5-Fuorouracil Cardiotoxicity

Cardiac Arrhythmia: Possible Complication from Treatment with Cisplatin

Cardiotoxicity is rarely observed during cisplatin chemotherapy. A possible synergistic toxic effect of cisplatin with etoposide on cardiac electrical activity is discussed. A case of a 60-year-old woman with squamous cell lung carcinoma who developed paroxysmal supraventricular tachycardia during cisplatin chemotherapy is reported. The potential cardiotoxicity should be considered when cisplatin is combined with other cardiotoxic agents or used in patients with cardiac disease.

Cardiotoxicity as a Result of 5-Fluorouracil Therapy

We report the case of a patient bearing a sigmoid colon carcinoma, stage IV, who after 11 months of antiblastic therapy, having completed a dose of 81,000 mg of 5-FU and CCNU, suffered a myocardial infarct. We attribute this compication to 5-FU. Due to the fact that the coronary angiogram did not confirm the arteriosclerotic nature of the lesion, we suggest that it could have been caused by an endoarteritis, resulting from an immuno-allergic or toxic cumulative process.

Ischemic Cardiopathy from CIS-Diamminedichloroplatinum (CDDP)

The authors report a case of ischemic cardiopathy that occured during therapy with CDDP in a woman with an ovarian cancer which had been extensively pre-treated with adriamycin.

Cardiotoxicity during Chemotherapy for Advanced Gastroenteric Tumors

The authors report two cases of patients with advanced gastroenteric carcinoma, which developed different cardiotoxicity patterns after the administration of cytotoxic drugs. The firsts patient showed a picture of dilatative cardiomyopathy with associated symptoms of angina pectoris and congestive heart failure; the second patient presented a cardiac arrhythmia after several administrations of S-fluorouracil. The possible mechanisms of these toxic effects, as well as the drug interactions are briefly discussed. Cardiotoxicity of cytotoxic drugs should be considered by oncologists even in patients with no previous history of cardiac disease.

Cardiac Toxicity of 5-Fluorouracil Report of a Case of Spontaneous Angina

We report a case of a patient with colon carcinoma and liver metastasis who presented chest pain after 5-fluorouracil (5-FU) administration. Clinical electrocardiographic evolution was similar to that observed in Prinzmetal's angina, and chest pain promptly resolved with nifedipine. These data suggest that coronary spasm may be the cause of cardiotoxicity due to 5-FU, and that calcium antagonists may probably be used in the prevention or treatment of 5-FU cardiotoxicity.

Cardiac Toxicity of 5-Fluorouracil: A Study on 1083 Patients

The possible onset of cardiotoxic manifestations during chemotherapy with 5-fluorouracil (5-FU) was evaluaetd in 1083 patients treated with the drug for various kinds of neoplasm. We recognized 17 cases of 5-FU cardiopathy (usually anginous crises but also myocardial infarction). The comprehensive incidence was 1.6 %, with a significantly greater risk (4.5 % vs 1.1 %) for patients with a positive anamnesis of previous cardiopathy. On the contrary, age and combination with other antiblastic drugs had no affect on the appearance of cardiopathy. We conclude that 5-FU cardiopathy, although rare, has to be taken into account in oncologic practice, chiefly in those patients already affected with cardiac diseases.

Cardiotoxicity of 5-Fluorouracil

A case is reported of cardiotoxicity during a multiple drug treatment with fluorouracil, vincristine and CCNU in a patient with a large bowel cancer without any precedent history of heart disease. The patient had chest pain, with an altered ECG and increased serum levels of αHBDH.

Fluoropyrimidine-associated cardiotoxicity: revisited

BACKGROUND

The syndrome of 5-fluorouracil (5-FU)-associated cardiotoxicity remains poorly defined.

PATIENTS AND METHODS

We performed a literature review (1969 - 2007) and compiled data derived from 377 evaluable cases out of 448 reported cases.

RESULTS

Patient age ranged from 14 to 86 years. Of the patients 65% were 55 years old and the male:female ratio was 1.5:1. The most commonly treated tumors were gastrointestinal (60%), head and neck (22%) and breast (4%). Of the patients 14% had a history of heart disease whereas cardiac risk factors were found in 37%. Mode of administration included: continuous infusion (72%); bolus (22.5%); intermediate infusion (3%); oral (2%); and intraperitoneal (1 patient). The dosages of 5-FU used were < 750 mg/m(2)/day (36%), 751 - 999 (16%), 1,000 (26%), 1,001 - 1,499 (4%) and 1,500 (16%). Of the patients 54% received 5-FU in combination with other chemotherapeutic agents (cisplatin 44%) whereas 51% received 5-FU alone or with leucovorin. Only 4% patients had undergone previous or concomitant radiation therapy to the mediastinum. Of cardiac incidents that happened 69% were seen during or within 72 h of the first cycle of 5-FU. Angina occurred in 45% of patients whereas myocardial infarction was seen in 22%, arrhythmias in 23, acute pulmonary edema in 5, cardiac arrest and pericarditis in 1.4 and heart failure in 2. Electro-cardiographic evidence of ischemia or ST-T changes were recorded in 69% of patients, but abnormal cardiac enzymes were found in only 12%. The cardiac symptoms were reproducible in 47%, including in one patient subsequently treated with 5-FU p.o. Symptoms were also elicited when the same patients were treated with lower doses or different schedules. Of the patients 68% responded to conservative anti-anginal therapy, although prophylactic coronary vasodilators had limited efficacy. Overall, 8% of patients showing cardiotoxicity on 5-FU administration died. Furthermore, 13% reexposed to 5-FU died.

