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Sudden death: case report A woman receiving trastuzumab developed left ventricular dysfunction and experienced sudden death, which may have been triggered by the use of tianeptine, diazepam and estazolam. In March 2008, at 57 years of age, the woman underwent breast conservation surgery for invasive ductal carcinoma of her left breast. Her past medical history included the following: a prior episode of multiform erythema [sic] attributed to lamotrigine; depressive syndrome treated with tianeptine, diazepam and estazolam [dosages and durations of therapies not stated]; and supraventricular extrasystoles, documented 6 months prior to surgery, treated with atenolol. She then underwent a prechemotherapy echocardiogram, which was remarkable for mild posterior leaflet mitral valve prolapse, and received six cycles of chemotherapy followed by adjuvant radiotherapy. Treatment resulted in minimal toxicity. She began receiving tamoxifen in September and adjuvant trastuzumab in October [dosage not stated]. In January 2009, she was briefly hospitalised for depression. On 16 March, an echocardiogram showed an asymptomatic decrease in her left ventricular shortening fraction (23%) and left atrial enlargement (64mm). Atenolol was switched to perindopril, and trastuzumab was withheld (last infusion on 9 March). However, 14 days later, the woman was found dead; there was no evidence of suicidal intent. A subsequent autopsy showed left ventricular hypertrophy, myocardial lymphocytic infiltrate and pulmonary congestion; there was no sign of breast cancer. Arrhythmia was assumed and reported as her cause of death. Author comment: "We believe that the patient now reported had sudden cardiac death from arrhythmia, which may have been triggered by the proarrhythmic effect on antidepressants, in the setting of subclinical LV [left ventricular] dysfunction. We caution on the potential cardiac risk of concomitant use of potentially proarrhythmic drugs, such as antidepressants, in patients undergoing treatment with trastuzumab, at least if there is impairment of LV function." Oliveira M, et al. Sudden death during adjuvant trastuzumab therapy of breast cancer. Annals of Oncology 21: 901, No. 4, Apr 2010. Available from: URL: http:/ 803021230 /dx.doi.org/10.1093/annonc/mdp587 - Portugal

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Reactions 19 Jun 2010 No. 1306