Comfort rapidly progressing to severe precordial pain radiating to the interscapular

Comfort rapidly progressing to severe precordial pain radiating to the interscapular region emerged. The patient was tachypnoic, in moderate distress. The infusion was stopped and the electrocardiogram (ECG) revealed sinus tachycardia (120 bpm), ST segment depressions (2 mm) in leads I, II, aVL, V4-V6 and T wave inversions in leads I, II, aVL, V4-V6 (Figure 1A,B).Anti-anginal treatment with glyceryl trinitrate (5 mg qd) and diltiazem (60 mg tid) as well as acetylsalicylic acid (100 mg qd) and low-molecular weight heparin (bemiparin 3,500 IU qd) were initiated. Symptoms were relieved in about 20 minutes. Cardiac enzymes were not elevated in two serial measurements at 6-hour intervals. Echocardiogram revealed no hypokinetic or akinetic myocardial regions. Left ventricular function was normal and no pericardial effusion or other abnormalities were identified. Twenty-four hours after the episode, T wave inversions insisted in leads I, aVL, V4-V6 and flattened T waves appeared in leads II and aVF (Figure 1C).Aramisulpride Bleomycin was discontinued and only etoposide-cisplatin chemotherapy was decided to be continued, without any symptom recurrence. Discussion Major cardiovascular toxicity (cerebral ischemic infarction, peripheral arterial thromboembolism, myocardial infarction) of bleomycin appears to be lower than 1 3. An acute chest pain syndrome, self-limiting with no apparent etiology or complications, is also described with a frequency of about 3 4. Although rare, acute chest pain and myocardial infarction cases during bleomycin chemotherapy have been described in the literature5-10. Patients having predisposing risk factors for cardiovascular disease seem to face a higher risk3. The pathophysiologic mechanism of the acute chestDIDAGELOS MFigure 1: A) admission ECG, B) ECG during pain (acute changes marked with red circles), C) ECG 24h after the episode (changes marked with blue circles).pain described during bleomycin infusion remains unclear.Elagolix sodium Serosal inflammation, manifesting as acute pleuropericarditis as part of the more generalized mucocutaneous toxicity common to bleomycin therapy, could be a possible explanation.PMID:24883330 A vascular etiology for the pain has also to be considered, since other pulmonary vascular diseases, such as pulmonary hypertension and pulmonary embolism may cause both substernal and pleuritic chest pain even in the absence of infarction4. Further courses of bleomycin are not contraindicated, however it seems reasonable to stop the drug in those with intolerable pain or ECG changes4. Slowing the rate of infusion, analgesics and (if indicated) anti-ischemic treatment should be applied for relieving the patient and preventing further complications3,4,6. We report here a case of a young woman presenting with atypical chest pain during bleomycin infusion and ECG signs of myocardial ischemia. Anti-anginal agents were immediately administered, improving clinical presentation, while antithrombotic treatment was initiated to prevent thrombus formation in the coronary circulation. Cardiac enzymes remained negative and echocardiographic findings showed no regional abnormality. The patient had no recurrence of the chest pain and bleomycin was excluded from future therapy. Cardiovascular complications pose a rare but potential fatal adverse effect of BEP chemotherapy and should be carefully addressed, especially in patients with additional cardiovascular risk factors11-13. Physicians dealing with bleomycin-based therapies may find this knowle.