Identification and Management of Immune Checkpoint Inhibitor–Related Myocarditis: Use Troponin Wisely

Myocarditis is an uncommon, but fearsome complication of immune checkpoint inhibitors (ICPis) because it may result in life-threatening heart failure, cardiogenic shock, and arrhythmias. Among more than 20,000 patients treated with nivolumab and/or ipilimumab until April 2016 and included in a safety database of Bristol-Myers Squibb regardless of adverse events (AEs), 0.09% experienced myocarditis and less than 0.03% experienced fatal myocarditis. Of all 964 patients at the Massachusetts General Hospital who received ICPis between November 2013 and July 2017, 1.14% developed myocarditis and 0.52% had major cardiovascular AEs. According to a recent study, 122 cases of ICPi-related myocarditis were recorded since 2013 in VigiBase, the WHO database of individual patient safety reports. Classification was severe in 84%, and death was more frequent with combination than with single immune therapy (66% v 40%).