We present the case of a 69-year-old female patient with a personal history of breast carcinoma who, after starting chemotherapy treatment, presented with an episode of chest pain.

HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION

Personal history
No known allergic drug reactions.
Cardiovascular risk factors: arterial hypertension. Dyslipidaemia. No known diabetes mellitus. No toxic habits.
Infiltrating breast carcinoma of non-special histological subtype G3, stage IIB, binodal pT2 (2.2 cm + 1.5 cm) distant 0.5 mm from upper margin and 0.3 cm from lower margin respectively, V1, pN1 (2/17), Mx. ER -, PR -, HER2 + (3+), ki67 20-30 %, CK 19+. Segmentectomy and axillary emptying of levels I and II was performed on 14/12/16. On 20/1/17 she was assessed in Oncology consultations and it was decided to start adjuvant chemotherapy with the following therapeutic plan:
FEC x 4 cycles (5-fluorouracil + epirubicin + cyclophosphamide) --> placlitaxel iv + trastuzumab sc x 12 weeks --> radiotherapy + trastuzumab three-weekly until completing one year. Echocardiogram prior to the start of chemotherapy: no structural heart disease and LVEF estimated by Simpson biplane of 60%.

Usual treatment: enalapril 5 mg (1-0-0), atorvastatin 40 mg (0-0-1), omeprazole 20 mg (1-0-0).

Current disease
patient with the personal history described above received the first cycle of chemotherapy (C1-FEC) on 10 February 2017. Six days later she presented with a prolonged episode (more than two hours) of oppressive central thoracic pain radiating to the left upper limb with vegetative crust. The pain gradually resolved without any medication. Consultation in the emergency department of our centre revealed elevated cardiac biomarkers, as well as electrocardiographic changes. Admission to the Cardiology Intermediate Care Unit was decided.
No previous similar episodes. No dyspnoea, no orthopnoea, no paroxysmal dyspnoea crises or other symptoms from a cardiological point of view.

Physical examination
On arrival at the ED, general condition was acceptable. Asymptomatic. Well hydrated and perfused. BP 110/60 mmHg, HR 100 bpm. Eupneic at rest, tolerating decubitus, not requiring supplementary oxygen therapy with SpO2 98%. Cardiac auscultation: rhythmic heart sounds, no murmurs. Pulmonary auscultation: preserved vesicular murmur, without aggregates. Abdomen was nondescript. No peripheral oedema or other signs of congestion.

COMPLEMENTARY TESTS
Admission electrocardiogram: sinus tachycardia at 100 bpm, left axis with QS in inferior face. QRS 80 ms. Deep symmetrical negative T waves in V2-6, DI, DII, aVL and aVF.
Chest X-ray: slight cardiomegaly. No images of parenchymal condensation. Minimal impingement of both costophrenic sinuses.

Laboratory: haemogram: leucocytes 7,270 (N 82.6%), Hb 14.3 g/dl, platelets 256,000. Renal function and ions: Cr 0.66 mg/dl, urea 35 mg/dl, sodium 132 mEq/l, potassium 4.1 mEq/l. Coagulation normal with INR 0.97. Cardiac biomarkers: TnT
US peak 788.8 ng/L (< 14 negative). Peak CK 599 mUu/ml (24-195).

Cardiac monitoring: no arrhythmic events of interest, in sinus rhythm at all times.

Echocardiogram on admission: dilated left atrium (AP diameter 40 mm, volume 41 cc/m)
AP 40 mm, volume 41 cc/m2). Mitral valve with slightly thickened leaflets, with preserved opening and tenting closure with moderate degree of insufficiency jet.
Dilated left ventricle (DTD 57 mm, VTDi 93 ml/m2, DTS 54 mm, VTSi 77 ml/m2). Normal myocardial thickness with 8 mm septum and inferolateral wall.
Global hypokinesia with severely depressed systolic function. LVEF estimated by Simpson biplane at 27%. Mitral filling pattern with impaired relaxation.
Mild aortic insufficiency. Non-dilated right ventricle with systolic function at the lower limit of normal (TAPSE 16 mm). Mild tricuspid insufficiency allowing an estimated PSAP of 46 mmHg. Dilated inferior vena cava with little inspiratory collapse. No pericardial effusion.
Coronary angiography: angiographically normal coronary arteries. Right dominance.
Cardiac MRI: left ventricle: LVEDD 65 mm, LVEDV 197 ml, LVESV 137 mL, LVEF 30%, with a systolic volume of 60 mL and an estimated cardiac output of 4.2 L/min. Right ventricle: RVEDVD 42 mm, RVEDVD 129 mL, RVSVD 75 mL, RVEF 41 %. Cine sequences show a central jet of mitral regurgitation. Late gadolinium enhancement sequences show no areas of myocardial fibrosis/shield.
Echocardiogram in consultation, after hospital discharge: non-dilated left ventricle with LVEDDVI of 51 mm with LVEF estimated by Simpson Biplane of 45%. Mild mitral insufficiency. Normal right chambers with preserved right ventricular systolic function.


EVOLUTION
Patient diagnosed with breast carcinoma of non-special histological subtype.
Segmentectomy and lymph node removal was performed in December 2016.
After assessment by Oncology, the first cycle of chemotherapy with FEC (5-fluorouracil + epirubicin + cyclophosphamide) was started at the beginning of February 2017.
One week later, she presented with an episode of prolonged chest pain with mobilisation markers of myocardial damage, electrocardiographic changes and severe left ventricular dysfunction not present in the previous echocardiogram. Coronary angiography was performed without evidence of coronary artery disease. Suspicion of acute toxic myocarditis was suspected and cardiac MRI was performed, which was finally ruled out. The patient had a good clinical evolution, with no new episodes of chest pain or signs of heart failure, and was discharged from hospital with the following treatment: bisoprolol 5 mg c/12 h, ramipril 2.5 mg c/24 h, eplerrenone 25 mg c/24 h, atorvastatin 40 mg c/24 h, esomeprazole 20 mg c/24 h.
After discharge from hospital, she was reviewed in Oncology and the next scheduled cycles of chemotherapy with FEC were suspended due to the existence of acute cardiotoxicity after the first cycle. Four weeks later she was assessed in the outpatient cardiology department and the echocardiogram was repeated with an improvement in LVEF.

DIAGNOSIS
Cardiomyopathy with severe left ventricular dysfunction induced by acute cardiotoxicity after starting chemotherapy treatment (5-FU + epirubicin + cyclophosphamide). NYHA functional class I/IV.
Infiltrating breast carcinoma of non-special histological subtype.
