5-Fluorouracil Induced Takotsubo Cardiomyopathy Complicated by Left Ventricular Thrombosis

Abstract

A 42-year-old woman with a remote history of smoking and recently diagnosed anorectal cancer presented with typical anginal chest pain, dyspnea, palpitations, and hallucinations. She was started on continuous 5flurouracil (5-FU) infusion five days before presentation. Her physical examination was significant for bilateral bibasilar crackles and tachycardia. Her bloodwork was significant for an increased troponin and brain natriuretic peptide (BNP). Electrocardiogram (EKG) showed sinus tachycardia with ST elevation in multiple contiguous leads, whereas transthoracic echocardiogram (TTE) showed estimated ejection fraction of 17% with severe global hypokinesis with apical akinesis and matted thrombus at the apex. Coronary angiogram showed 20% occlusion of the left anterior descending artery. She was diagnosed with 5-FU induced Takotsubo cardiomyopathy complicated by left ventricular (LV) thrombosis. 5-FU was discontinued, uridine triacetate was given as reversal agent. Aspirin and apixaban were started for three months for LV thrombosis. Her six-week TTE showed return of normal heart function with resolution of LV thrombosis.

Portal vein thrombosis after cetuximab and 5-fluorouracil therapy in a patient with advanced colon cancer and decompensated cirrhosis: a case report and review of the literature

“…Cetuximab, as an anti-EGFR /HER monoclonal antibody, has antiangiogenic activity [ 26 ], which is thought to be a possible cause of thrombosis. Fluorouracil, on the other hand, may induce thrombosis through mechanisms involving vascular endothelial injury, resulting in vasoconstriction and spasms [ 27 ]. However, in this case of advanced colon cancer and cirrhosis, the cause of thrombosis was more likely the result of multiple factors, which may be related not only to anti-tumor treatments but also to the underlying physical condition.…”

Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus

“…In 2018, the non-vitamin K antagonist oral anticoagulants were introduced in the International Expert Consensus Document on Takotsubo Syndrome as a therapeutic option in patients with LV thrombus and/or embolization [ 76 ]. Although there is little experience in this direction, they have proven to be effective and safe [ 85 , 86 ]. No residual thrombosis was identified at the six-week follow-up, and no thromboembolic or hemorrhagic events were recorded during anticoagulation.…”