Mechanisms of Myocardial Ischemia in Cancer Patients: A State-of-the-Art Review of Obstructive Versus Non-Obstructive Causes

Abstract

In patients with cancer, myocardial infarction (MI) has distinct features and mechanisms compared to the non-oncology population. Triggers of myocardial ischemia specific to the oncology population have been increasingly identified. Coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary oxygen supply-demand mismatch are all causes of MI that have been shown to have specific triggers related to either the treatments or complications of cancer. MI can occur in the presence or absence of atherosclerotic coronary artery disease (CAD). MI with nonobstructive CAD (MINOCA) is a heterogeneous syndrome that has distinct pathophysiology and different epidemiology from MI with significant CAD (MI-CAD). Recognition and differentiation of MI-CAD and MINOCA is essential in the oncology population, due to unique etiology and impact on diagnosis, management, and overall outcomes. There are currently no reports in the literature concerning MINOCA as a unified syndrome in oncology patients. The purpose of this review is to analyze the literature for studies related to known triggers of myocardial ischemia in cancer patients, with a focus on MINOCA. We propose that certain cancer treatments can induce MINOCA-like states, and further research is warranted to investigate mechanisms that may be unique to certain cancer states and types of treatment.

Incidental Detection of Myocardial Ischemia on Whole-Body PET/CT in a Patient With Carcinoma Lung

“…Under resting condition (low serum-glucose and insulin levels), myocardium primarily uses free-fatty acids owing to its higher energy yield; however, in ischemic states, myocardium shifts to glycolytic pathway for more efficient energy production. Oncologic 18 F-FDG PET/CT imaging often reveals variable patterns of myocardium FDG uptake ranging from no significant, diffuse, and focal/regional 1–4 . However, regional uptake in the myocardium may represent ischemic myocardium, particularly in regions other than basal anterolateral and basal inferolateral segments as in the present case 5–8 .…”