免疫检查点抑制剂相关心脏不良反应的诊治进展及管理策略  

Management of cardiac adverse events related to immune checkpoint inhibitors

作　　者：艾罗燕 余一祎 AI Luo-yan;YU Yi-yi(Department of Medical Oncology, Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China;Department of Cancer Prevention Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China;Department of Evidence-Based Medicine Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China)

机构地区：[1]复旦大学附属中山医院肿瘤内科,上海200032 [2]复旦大学附属中山医院肿瘤防治中心,上海200032 [3]复旦大学附属中山医院循证医学中心,上海200032

出　　处：《中国临床医学》2020年第6期917-921,共5页Chinese Journal of Clinical Medicine

基　　金：上海市科学技术委员会基金(19DZ1910102);2020复旦大学附属中山医院智慧医疗专项基金(2020ZHZS02).

摘　　要：免疫检查点抑制剂(immune checkpoint inhibitors,ICIs)给肿瘤治疗带来了翻天覆地的变化,标志着免疫治疗新时代的开启。与此同时,免疫治疗相关不良反应报道也日趋增多。免疫相关心脏不良反应虽发生率较低,但病死率极高,严重影响肿瘤患者临床转归。患者可表现为乏力、气促、胸痛、心悸等症状。实验室指标可见肌钙蛋白、氨基末端脑钠肽前体(NT-proBNP)等升高。心电图显示可有新发的传导阻滞。心脏核磁共振(cardiac magnetic resonance,CMR)显示心肌炎表现。约半数患者超声心动图示左室射血分数<50%。心内膜心肌活检作为诊断的金标准,常见组织学表现为以T细胞为主的淋巴细胞浸润。治疗上以早期应用足量激素为主,可酌情使用英夫利昔单抗、免疫球蛋白等免疫抑制剂。对使用ICIs的所有患者,尤其是伴有糖尿病病史、自身免疫性疾病病史或联合治疗的患者,用药早期建议严密监测心悸、气促、乏力等症状以及肌钙蛋白、NT-proBNP等指标。Immune checkpoint inhibitors(ICIs)have greatly improved clinical outcomes in multiple cancer types and are regarded as a new beginning of cancer immunotherapy.However,high-grade immune-related adverse events can occur.Cardiotoxic effects are not common,but are often serious complications with a relatively high mortality.Patients may have symptoms of fatigue,shortness of breath,chest pain,and palpitation.The laboratory indexes showed the increase of troponin and N-terminal B-type natriuretic peptide(NT-proBNP).The electrocardiogram shows that there may be a new conduction block.Cardiac magnetic resonance(CMR)shows myocarditis,and about half of the patients show left ventricular ejection fraction less than 50%by echocardiography.Endocardial biopsy is the gold standard for diagnosis,and the common histological manifestation is lymphocyte infiltration dominated by T cells.Early use of sufficient steroids is the main treatment,and immune-suppressants such as infliximab and immunoglobulin can be used as appropriate.For all patients using ICIs,especially those with a history of diabetes,autoimmune disease or combined treatment,it is recommended to closely monitor the symptoms such as palpitation,shortness of breath,fatigue and troponin,NT-proBNP and other indexes in the early stage of treatment.

关 键 词：免疫检查点抑制剂 心脏相关不良反应 管理策略 类固醇激素 

分 类 号：R246.5[医药卫生—针灸推拿学]