LETTER TO THE EDITOR

An Overlooked Cardiac Adverse Effect of Letrozol Therapy: Myocardial Infarction due to Coronary Thrombus Formation Letter to Editor: A 48-year-old postmenopausal woman with no previous cardiovascular risk factor was presented to our emergency room with squeezing chest pain and perspiration for 30 minutes. Past medical and family history were unremarkable except breast cancer. She has been diagnosed as infiltrative ductal carcinoma of the left breast and underwent left sided modified radical mastectomy 8 years ago. She also had been given adjuvant chemo/radiotherapy just after surgery. Control visits at oncology department revealed no recurrence for 10 years. During last control visit (15 days ago), positron emission tomography/computed tomography showed recurrence at left axillary lymph nodes. Hence, an aromatase inhibitor (AI) of letrozol 25 mg/ day was initiated. Her chest pain occurred on 5th day of letrozol therapy. Initial electrocardiography on admission revealed acute anterior ST segment elevation myocardial infarction (STEMI) (Fig. 1). Physical examination revealed blood pressure of 120/70 mm Hg, pulse of 77 bpm, normal cardiovascular system findings. Biochemistry panel and hemogram were in

normal reference limits. Aspirin 300 mg, unfractioned heparin 4,000 IU bolus, clopidogrel 600 mg, atorvastatin 80 mg, and metoprolol 50 mg were initiated at emergency room. She has been transferred to the cath laboratory for immediate coronary angiography, which showed that normal circumflex and right coronary (RCA) arteries and surplus of intracoronary thrombus formation at proximal segment of left anterior descending artery (LAD) (Fig. 2a). Tirofiban was administered as an intracoronary bolus injection and resulted with no change in thrombus burden (Fig. 2b). Therefore, bare metal stent implantation was performed to the proximal segment of the LAD with excellent angiographic result (Fig. 2c). The patient was followed at the coronary care unit after the procedure. Intravenous tirofiban infusion after percutaneous coronary intervention was continued. The patient discharged from hospital eventless and she was asymptomatic at 3rd month follow-up visits. Recently, as a new class of adjuvant hormonal therapy in hormone-receptor positive breast cancer patients, AIs have gained an important therapeutic

Figure 1. Electrocardiography on admission to emergency room revealed sinus rhythm with precordial ST segment elevation. ur Canpolat, MD, Address correspondence and reprint requests to: Ug €rkiye Yu €ksek _Ihtisas Training and Research Hospital, Cardiology Clinic, Tu Ankara 06100, Turkey, or e-mail: [email protected] DOI: 10.1111/tbj.12433 © 2015 Wiley Periodicals, Inc., 1075-122X/15 The Breast Journal, 2015 1–2

role (1,2). In several clinical trials, AIs have revealed superior efficacy and toxicity profiles compared to tamoxifen. However, there were controversies regarding increased risk of cardiovascular adverse events

2 • letter to the editor

(a)

(b)

(c)

with AIs and its association with lipid dysfunction. Impact of AIs on cardiovascular morbidity and mortality, through impaired lipid profiles or other mechanisms is unclear (3,4). Previously, Canpolat et al. (5) reported a postmenopausal patient with breast cancer who has developed intracoronary thrombus at RCA just after initiation of letrozol therapy. Similarly, our patient had no previously known cardiovascular risk factor in whom anterior STEMI due to intracoronary thrombus formation has been developed. As a result, AIs should be administered cautiously in postmenopausal women with breast cancer. Because of the increased risk for cardiovascular adverse events, those patients should be evaluated regularly and managed to minimize cardiovascular risks during AI treatment. CONFLICTS OF INTEREST None. Samet Yilmaz, MD Sedat Avci, MD U gur Canpolat, MD

Figure 2. Coronary angiography showed high burden of intracoronary thrombus at proximal segment of left anterior descending artery (a) which has not been regressed with intracoronary tirofiban administration (b). So, bare metal stent implantation was performed successfully.

Fatma Nurcan Basßar, MD Cardiology Clinic _ T€ urkiye Y€ uksek Ihtisas Training and Research Hospital Ankara Turkey REFERENCES 1. Clemons M, Coleman RE, Verma S. Aromatase inhibitors in the adjuvant setting: bringing the gold to a standard? Cancer Treat Rev 2004;30:325–32. 2. Breast International Group 1–98 Collaborative G, Thurlimann B, Keshaviah A, et al. A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N Engl J Med 2005;353:2747–57. 3. Gandhi S, Verma S. Aromatase inhibitors and cardiac toxicity: getting to the heart of the matter. Breast Cancer Res Treat 2007;106:1–9. 4. Cohen MH, Johnson JR, Justice R, Pazdur R. Approval summary: letrozole (Femara(R) tablets) for adjuvant and extended adjuvant postmenopausal breast cancer treatment: conversion of accelerated to full approval. Oncologist 2011;16:1762–70. 5. Canpolat U, Sunman H, Kaya EB, Aytemir K, Oto A. Myocardial infarction due to coronary thrombus formation in a postmenopausal woman with breast cancer after initiation of letrozol therapy. Int J Cardiol 2012;160:e1–2.

An Overlooked Cardiac Adverse Effect of Letrozol Therapy: Myocardial Infarction due to Coronary Thrombus Formation.

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