CONCLUSIONS

Our review suggests that 5-FU cardiotoxicity is an infrequent but real phenomenon that is independent of dose and may be related to a continuous infusion schedule. The presence of cardiac risk factors is not predictive. Patients should be observed closely and 5-FU administration discontinued if cardiac symptoms develop. A rechallenge with 5-FU should be reserved only for those patients in whom there is no reasonable alternative therapy and should be performed in the setting of aggressive prophylaxis and close monitoring.

Cardiotoxicity of fluoropyrimidines in different schedules of administration: a prospective study

BACKGROUND

Cardiotoxicity associated with 5-Fluorouracil (5FU) administration has been infrequently reported in literature, albeit various series of acute coronary syndromes have recorded a low but definite incidence of the above toxicity. In the present study, patients undergoing 5FU-based and oral capecitabine (Xeloda-based chemotherapy were tested for the potential development of cardiac-related symptoms during their administration.

PATIENTS AND METHODS

Six hundred and forty-four patients entered the study. Those experiencing any cardiac-related symptoms during 5FU infusion or oral capecitabine were subjected to ECG and serum cardiac enzymes determination. If cardiotoxicity was confirmed, 5FU infusion or oral capecitabine were interrupted, sublingual nitrates administered and cardiac monitoring initiated, while patients with >two-fold enzyme elevation were followed in a coronary care unit for at least 72 h. Cases with acute myocardial infarction were excluded from further 5FU or oral capecitabine treatment.

RESULTS

Overall 26 patients (4.03%) developed symptoms and/or ECG abnormalities due to 5FU and capecitabine. Patients with continuous 5FU infusion presented a higher incidence of cardiotoxicity [14/209; 6.7%, 95% confidence interval (CI) = 3.3-10.1%] than the remaining (7/317; 2.3%, 95% CI = 0.8-3.3%) (P < 0.012). Specifically, an increased incidence of cardiac-related events was encountered in patients with continuous 24-h 5FU + LV infusion for 5 days (12.5%, 95% CI = 2.3-22.7%) rather than in patients with the same schedule without LV (5.3%, 95% CI = 1.95-8.67%) (P < 0.027), as well as in patients with short 5FU + LV administration (2.4%, 95% CI = 0.9-3.9%) (P < 0.019). Overall, 3/54 patients (5.5%, 95% CI = -0.6-11.1%) on oral capecitabine developed cardiac-related events. Seven out of the 20 patients suffered an acute myocardial infarction, 6 developed ischemia only, while 4 more patients had ECG consistent with coronary vasospasm and 3 with conduction disturbances, of which one subsequently died. Patients administered oral capecitabine had a similar incidence of cardiac-related events; 1/22 (4.5%) patients with advanced breast cancer and 2/32 (6.2%) with colorectal cancer.

CONCLUSIONS

The present study supports the toxic effect of 5-FU on the myocardium, which is largely schedule-dependent, whereas a low but finite risk of such toxicity has been observed with oral capecitabine. A high level of alertness is required when using fluoropyrimidines (i.v. 5FU or oral capecitabine), while their toxic effect on the coronary endothelium and myocardium merits further investigation.

Vascular Toxicity of Antineoplastic Agents

Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.

Severe cardiotoxicity during 5-fluorouracil chemotherapy: a case and literature report

The chemotherapeutic agent 5-fluorouracil (5-FU) is a widely accepted part of many cancer treatment protocols. Its cardiotoxic potential is known, but considered uncommon and usually not life threatening, although some cases of severe cardiotoxicity related to 5-FU have been reported. The pathogenesis of cardiotoxicity caused by 5-FU is not clear. We report a case of sudden onset of severe cardiac failure, without ischemic symptoms or signs, during 5-FU treatment with serious consequences, in a previously healthy 23-year-old patient with squamous cell carcinoma of the tongue. Endomyocardial biopsy showed proliferation of the sarcoplasmic reticulum with marked vacuolization, similar to that found with doxorubicin cardiotoxicity. Because 5-FU cardiotoxicity is unpredictable and can have potentially fatal consequences, it requires, in our opinion, further clarification. With this well-documented case, including an endomyocardial biopsy, we hope to encourage additional efforts to investigate the pathophysiologic mechanisms of 5-FU cardiotoxicity.

