[Third degree atrio-ventricular blockade during a myocarditis occurring under anti-PD1 : Case report and literature review]

Exploring Pembrolizumab-Induced Myocarditis, Myositis, and Myasthenia Gravis: A Comprehensive Literature Review and Case Presentation on Bladder Cancer

Pembrolizumab, a humanized monoclonal anti-programmed cell death protein 1 (PD1) antibody, has shown efficacy in various malignancies. This article presents a case of stage III squamous cell carcinoma of the bladder treated with pembrolizumab, resulting in the development of a rare overlap syndrome known as myocarditis, myositis, and myasthenia gravis (IM3OS). While immune checkpoint inhibitors like pembrolizumab demonstrate notable antitumor activity, they also pose the risk of severe immune-related adverse events. The case underscores the importance of the early detection of IM3OS and the potential dangers associated with delayed diagnosis, offering valuable insights for healthcare providers managing patients on pembrolizumab therapy.

Cardiac arrhythmias associated with immune checkpoint inhibitors: A comprehensive disproportionality analysis of the FDA adverse event reporting system

Introduction: With the widespread application of Immune checkpoint inhibitors (ICIs), it is important to explore the association between ICIs and cardiac arrhythmias and to characterize the clinical features of ICI-associated cardiac arrhythmias in real-world studies. Objective: The purpose of this study was to characterize the main features of ICI-related cardiac arrhythmias. Methods: From January 2017 to June 2021, data in the Food and Drug Administration Adverse Event Reporting System (FAERS) database were retrieved to conduct the disproportionality analysis. For the ICI-related cardiac arrhythmia detection, signals were detected by reporting odds ratio (ROR) and information component (IC), calculated using two-by-two contingency tables The clinical characteristics of patients reported with ICI-related cardiac arrhythmias were compared between fatal and non-fatal groups, and the time to onset (TTO) following different ICI regimens was further investigated. Multivariate logistic regression was used to evaluate the association between concurrent cardiotoxicities and ICI-associated arrhythmias. Results: We identified a total of 1957 ICI-associated cardiac arrhythmias reports which appeared to influence more men (64.44%) than women (30.76%), with a median age of 68 [interquartile range (IQR) 60-75] years. Cardiac arrhythmias were reported most often in patients with lung, pleura, thymus and heart cancers (38.02% of 1957 patients). Compared with the full database, ICIs were detected with pharmacovigilance of cardiac arrhythmias (ROR025 = 1.16, IC025 = 0.19). Anti-PD-1 and anti-PD-L1 monotherapies were found to be related to higher reporting of arrhythmias, corresponding to ROR025 = 1.03, IC025 = 0.06 and ROR025 = 1.27, IC025 = 0.29, respectively, with the exception of anti-CTLA-4 monotherapies (ROR025 = 0.57, IC025 = -1.21). The spectrum of arrhythmias induced by ICIs differed among therapeutic regimens. There was no significant difference in the onset time between monotherapy and combination regimen. Moreover, reports of ICI-associated arrhythmias were associated with other concurrent cardiotoxicity, including cardiac failure [ROR 2.61 (2.20-3.09)], coronary artery disorders [ROR 2.28 (1.83-2.85)], myocardial disorders [ROR 5.25 (4.44-6.22)], pericardial disorders [ROR 2.76 (2.09-3.64)] and cardiac valve disorders [ROR 3.21 (1.34-7.68)]. Conclusion: ICI monotherapy and combination therapy can lead to cardiac arrhythmias that can result in serious outcomes and tend to occur early. Our findings underscore the importance of early recognition and management of ICI-related cardiac arrhythmias.

Bradyarrhythmias in Cardio-Oncology

The relationship between bradyarrhythmias and cancer therapies has not been well described but is increasingly recognized. There have been extensive advances in oncological pharmacotherapy, with several new classes of drugs available including targeted agents, immune checkpoint inhibitors and CAR T cell therapy. This increasing repertoire of available drugs has revolutionized overall prognosis and survival of cancer patients but the true extent of their cardiovascular toxicity is only beginning to be understood. Previous studies and published reviews have traditionally focused on conventional chemotherapies and in arrhythmias in general, particularly tachyarrhythmias. The number of patients with both cancer and cardiovascular problems is increasing globally and oncologists and cardiologists need to be adept at managing arrythmia based scenarios. Greater collaboration between the two specialties including studies with prospective data collection in Cardio-Oncology are much needed to fill in knowledge gaps in this arena. This case-based review summarizes current available evidence of cancer treatment-related bradyarrhythmia incidence (including its different subtypes), possible mechanisms and outcomes. Furthermore, we propose a stepwise surveillance and management protocol for patients with suspected bradyarrhythmia related to cancer treatment.