Background:
Immune checkpoint inhibitors (ICIs) have become a cornerstone of modern oncologic therapy but are associated with cardiovascular toxicity. Myocardial injury—including myocarditis, microvascular dysfunction, and acute coronary syndromes (ACS)-like presentations without obstructive coronary artery disease—has increasingly been reported. However, real-world data on the incidence of ACS requiring percutaneous coronary intervention (PCI) in this population are limited.
Methods:
We conducted a retrospective analysis of 512 consecutive cancer patients receiving ICI therapy who were evaluated at a dedicated cardio-oncology center between 2018 and 2023. Demographic characteristics, cardiovascular risk factors, cancer type and treatment, laboratory findings, imaging data, and clinical outcomes were systematically collected. The primary endpoint was myocardial infarction requiring PCI. Secondary endpoints included ischemic events without PCI, ICI-associated myocarditis, and non-ischemic myocardial injury.
Results:
The cohort had a median age of 62.9 ± 14.2 years; 39.8% were female. The most common cardiovascular comorbidity was hypertension (56.6%), followed by atrial fibrillation (10.2%) and pre-existing coronary artery disease (8.6%). Left ventricular ejection fraction was preserved (>50%) in 87.1% of patients.
During follow-up, troponin elevation occurred in 6.6% (n = 34). Fourteen patients (2.7%) developed myocardial infarction, and 12 patients (2.3%) underwent PCI. Newly diagnosed coronary artery disease was observed in 1.6% (n = 8). Myocarditis occurred in 4.9% (n = 25), while isolated non-ischemic myocardial injury was identified in 0.6% (n = 3).
Conclusion:
In this real-world cardio-oncology cohort, the incidence of myocardial infarction requiring PCI among patients receiving ICI therapy was low (2.3%). Myocarditis (4.9%) and isolated myocardial injury occurred at expected frequencies. Most cardiac biomarker elevations were not related to obstructive coronary disease, highlighting the diagnostic challenge in this setting. These findings underscore the need for structured evaluation pathways to promptly identify patients with ACS who benefit from urgent coronary intervention while accurately recognizing immune-mediated myocardial injury in this high-risk-population.
