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Enigma of Chronic Troponin Elevation: Exemestane as an Unusual Offender FREE TO VIEW

Sukriti Kamboj, MD; Abhishek Mishra, MD; Cynthia Lynch, MD; Dwight Stapleton, MD
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Internal Medicine, Robert Packer Hospital/Guthrie, Sayre, PA

Chest. 2014;146(4_MeetingAbstracts):653A. doi:10.1378/chest.1991292
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SESSION TITLE: Cancer Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Aromatase inhibitors (AIs) are relatively newer agents used in HER-2 positive breast cancer in post-menopausal women. These agents inhibit conversion of androgens to estradiol, thus reducing estrogen levels in plasma and tissue.

CASE PRESENTATION: 61 years old female with multiple co morbidities including Breast CA (DCIS, HER-2 positive) on exemestane as an adjuvant therapy, Coronary artery disease (CAD) with per cutaneous intervention (2008). She had multiple hospital admissions for worsening shortness of breath/chest pain. Troponin was determined to be persistently elevated during every hospitalization in 2012 irrespective of discharge diagnosis. Elevated troponin was initially thought to be secondary to CAD and it’s complications, but cardiac catheterization showed no new coronary lesions and stents were patent. Echocardiogram showed progressive drop in left ventricular ejection fraction as well as new global wall motion abnormalities. The elevated troponin were an enigma. In absence of any other clear cause exemestane was attributed as cause of cardio toxicity. Different sources have discussed Cardio toxicity as a side effect of exemestane though there is no specific mention of chronic troponin elevation. Exemestane was discontinued and interestingly, Troponin was documented as negative, within a month and remained so.

DISCUSSION: We present a unique case of cardio toxicity and chronic troponin elevation secondary to exemestane. AIs causing increased risk of cardiovascular events /cardio toxicity has been a controversial issue. The Intergroup Exemestane study (IES) trial showed a trend towards increased cardiac events with exemestane as compared with tamoxifen.1 Other trials like ABCSG 8 study and ARNO-95 trial, BIG trial and IES trial showed statistically significant difference in cardiac events between AI and Tamoxifen groups. Exact mechanism of AIs causing cardio toxicity or chronic troponin elevation is unknown. It could be direct toxicity from the drug or it may be due to altered micro vascular changes secondary to lipid disorder. AI have been associated with greater rate of lipid metabolism disorders.

CONCLUSIONS: To summarize advances in adjuvant systemic therapy has reduced mortality rate associated with breast cancer. More women are now surviving and also receiving endocrine treatments. Additional research is required to address long term toxicity of these drugs.

Reference #1: Coombes RC, et al. First mature analysis of the Intergroup exemestane study [abstract 527] Proc Am Soc Clin Oncol. 2006;24:527.

Reference #2: Jakessz R, ,et al. Switching of postmenopausal women with endocrine responsive early breast cancer to anastrazole with 2 years adjuvant tamoxifen: combined results of the ABCSG trial 8 and ARNO 95 trial. Lancet 2005;366:455-62.

Reference #3: Mouridsen H et al: Cardiovascular adverse events during adjuvant endocrine therapy for early breast cancer using letrozole or tamoxifen: safety analysis of big 1-98 trial. J Clin Oncol. 2007;25:1-16

DISCLOSURE: The following authors have nothing to disclose: Sukriti Kamboj, Abhishek Mishra, Cynthia Lynch, Dwight Stapleton

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