Toxic cardiogenic shock in a patient receiving weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin

A 54-year-old man was treated with weekly 24-h infusion of high-dose 5-fluorouracil (2600 mg/m2) and leucovorin (100 mg/m2) for metastatic colon cancer. At first, he tolerated the treatment well and no significant toxicity was identified. After a total of eight courses of treatment, a stable disease was observed, but mild shortness of breath was found on occasion. The patient had no previous history of cardiac disease and the heart performance assessed by left ventricular ejection fraction before treatment was normal. Unfortunately, acute pulmonary edema with lethal cardiogenic shock occurred during the ninth course of treatment, in spite of intensive medical treatment. The chest X-ray showed extreme cardiomegaly. Repeated assessment of his heart function by echocardiogram and ventricular ejection fraction revealed a very poor cardiac performance. Toxic cardiogenic shock during weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin is extremely rare. To the best of our knowledge, no case has been reported in the English literature. We report a case and the relevant literature about the incidence, clinical picture and possible pathophysiology on 5-fluorouracil-related cardioxicity is reviewed.

Fluorouracil cardiotoxicity

OBJECTIVE

To review the clinical manifestations, postulated mechanisms, and therapeutic implications of fluorouracil-induced cardiac toxicity.

DATA SOURCE

A MEDLINE search was used to identify pertinent literature.

STUDY SELECTION

Studies and case reports on fluorouracil cardiotoxicity were identified through a MEDLINE search. A manual review of bibliographies of identified articles was performed to ensure that all pertinent articles were included.

DATA EXTRACTION

Data pertaining to all aspects of fluorouracil cardiac toxicity, including pathogenesis, predisposing factors, clinical manifestations, and therapeutic implications, were evaluated.

DATA SYNTHESIS

Estimates from large series suggest a 1.6-2.3 percent incidence of clinically demonstrated cardiotoxicity. Predisposing factors include the presence of coronary artery disease and concurrent radiotherapy. Postulated mechanisms include direct myocardial ischemia, coronary spasm, or cardiotoxic impurities in fluorouracil formulation. Clinical manifestations include chest pain, nausea, diaphoresis with typical ischemic electrocardiographic (ECG) changes, relieved to normal after stopping the drug therapy. Nitrates and calcium-channel blockers do not protect against cardiotoxicity.

CONCLUSIONS

Fluorouracil cardiotoxicity may be much more common and clinically significant than previously thought. A high index of suspicion for cardiotoxicity must be maintained when the drug is administered, especially in the presence of heart disease and concomitant radiation therapy. In the presence of chest pain, it is mandatory to stop the infusion and, if possible, to replace fluorouracil with another chemotherapeutic agent.

The syndrome of 5-fluorouracil cardiotoxicity. An elusive cardiopathy

BACKGROUND

A case of reversible cardiogenic shock linked to 5-fluorouracil (5-FU) was observed. Recognizing the increasing use of 5-FU, the authors tried to map this syndrome.

METHODS

They reviewed 134 additional case reports, retrieved information from literature searches, focused on clinical features, and discussed possible pathophysiologic findings and prevention of this syndrome.

RESULTS

Although angina and electrocardiographic changes were common and reproducible (approximately 90% each), coronary artery disease was found in a few patients. A total of 33 patients had severe left ventricular dysfunction, 28 without evidence of myocardial infarction. The symptoms were responsive to conservative management (90%).

CONCLUSIONS

Cardiac toxicity is a little known complication of 5-FU therapy, with an unknown but significant incidence. It is highly treatable.

Vascular events in patients receiving high-dose infusional 5-fluorouracil-based chemotherapy: the University of Chicago experience

In a retrospective review, 22 of a total of 244 patients (9%) patients with head and neck or gastrointestinal cancer who were treated with infusional 5-fluorouracil (5-FU)-based chemotherapy regimens experienced thrombotic vascular events. These events occurred concurrently with treatment or several months following the completion of therapy and consisted mainly of cardiac arrhythmias, myocardial infarction, sudden death, and thromboembolism. The temporal relationship of these vascular events to the time of treatment suggests that infusional 5-FU may have been the underlying cause.

5-Fluorouracil cardiotoxicity: a critical review

5-Fluorouracil is a commonly administered chemotherapy agent that has infrequently been associated with cardiotoxicity. This review highlights the clinical features of this syndrome as described in reports from the medical literature. Clinical and laboratory evidence supporting proposed underlying mechanisms are reviewed.

