Acute myocardial infarction following G-CSF treatment

Background: Granulocyte-colony stimulating factors (G-CSF) are commonly used for prevention of chemotherapy-induced neutropenia. G-CSF and granulocyte-macrophage colony-stimulating factor treatment also have been associated with coronary neovascularization, however the clinical benefits remain unclear due to limited and inconclusive clinical data.

Case Report: A 62 year old male patient with small cell lung cancer received 6 mg pegfilgrastim on day 4 of his second cycle of chemotherapy with carboplatin, etoposide and atezolizumab. On the following day the patient presented with an acute posterior myocardial infarction (STEMI). Coronary angiography showed an absence of atherosclerosis but found an acutely occluded RCA (Fig 1). Aspiration thrombectomy was performed with the Indigo CAT RX Aspiration System, which allows sustained mechanical aspiration, resulting in a substantial reduction in thrombus burden and TIMI III flow (Fig 2A and B). Blood analysis initially revealed leukocytosis (82.13/nl) and thrombocytosis (773/nl). The patient was closely monitored for other clinical manifestations of hyperviscosity syndrome. Sources for embolism were ruled out by transesophageal echocardiography. The blood counts were normalized at discharge.

Conclusion: Leukocytosis secondary to G-CSF treatment must be considered as a potential cause for acute myocardial infarction in cancer patients without history for cardiovascular disease. Thrombectomy remains an important adjunctive tool on a case-by-case basis. 

Fig 1 Initial coronary angiography of the RCA 



Fig 2A RCA post aspiration thrombectomy 



Fig 2B Thrombi removed by the Indigo CAT RX Aspiration System