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Rechallenging Patients With Fluoropyridine-Induced Coronary Vasospasm: 5 Success Stories
Ushma V Majmudar1, Kriti Dhamija2, Eiraj Khan2
1Department of Cardiology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
JACC. Case Reports
|August 15, 2025
Summary
Patients receiving fluoropyrimidines for cancer may develop coronary vasospasm, causing chest pain. Early diagnosis and management, including specific testing and a premedication protocol, are crucial for successful treatment and patient outcomes.
Area of Science:
- Cardiology
- Oncology
- Pharmacology
Background:
- Fluoropyrimidines (5-fluorouracil, capecitabine) are common chemotherapies for solid organ cancers.
- A known side effect is drug-induced coronary vasospasm, presenting as chest pain syndromes.
- This vasospasm can lead to life-threatening myocardial ischemia, necessitating urgent evaluation.
Observation:
- Patients on fluoropyrimidines presenting with chest pain require emergent assessment.
- Initial evaluation includes electrocardiogram and troponin testing to exclude acute coronary syndrome.
- Further coronary evaluation via CT angiography or cardiac catheterization is guided by patient acuity.
Findings:
- Exercise stress testing is contraindicated in patients with active coronary vasospasm due to the risk of exacerbating ischemia and inducing arrhythmias.
- Fluoropyrimidine-associated coronary vasospasm can be definitively diagnosed through appropriate cardiac evaluation.
- A standardized vasodilatory premedication protocol, combined with multidisciplinary support, enables safe and effective rechallenge with fluoropyrimidines.
Implications:
- Establishes a diagnostic and management algorithm for fluoropyrimidine-induced coronary vasospasm in emergency settings.
- Highlights the contraindication of exercise stress testing in active vasospasm.
- Demonstrates the feasibility and effectiveness of rechallenging patients with fluoropyrimidines after vasospasm, using a specific protocol, leading to successful outcomes.
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