Imatinib-induced decompensated heart failure in an elderly patient with chronic myeloid leukemia: case report and literature review
An 88-year-old male with CML was admitted to our hospital on August 24, 2010 because of significantly high white blood cell and platelet counts. He had been diagnosed with MDS-U in September 2009 and CML in August 2010. Cytogenetic studies had shown positive results for the t(9;22) PDGFR fusion gene and BCR-ABL (12.2% b2a2). His medical history included hypertension (well controlled), type 2 diabetes mellitus (well controlled), and permanent atrial fibrillation with a satisfactory heart rate. On admission, B-type natriuretic peptide (BNP) concentrations were 2,467 pg/mL and a chest X-ray film was normal (). An ECG revealed T-wave inversion and ST-segment depression in I, aVL, V5 and V6. An echocardiogram showed left and right atrial enlargement ().\nOn physical examination, the patient was in good general condition and his vital signs were within the normal range. No orthopnea or jugular venous distension was detected. Clear breath sounds were heard bilaterally; no rales were heard. There was no cardiac enlargement and the rhythm was irregular (heart rate, 86 beats/min). The first heart sound at the apex was faint, no cardiac murmurs were heard. There was no hepatomegaly or edema of the lower limbs.\nOn August 25, 2010, oral imatinib mesylate monotherapy (Gleevec, Novartis, 400 mg once daily) was started. The patient complained of mild abdominal distension. On the 2nd day after the initiation of therapy, he developed nausea and vomiting. His dose of imatinib was reduced to 200 mg daily and his gastrointestinal symptoms improved slightly. On day 4 of imatinib therapy, the patient complained of orthopnea and moderate edema was found in both legs. Biochemical test showed a plasma BNP concentration of 14,228 pg/mL. Plasma TnI, blood urea nitrogen and serum creatinine were in the normal range (). An echocardiogram showed a slightly decreased LV ejection fraction (EF) and enlarged left atrial and ventricular chambers (). A chest X-ray film revealed an enlarged cardiac profile and a pleural effusion (). His ECG was similar before and after imatinib treatment. A diagnosis of acute heart failure was made and imatinib discontinued. He was prescribed comprehensive therapy including oxygen inhalation, diuretics and vasodilators according to the ACC/AHA 2009 guidelines for the diagnosis and management of heart failure in adults. By September 11, 2010, the patient's symptoms and signs of heart failure had resolved and findings of biochemical tests, chest X-ray film and echocardiogram were all consistent with recovery.