Ibrutinib: A Lifesaver With the Potential to Harm
A 64-year-old anesthesiologist with a medical history of hypertension and high-risk chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (complex cytogenetics with 17pDEL) complicated by hyperviscosity from elevated monoclonal IgG managed on ibrutinib, rituximab, and bendamustine presented with recent onset of exertional angina. Following a positive exercise stress echocardiogram with stress-induced wall motion abnormalities, he was referred for a coronary angiogram. Angiogram revealed severe multivessel coronary artery disease (CAD): long 80% tandem stenosis of the proximal to mid left anterior descending artery (LAD), chronic total occlusion (CTO) of mid LAD after a small D2 branch with left-left collaterals, 80% mid right coronary artery stenosis, CTO of the mid circumflex with faint collaterals, and 80% stenosis in the obtuse marginal 1 branch. A thorough evaluation by cardiothoracic surgery and interventional cardiology was performed with consideration of his complex situation given his high-risk CLL and ongoing therapy with ibrutinib, which is associated with platelet dysfunction and an elevated risk of bleeding. Ultimately, the patient and team opted to proceed with percutaneous coronary intervention (PCI) with coronary stenting despite the requirement for dual antiplatelet therapy (DAPT). PCI with drug-eluting stents was successfully performed for the right coronary artery and circumflex stenoses but not for the LAD CTO. A transthoracic echocardiogram at the time showed a normal left ventricular systolic function with an estimated ejection fraction of 55% with no regional wall motion abnormalities and grade I diastolic dysfunction. He was started on optimal medical therapy including metoprolol, high-intensity statin, aspirin, and clopidogrel with significant improvement in his anginal symptoms. Furthermore, the patient's CLL remained stable with improvement in his hyperviscosity. The decision was made to defer further attempts to revascularize the LAD CTO unless clinically indicated due to an acute coronary syndrome or progressive angina despite medical therapy.
In follow-up, the patient is doing well with minimal exertional angina and no complaints of palpitations or reports of major bleeding. He does note mild nuisance bleeding and easy bruising. There have also been no findings of any atrial arrhythmias during subsequent clinic visits. His CLL is under control with daily ibrutinib, monthly rituximab, and bendamustine.
What is the most common cardiovascular side effect of the Bruton tyrosine kinase inhibitor ibrutinib?