Associazione Nazionale Medici Cardiologi Ospedalieri



Cardiovascular toxicity in metastatic prostate cancer treatment: balancing risks, treating consequences

Livrieri Anna Altamura(Bari) – UOC Cardiologia PO Altamura (BA) | Massari Francesco Altamura(Bari) – UOC Cardiologia PO F Perinei Altamura (BA) | Scicchitano Pietro Altamura(Bari) – UOC Cardiologia PO F Perinei Altamura (BA)


Enzalutamide inhibits the receptor of androgen hormones. It is administered for treating metastasized prostate cancer. Enzalutamide is known to have a cardiotoxic effect.


A 76 year-old man on-treatment for hypertension and overall good health underwent radical prostatectomy and bilateral ileo-obturator lymphadenectomy in 2021 for prostate cancer.

In July 2023, infiltrated lymph node and lung/bone metastases were identified. Therefore, oncologist started Enzalutamide administration, i.e. Androgen Deprivation Therapy. Ecocardiography before therapy showed no alterations in cardiac morphology with normal left ventricle ejection fraction (LVEF).

Three months after Enzalutamide administration, he experienced worsening dyspnea and peripheral lower extremity edema. He was admitted to the emergency Department of our hospital due to worsening dyspnea at rest, diffuse crackles and increased values in brain natriuretic peptide (BNP, 3203 pg/mL) and troponins. He was transferred to Intensive Care Unit for acute heart failure. Instrumental findings: 2D ECHOCARDIOGRAPHY: LVEF ~20%, marked global hypocontractility at strain evaluation (GLS -9.3%); LUNG ULTRASOUND: abundant bilateral basal pleural effusion on the right extending to the middle field with atelectasis of the contiguous parenchyma; 24h Holter ECG: frequent supraventricular and ventricular ectopic arrhythmias.

He begins non-invasive ventilation (NIV), high-dose diuretics, and Levosimendan. We observed amelioration in symptoms, reduction in pleural effusion, peripheral edema, and BNP levels (from 3203 pg/ml to 468.6 pg/ml).

We proceed with weaning from NIV by monitoring respiratory function and performance by means of blood gas analysis. Amelioration in congestion status was evaluated by bioimpedance.

After clinical stabilization, coronary angiography was performed which highlighted a bi-vessel obstructive coronary artery disease (long critical stenosis, ~80%, on the proximal-middle section of the left anterior descending artery, ~70% at middle section of circumflex and proximal section of first margianl). Therefore, revascularization by PCI plus DES was performed on proximal-middle LAD and on CX-MO1.

Patient was discharged soon after in stable condition and underwent outpatient follow-up.


Enzalutamide might provoke important cardiotoxic effects. It might induce acute cardiac impairment and/or coronary artery diseases. Further analysis and evaluations should be performed.