Hypotension as a manifestation of cardiotoxicity in three patients receiving cisplatin and 5-fluorouracil

Cardiac symptoms, including hypotension, developed in three patients with advanced colorectal carcinoma while being treated with cisplatin (CDDP) and 5-fluorouracil (5-FU). In two patients, hypotension was associated with severe left ventricular dysfunction. All three patients required therapy discontinuation. Cardiac enzymes remained normal despite transient electrocardiographic (EKG) changes. The presentation and cardiac evaluation (hemodynamic, echocardiographic, and scintigraphic) of these patients suggest new manifestations of 5-FU cardiotoxicity that may be influenced by CDDP. The possible pathophysiologic mechanisms are discussed.

5-Fluorouracil-associated cardiotoxicity

Cardiotoxicity manifested as myocardial ischemia is not generally recognized as a side effect of 5-fluorouracil. However, there have been at least 35 cases reported since 1975. In only one of these cases was a somewhat detailed evaluation done to rule out underlying coronary disease. The case reported here of 5-FU cardiotoxicity included an extensive cardiac evaluation to rule out underlying coronary disease and to assess spasm. The literature on 5-FU cardiotoxicity is also reviewed, and its possible mechanisms are analyzed.

5-Fluorouracil cardiotoxicity: left ventricular dysfunction and effect of coronary vasodilators

Seven patients developed clinical features simulating myocardial ischemia less than 72 hours after 12 of 13 separate intravenous 5-fluorouracil administrations; 9 episodes were associated with chest pain, 3 with hypotension, 3 with ventricular tachycardia and 1 with cardiogenic shock. Left ventricular dysfunction was demonstrated by echocardiography in 5 separate episodes, 2 with interval improvement upon repeat echocardiograms. Pretreatment with nitrates and/or calcium channel blockers failed to prevent recurrence of cardiotoxicity during 5 of 6 repeat 5-fluorouracil administrations. Therapy with 5-fluorouracil is associated with cardiotoxicity simulating myocardial ischemia with left ventricular dysfunction. Pretreatment with coronary vasodilators may not prevent this phenomenon.

Adriamycin and Epirubicin Treatment Monitored by Radionuclide Ejection Fraction during Therapy and Follow-Up

Twenty-four patients with advanced breast cancer were studied with serial determinations of the radionuclide ejection fraction at rest (RST-LVEF) during anthracycline chemotherapy (CT) and with a mean follow-up (FU) of 8 months. We had 2 cases of anthracycline congestive heart failure (CHF) during FU, 3 and 12 months respectively after the end of CT. The RST-LVEF changes observed during CT were not able to predict which patients were to develop a symptomatic cardiomyopathy. The type of RST-LVEF change that is generally considered a worsening of cardiac performance is a decline ≥ 15 %. We had this type of RST-LVEF change, in addition to the 2 CHF, in 5 other patients without symptomatic cardiomyopathy. Nevertheless none of these 5 patients attained pathological values of RST-LVEF, while the 2 CHF showed symptomatic cardiomyopathy only when RST-LVEF became clearly pathologic (≤ 46 %). Therefore, although in our study the RST-LVEF changes during CT did not have predictive value for CHF, the method may give a notable clinical contribution all the same. In fact, by submitting the patients with a RST-LVEF fall ≥ 15 % to frequent sequential RST-LVEF determinations and stopping the CT if the RST-LVEF becomes pathologic it is possible to avoid severe and irreversible CHF.

Radionuclide angiography and endomyocardial biopsy in the assessment of doxorubicin cardiotoxicity

Thirty-eight patients with a mean age of 53.2 years (19 to 75 years of age), who were receiving doxorubicin (D) for malignant disease, were studied in order to determine the relationship between functional and morphologic myocardial changes at different dose levels. Serial patient evaluations included physical examination, chest x-ray, electrocardiogram (ECG), endomyocardial biopsy (EMB), and rest-exercise gated nuclear angiography (GNA), at doses of D ranging from 144 to 954 mg/m2 (mean, 426 mg/m2). Physical examination, chest x-ray, and ECG proved to be insensitive predictors of D cardiotoxicity. Correlation of GNA and EMB in 31 patient evaluations, exclusive of known heart disease, did not reveal any false-positive angiograms, and all abnormal GNAs were associated with abnormal biopsies. Use of stress GNA uncovered six abnormal ventricles which could have been missed with a rest GNA alone. It has been suggested that: (1) GNA is a reliable monitor of D therapy; (2) an exercise study should be performed when the rest ejection fraction is normal, but is unnecessary when the rest EF is abnormal; (3) all patients with a resting ejection fraction of less than 45%, exclusive of other cardiac disease, should have D discontinued; and (4) endomyocardial biopsy is useful in assessing D cardiotoxicity in patients with other possible causes of an abnormal GNA.