Ischemic Mimics in Cardio-Oncology: A Case of Post-Chemotherapy MINOCA

• hela ben turkia

  regional hospital of Ben Arous

• Raja Fadhel

• Amira Bekir

• Youssef Ebn Ebrahim

• Syrine keskes

• Sami Souissi

Advances in neoadjuvant therapies for breast cancer have increased the incidence of acute cardiotoxicity, often presenting as a diagnostic challenge in the emergency setting. We report the case of a 35-year-old female with invasive breast carcinoma, currently receiving neoadjuvant chemotherapy, who presented with acute retrosternal chest pain and ST-segment elevation in the anterior leads. Initial laboratory findings revealed a massively elevated cardiac troponin I level (5,830.60 ng/L) and severe chemotherapy-induced neutropenia. Emergency coronary angiography demonstrated unobstructed epicardial coronary arteries, establishing a working diagnosis of Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). Subsequent transthoracic echocardiography revealed apical and periapical akinesia, a phenotype consistent with Takotsubo cardiomyopathy. In the context of active oncological treatment, the diagnostic crossover between stress-induced cardiomyopathy and therapy-related myocarditis, particularly immune checkpoint inhibitor-associated myocarditis is critical. While Takotsubo syndrome is primarily managed with supportive care, acute myocarditis mandates immediate cessation of antineoplastic agents and the initiation of high-dose corticosteroids. This creates a formidable therapeutic paradox in the setting of severe neutropenia, where systemic immunosuppression poses a high risk of life-threatening sepsis. This case underscores that in patients presenting with a STEMI-like MINOCA during chemotherapy, clinical and echocardiographic findings may be insufficient for differentiation. Early Cardiac Magnetic Resonance (CMR) imaging is the definitive arbiter required to distinguish between these entities. Accurate diagnosis is essential to balance the management of fulminant cardiovascular events with the safe continuation of life-saving oncological care.

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