Background The cardiotoxicity of ramucirumab is still insufficiently known. Careful cardiovascular evaluation should be recommended prior to and during ramucirumab therapy

Purpose To describe the consequences of an acute coronary syndrome (ACS) on the pharmacotherapeutic treatment of a patient with gastric adenocarcinoma receiving ramucirumab.

Material and methods Data was obtained by reviewing the electronic medical records. Karch–Lasagna, Naranjo and WHO-UMC algorithms have been used.

Results A 70-year-old male, former smoker and with hypertension, was diagnosed with gastric adenocarcinoma (uT4N+) in April 2012. He underwent chemotherapy, chemo-radiotherapy and gastrectomy (pT1a,N1,M1). In July 2014, due to locoregional progression, he again received chemotherapy.

In March 2016, the third line of chemotherapy with paclitaxel (P) and ramucirumab (R) was started. After four cycles the patient had a radiological response. Then paclitaxel was discontinued due to asthaenia, subsequently administrating ramucirumab.

On April 2017, after 29 doses of ramucirumab and in the absence of progression, the patient presented angina on exertion. 72 hours’ later, he went to the Emergency Department because of chest pain at rest. He was diagnosed with ACS Killip 1. A cardiac catheterisation was performed, observing critical lesions at the right coronary and posterior descending arteries. A percutaneous revascularisation was required. Ramucirumab’s administration was stopped and a yellow card was completed. The echocardiogram assessment upon discharg revealed a normal left-ventricular systolic function and no regional contractility deficits.

Three months’ later, in July 2017, radiological progression was observed. Progression-free survival (PFS) was 16 months, much higher than the median PFS observed at pivotal trial (median=4.4 months) and even greater than overall survival (median=9.6 months) in the same study.

Karch–Lasagna established a ‘probable’ relation between ACS and ramucirumab. WHO-UMC and Naranjo algorithms classified it as ‘possible’. The patient’s cardiovascular risk factors were significant regardless of the use of ramucirumab.

The patient is currently receiving paclitaxel-bevacizumab, without cardiovascular events and stable disease. Overall survival since the onset of ramucirumab is 18 months.

Conclusion The appearance of an ACS has caused the suspension of an effective drug such as ramucirumab despite the doubtful causal relation between them if we take into account the cardiovascular risk factors of the patient.

No conflict of interest