The development of congestive heart failure and ventricular tachycardia after first exposure to idarubicin in a patient with acute myeloid leukaemia

Abstract

Although anthracyclines are recognized as efficacious chemotherapeutic agents with broad-spectrum anticancer activity, their clinical use is limited by their chronic accumulative dose-dependent cardiac toxicity. Three forms of anthracycline-induced cardiotoxicity have been described: acute or subacute cardiac injury, chronic cardiotoxicity resulting in cardiomyopathy, and late-onset ventricular dysfunction with arrhythmias. Acute and subacute anthracycline toxicities are most often manifested as arrhythmias, pericarditis-myocarditis, subclinical cardiomyopathy, left ventricular dysfunction, and sudden death [1,2]. However, acute cardiac toxicity is uncommon and is usually subclinical in nature or is associated with mild clinical symptoms lacking significant consequences. This report describes a case of severe subacute congestive heart failure (CHF) and ventricular tachycardia (VT) developing in response to the first exposure to idarubicin.A pale-faced 34-year-old woman presented to our haematology outpatient clinic with the complaint of general malaise of 1 month's duration. No systemic disease had occurred prior to this illness and she had no history of coronary artery disease, smoking, or illegal substance abuse. Bone marrow examination confirmed the presence of acute myeloid leukaemia (AML), M6 subtype. Induction chemotherapy with idarubicin and cytarabine was therefore initiated. Idarubicin was administered at 12 mg m -2 day -1 for 3 days by a 30-min intravenous infusion, and cytarabine was administered at 100 mg m -2 day -1 for 7 days by continuous (24 h) intravenous infusion. A neutropenic fever developed on day 10,and empirical antibiotic therapy with piperacillin/tazobactam and amikacin was prescribed. Because the fever persisted, antibiotic therapy was changed to meropenem on day 15 and fluconazole was added on day 18. When blood laboratory analyses conducted on day 17 revealed the presence of hypokalaemia, potassium (KCl solution) was given intravenously.Even after aggressive potassium chloride supply, serum levels of potassium on day 27 were 2.53 mmol l -1 . On day 20, the patient displayed tachypnoea and shortness of breath. Chest x-ray revealed cardiomegaly and right pleural effusion. Echocardiography performed on day 26 revealed chamber dilation of the left atrium and left ventricle, generalized hypokinetic wall motion, and a left ventricular ejection fraction (LVEF) of 23% (Figure 1).Prior to the development of CHF,the patient exhibited no symptoms or signs of arrhythmia or pericarditis-myocarditis. Cardiac marker measurements of creatine kinase isoenzyme (CK-MB) and troponin-I on day 24 were all within normal ranges.Frequent ectopic premature ventricular beats were detected on day 27, with the arrhythmia progressing to VT and ventricular fibrillation on day 28. Because of a sudden loss of consciousness, cardiopulmonary resuscitation with defibrillation was performed immediately. Intubation with ventilatory support and an intra-arterial balloon pump were placed to manage cardiogenic shock and pulm...

Anthracycline-related cardiotoxicity in older patients with acute myeloid leukemia: a Young SIOG review paper

“…3,4 Acute cardiotoxicity is typically not dose-dependent and may present as acute HF, arrhythmia, or myocarditis. [5][6][7][8] The spectrum of clinical presentation of chronic cardiotoxicity ranges from subclinical LVEF decline to HF. Cardiotoxicity is frequently found following anthracycline use and is generally defined as .10% decrease in LVEF to final LVEF ,50%.…”

The heart after idarubicin overdose. Cardiac death in a patient with acute promyelocitic leukaemia

“…Timing of administration is likely crucial; indeed, our patient died after receiving 175 mg/m 2 distributed in 4 administrations over 6 days, and a cumulative dose of just 36 mg/m 2 has been reported to cause severe heart failure and ventricular tachycardia, when administered with a similar schedule [9] (for details, see Table 1). …”

First-dose idarubicin cardiomyopathy: a case of new heart failure after induction chemotherapy for acute myeloid leukaemia

“…Many documented cases of doxorubicin cardiotoxicity exist. However, only one case of acute first-exposure idarubicin cardiotoxicity has been documented 2. Herein, we describe a case of acute cardiomyopathy within days following induction cycle of idarubicin-based treatment for acute myeloid leukaemia.…”