Carfilzomib induced cardiotoxicity in a multiple myeloma patient
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Carfilzomib induced cardiotoxicity in a multiple myeloma patient Arnold Méndez-Toro1*, Cándida Díaz-Brochero2 and Estivalis Acosta-Gutiérrez2
Abstract Proteasome inhibitors such as carfilzomib are indicated in multiple myeloma patients showing relapse and/or refractoriness of clonal activity. However, this therapy has been associated with a significant incidence of cardiotoxicity, especially in patients with known cardiovascular risk factors. Here we report a case of a 60-year-old woman with multiple myeloma, who developed severe congestive heart failure with positive myocardial injury biomarkers together with impaired LVEF and GLS, after treatment with carfilzomib. Therefore, chemotherapeutic drug was discontinued and neurohormonal blocking and diuretic therapy was started resulting in amelioration of symptoms, without changes in LVEF but with significant GLS improvement. Although high-grade cardiotoxicity is relatively rare in patients with non previous cardiac risk factors, it was a predictable side effect of carfilzomib use. Recognition of this syndrome is critical to instauration of appropriate therapy and prevention of morbimortality. Keywords: Proteasome inhibitor, Multiple myeloma, Carfilzomib, Heart disease, Heart failure, Cardiotoxicity
Background Multiple myeloma (MM) is a clonal plasma cell pathology that represents approximately 10% of the malignant hematological disorders. Average survival is approximately 5 to 7 years, with variations according to individual’s characteristics, tumor stage, cytogenetic alterations, and treatment response [1]. The phases of cancer treatment include initial therapy with immunomodulators, protease inhibitors, and dexamethasone. Subsequently, if the patient is eligible, autologous stem cell transplant (ASCT) is performed. A maintenance phase follows, and its duration varies according to the identified cytogenetic profile and individual risk factors. Finally, the last phase consists of treating patients with refractoriness or relapse despite established management. In the latter case, triple therapy with immunomodulators, dexamethasone, and proteasome inhibitors (PI) such as carfilzomib is indicated. The function of carfilzomib is to irreversibly inhibit the * Correspondence: [email protected] 1 Cardiology Unit, Universidad Nacional de Colombia, Hospital Universitario Nacional de Colombia, Bogotá, Colombia Full list of author information is available at the end of the article
protease activity of 20S proteasome, −which is responsible for inter-cellular protein degradation through the ubiquitin-proteasome–, and to disrupt cellular signaling pathways, leading the cell to apoptosis [2]. One of the most relevant adverse events of carfilzomib is its cardiotoxicity, which covers a broad range of clinical signs and symptoms classified into five categories according to its severity: 1: mild, 2: moderate, 3: severe, 4: life threatening or disabling, and 5: fatal. The last three categories described above correspond to high-grade cardiovasc
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