check point inhibitor myocarditis can present as acute heart failure

  • related: Oncology
  • tags: #literature #icu

The immune checkpoint inhibitor pembrolizumab targets PD-1 (named programmed cell death-1 after antiapoptotic activities were found, but now known to have a more important role as a T-cell inhibitor) and has been shown effective in non–small cell lung cancer. Immune checkpoint inhibitors, however, have the potential to induce myocarditis, as in this case, which can cause acute congestive heart failure and may even be fatal. Because the myocarditis results from immune activation, the therapy is immunosuppression. Many cases respond to steroids and cessation of therapy, but severe reactions to immune checkpoint inhibitors can be fatal, especially if other organs are involved. Adjunctive treatments for heart failure are given as well, but digoxin has not been shown to improve prognosis in heart failure, and although β-blockers are useful long term, they should not be started in the acute phase, particularly in the setting of hypotension. IV immunoglobulin has not been shown to be effective in checkpoint inhibitor–associated myocarditis.123

A 32-year-old woman is being treated for non-small cell lung cancer with the immune checkpoint inhibitor pembrolizumab. She presents to the ED with shortness of breath. Her BP is 80/60 mm Hg, heart rate is 125/min, respiratory rate is 34/min, and temperature is 37°C. She has jugular venous distension and bilateral crackles. Chest radiography shows bilateral interstitial infiltrates with a small right pleural effusion. Which of the following is most likely to produce clinical improvement?

Footnotes

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  2. Esfahani K, Meti N, Miller WH Jr, et al. Adverse events associated with immune checkpoint inhibitor treatment for cancer. CMAJ. 2019;191(2):E40-E46. PubMed ↩

  3. Mahmood SS, Fradley MG, Cohen JV, et al. Myocarditis in patients treated with immune checkpoint inhibitors. J Am Coll Cardiol. 2018;71(16):1755-1764. PubMed ↩