SHM Converge Scientific Abstract ePoster Gallery-Reversible 5-Fluorouracil Cardiotoxicity Mimicking Acute Coronary Syndrome: Importance of Vasodilator Prophylaxis for Safe Re-Challenge

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This case describes a 77-year-old man with hypertension who presented with 7 weeks of diarrhea and was found on colonoscopy to have a large circumferential friable rectal mass. Biopsy showed poorly differentiated mucinous adenocarcinoma with signet-ring features arising from a tubulovillous adenoma, staged T4N2M0. He began neoadjuvant modified FOLFIRINOX, which included a 48-hour continuous infusion of 5-fluorouracil (5-FU).<br /><br />About 28–30 hours into the infusion, he developed acute chest pain, shortness of breath, hypoxia, pulmonary edema, transient ST-segment elevations, and a rising troponin. Echocardiography showed severe global hypokinesis with left ventricular ejection fraction of 25%, while urgent coronary angiography revealed patent coronaries with only mild non-obstructive disease. The overall clinical picture was consistent with 5-FU-induced coronary vasospasm and secondary cardiomyopathy mimicking acute coronary syndrome.<br /><br />His symptoms improved after stopping 5-FU and providing aggressive supportive care, including diuresis and heart-failure-directed therapy. Cardiac function normalized, and he was discharged on guideline-directed medications. Importantly, he was later successfully rechallenged with bolus 5-FU rather than continuous infusion, along with prophylactic vasodilator therapy using amlodipine and isosorbide mononitrate, and did not have recurrent cardiotoxicity.<br /><br />The report emphasizes that 5-FU cardiotoxicity is uncommon but potentially life-threatening, occurs more often with continuous infusion than bolus dosing, and can present even in patients without known coronary artery disease. Early recognition, immediate discontinuation of the drug, and supportive treatment are critical. In many cases, fluoropyrimidine therapy can still be continued safely with a modified regimen and vasodilator prophylaxis, preserving access to potentially curative cancer treatment.

Asset Subtitle

Brendan Boardwine

Meta Tag

Author List Aarjuv Majmundar, Aashima Gupta, Brendan Boardwine, Brett D. Cohen, Kyle Tio, Michael Durkin, Saran Singh

Category Clinical Vignettes

Concept Fluorouracil

Concept Cardiotoxicity

Concept Coronary Vasospasm

Concept Acute Coronary Syndrome

Concept Continuous Infusion

Distinguished Non-Finalist

Presenter Organization St. Luke's University Hospital

Presenting Author Brendan Boardwine

Track Adult

Keywords

5-FU cardiotoxicity

coronary vasospasm

rectal cancer

continuous infusion

mucinous adenocarcinoma

signet-ring features

acute coronary syndrome mimic

cardiomyopathy

bolus rechallenge

vasodilator prophylaxis

Fluorouracil

Cardiotoxicity

Coronary Vasospasm

Acute Coronary Syndrome

Continuous Infusion