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5-Fluorouracil-induced cardiotoxicity during chemotherapy for adenocarcinoma of the small bowel.

CASE REPORT A 57-year-old woman with a medical history of hypertension, type 2 diabetes mellitus, hyperlipidemia, and metastatic adenocarcinoma of the small bowel (Figure 1) receiving intravenous 5-fluorouracil (5-FU)–based chemotherapy developed three episodes of “pressure-like” chest pain radiating to the left arm. The first episode occurred while finishing her first cycle of 5-FU. An electrocardiogram (ECG) study performed during the chest pain episode showed nonspecific anterolateral ST-T changes (Figure 2). Results of serial cardiac enzyme analyses were normal. Pain resolved on nitroglycerin drip and IV morphine, and the ECG changes resolved an hour later (Figure 3). The second episode occurred a week later with the start of her second cycle of IV 5-FU. This time, the chest pain was more intense and associated with shortness of breath and diaphoresis. Electrocardiogram showed ST segment elevation in leads I and aVL, with hyperacute T waves in leads V1 thru V6 (Figure 4). Acute myocardial infarction (MI) was suspected. Serial cardiac enzymes were again normal. The patient was treated with IV metoprolol, nitroglycerin, and IV morphine. Her chest pain resolved, as did the ECG changes (Figure 5). The third episode of chest pain occurred on the day of discharge. Cardiac catheterization was performed and results were found to be within normal limits (Figures 6–10). A stress test (Figure 11) and myocardial SPECT (single photon emission computed tomography) scan were performed — the results of both were normal (Figures 12 and 13). A diagnosis of coronary vasospasm due to 5-FU was supported by the cardiac testing.