Rechallenging Patients With Fluoropyridine-Induced Coronary Vasospasm

Patients on fluoropyrimidines (5-fluorouracil, capecitabine) for solid organ cancers typically present with chest pain syndromes due to drug-induced coronary vasospasm. Given the potential for life-threatening ischemia, emergent evaluation is warranted. We propose the following approach for diagnosis and management when encountering these patients in inpatient/emergency settings. Evaluation initially includes electrocardiogram and troponin testing (preferably high sensitivity) to rule out acute coronary syndrome, followed by coronary evaluation (computed tomography angiography or left heart catheterization) based on patient acuity. Exercise stress testing is contraindicated in active coronary spasm to avoid exacerbating ischemia and inducing ventricular arrhythmias. Once fluoropyrimidine-associated vasospasm is definitively diagnosed, rechallenge using a standardized vasodilatory premedication protocol in conjunction with multidisciplinary support is both feasible and effective, as evidenced by the successful outcomes in our 5 patients.