Pembrolizumab, a humanised monoclonal antibody and immune checkpoint inhibitor (ICI) that blocks programmed death receptor 1 and its ligands, is an effective immunotherapy for malignancies such asmelanoma, lung, head and neck, cancers, and Hodgkin’s lymphoma. It has an overall response rate between 73% and 83%, with complete response rate of 27%–30%. It is well tolerated with minor side effects in 70% of cases characterised by fatigue, rash, pruritus and diarrhoea. In rare cases, more serious and life-threatening complications can occur at a rate of 0.3%–1.3%. We report a case of a woman in her 70s with non-small-cell lung cancer treated with ICI. She presented to the emergency department with left-sided ptosis and muscle weakness 3 weeks of her first dose of pembrolizumab infusion as a treatment plan of her cancer. She was diagnosed with myasthenia gravis, myocarditis and myositis as ICI-induced immune-related adverse effects resistant to medical intervention. We wish to raise awareness of the triad of life-threatening complication of ICI therapy that accounts for 30%–50% of fatal complications.

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Chronic coronary syndrome (CCS) is a newly proposed entity by the European Society of Cardiology that replaces stable coronary artery disease (CAD), which is defined as a progressive process of plaque accumulation in coronary circulation with associated functional changes. CCS has replaced stable CAD to raise awareness that despite the clinically silent nature of the disease, there are progressive pathological changes occurring in the coronary arteries. This has allowed clinicians to review the current various diagnostic modalities, methods of risk stratifying patients based on different models and the various management options available, including lifestyle modifications, pharmacological therapies, and revascularization. With the emergence of this new entity, great emphasis has been placed on the consolidation of our comprehension of the dynamic character of the disease and the preventative actions that aim to reduce the cardiovascular disease burden.

Funding Acknowledgements Type of funding sources: None. Background Extensive coronary artery disease (CAD) is common in diabetes mellitus. This relation between the extent of CAD and prediabetes (pDM)is less well established. Purpose To explore whether non-diabetic hyperglycaemia, assessed by HbA1c, is associated with extent of angiographic CAD, independent of traditional cardiovascular risk factors. Methods Retrospective cohort analysis of consecutive patients, without known DM undergoing coronary angiography for stable angina, who were screened for hyperglycaemia over 18 months. HbA1c was measured; pre-diabetes was defined as HbA1c 5.7-6.4%.Extent of CAD was assessed using the SYNTAX score. Presence of CAD was defined as visually estimated ≥50% luminal obstruction in arteries ≥1.5 mm diameter. Age, BMI, risk factors for CAD, HbA1c, total and LDL-cholesterol were recorded. The pre-diabetes and normal groups were compared using Mann-Whitney test for continuous variables and chi-squared test for categorical variables. Multiple logistic and linear regressions were used to assess the effect variables on SYNTAX score. Spearman rank correlation was used to assess the relation between HbA1c and SYNTAX score. Results 1071 patients had angiograms done. 207 had DM, 19 had new diagnosis of DM and 181 missed the screening leaving 664 who had HbA1c measured. 51 poor quality angiograms were excluded from SYNTAX calculation. Data was analysed for 613 (306 normal, 307 pDM) patients. The patients with prediabetes were older, had higher prevalence of risk factors, BMI, fasting glucose and SYNTAX score. HbA1c (OR 2.07, 95% CI 1.32 to 3.25, p=0.002) and the presence of pDM (OR 1.89, 95% CI 1.32 to 2.69, p<0.001) independently predicted the presence of CAD. HbA1c (Coefficient 2.42, SE 1.09, p=0.027) and the presence of pDM (Coefficient 2.25, SE 0.92, p=0.015) independently predicted the SYNTAX score. The correlation between HbA1c and SYNTAX score was weak but significant (Spearman's coefficient 0.206, 95% CI 0.129 to 0.281, p<0.0001). Conclusion HbA1c predicts the extent of CAD as measured by SYNTAX score in patients without known diabetes. Presence of pre-diabetes is an independent predictor of extent of CAD.