CONGRESS ABSTRACT

A 87-year-old woman presented at ED with typical chest pain and SARS-COV2 infection. Past medical history included multiple myeloma treated with Lenalidomide/Daratumumab (started in the previous 15 days) and previous bioprosthetic aortic valve replacement. The initial ECG showed sinus tachycardia, LFB and "lambda-like" ST-segment elevation in the precordial leads (F1A). Coronary angiography revealed non-obstructive coronary arteries (F2). On echo: hypertrophic left ventricle with depressed systolic function (EF 45%) related to apical and mid walls akinesia (TTS-like); no bioprosthetic valve disfunction and failure; no LVOT obstruction; VEXUS 1. Lab tests showed severe hypokalemia (K 2.6 mmol/l), hypocalcemia (Ca 8.15 mmol/L), severe neutropenia, increase hsTnI values (20000 pg/ml) and CRP.  On serial ECGs there were a marked ST-segment elevation in the precordial leads with triangular waves mimicking the "shark fin" pattern and QTc prolongation (F1B). After electrolytes imbalance correction and on 7th day after Lenalidomide suspension, the ECG showed reduction in ST-segment elevation (F1C) and partial recovery of segmental kinesis, with persistent reduction of longitudinal strain in the anteroseptal regions of left ventricle (F3). In our opinion this case may be due to acute cancer therapy-related cardiovascular toxicity presenting as Takotsubo-like syndrome exacerbated by electrolyte imbalances and systemic inflammatory state reversible when therapy was stopped. Lenalidomide, an immunomodulatory and antiangiogenic agent, can lead to acute cardiotoxicity with HF, arrhythmias, VTE, myocarditis and acute myocardial infarction, probably via proteasome-mediated protein degradation and endothelial injury. Furthermore, it may be associated with hypokalemia and hypocalcemia, which, although rare, can present with electrocardiographic patterns resembling a shark fin appearance and QTc prolongation. Moreover, hypocalcemia causes coronary spasm. Acute hypersensitivity or immune-mediated myocarditis cannot be ruled out in our case because the patient refused to undergo CRM. The shark and lambda are ECG patterns associated with OMI and poor prognosis unlike our case. In conclusion, this clinical case demonstrates the importance of investigating potential underlying causes of MINOCA to uncovering the "hidden culprit" of ischemia and highlights the need for strict follow-up in patients treated with multiple myeloma cancer therapy.