Arterial Thrombosis in a Patient With Cancer: What are the Causes?

A 64-year-old male patient with a history of tobacco use (30-pack-year history; quit 5 years prior), hypertension, and dyslipidemia presents to your cardio-oncology clinic after being hospitalized for acute coronary syndrome (ACS). He was diagnosed 2 months prior with stage IIIB non-small cell lung cancer and was initiated on cisplatin and gemcitabine therapy. He tolerated his chemotherapy well, but approximately 4 weeks prior he developed sudden onset of chest pain, dyspnea, and diaphoresis while at home. Upon presentation to the emergency department, he was found to have ST-segment elevations in leads II, III, and aVF with positive troponin-I biomarker elevation with a clinical presentation consistent with an ST-segment elevation myocardial infarction (MI).

Emergent cardiac catheterization demonstrated complete occlusion of his mid-right coronary artery with no significant coronary artery disease in his other territories. He underwent percutaneous coronary intervention (PCI) with a drug-eluting stent to his right coronary artery without complications. A post transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 40-45% with inferior wall hypokinesis and no significant valvular or pericardial disease. He was discharged 2 days later on aspirin, clopidogrel, carvedilol, atorvastatin, and lisinopril, with plans to continue his chemotherapy.

He is asymptomatic from his MI and is undergoing cardiac rehabilitation as an outpatient, although sessions are limited due to his fatigue and side effects from chemotherapy. He is tolerating his post-MI cardiac medications well. You continue to uptitrate his cardiac medications as tolerated. He asks which factors have contributed to his presentation of ACS and what this means for his overall prognosis.

In this patient with advanced lung cancer receiving chemotherapy, what risk factors increased his risk of ACS, and what is his overall prognosis?

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