicities, cardiomyopathy appears to be the least reported. In one estimate, out of 13,900 patients reporting any side effects with gemcitabine, only 30 patients (0.22%) had cardiomyopathy. CASE PRESENTATION: A 67-year-old lady with history of metastatic pancreatic adenocarcinoma presented to the emergency department with new onset dyspnea and lower extremity edema for the past week in the setting of recent completion of sixth cycle of adjuvant chemotherapy with gemcitabine. She was hypoxic on arrival with oxygen saturation of 70% on room air. Physical exam was significant for accessory muscle use, bibasilar crackles and 2+ lower extremity edema. Her labs on admission were: Hb 9.6 g/dl, WBC 18.8 k/ul, Platelets 70 k/ul, Sodium 138 mmol/l, Potassium 4.8 mmol/l, Glucose 195 mg/dL, Cr 1.7 mg/dL and pro-BNP 38,400 pg/mL. Chest x-ray showed extensive pulmonary edema with bilateral pleural effusions. EKG showed sinus tachycardia with nonspecific ST changes. Serial troponins were unremarkable. 2D Echocardiogram revealed diffuse hypokinesis and an ejection fraction of 36% which was markedly reduced from baseline of 67%, a month earlier. Acute onset of cardiomyopathy with volume overload was managed with aggressive diuresis. Gemcitabine was indefinitely held for concern of cardiotoxicity. The symptoms improved after this treatment. DISCUSSION: Gemcitabine induced cardiomyopathy is an uncommon condition and requires a high index of suspicion. Mortality rate can be as high as 17%. Evidence of normal ejection fraction prior to initiation of gemcitabine therapy proves a temporal relation between gemcitabine use and subsequent development of acute cardiomyopathy. CONCLUSIONS: This case highlights the significance of early recognition and prompt diagnosis of gemcitabine induced cardiomyopathy. Here, we describe a patient with no known cardiac history receiving gemcitabine for pancreatic cancer who developed rapid onset of cardiomyopathy. Symptoms improved with discontinuation of gemcitabine and aggressive diuresis. REFERENCE #1: Hilmi M, Ederhy S, Waintraub X, et al. Cardiotoxicity Associated with Gemcitabine: Literature Review and a Pharmacovigilance Study. Pharmaceuticals (Basel). 2020;13(10):325. Published 2020 Oct 21. doi:10.3390/ph13100325 REFERENCE #2: Alam, Salma et al. "Gemcitabine-Induced Cardiotoxicity in Patients Receiving Adjuvant Chemotherapy for Pancreatic Cancer: A Case Series." Case reports in oncology vol. 11,1 221-227. 5 Apr. 2018, doi:10.1159/000488139 DISCLOSURES: No relevant relationships by Sana Fatima, source=Web Response No relevant relationships by Shumail Syed, source=Web Response