Most important cardiotoxicity of immune checkpoint inhibitors – Cardiology MCQ – Answer

Most important cardiotoxicity of immune checkpoint inhibitors – Answer

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Cardiotoxicity of immune checkpoint inhibitors – Correct answer: 1. Fulminant myocarditis

Immunotherapy with immune checkpoint inhibitors is becoming standard of care for multiple types of malignancies. Important immune checkpoint inhibitors are ipilimumab which acts against cytotoxic T lymphocyte-associated antigen 4 (CTLA-4); nivolumab and pembrolizumab which act against programmed cell death 1 (PD-1) and atezolizumab which targets PD-1 ligand (PD-L1).

Autoimmune fulminant myocarditis has been described in persons treated with immune checkpoint inhibitors [2]. It is associated with profound hemodynamic compromise progressing to circulatory collapse. Mechanism of toxicity is possibly related to the role of PD-1 in protecting the cardiomyocyte from autoimmune attacks [3].


  1. Varricchi G, Galdiero MR, Marone G, Criscuolo G, Triassi M, Bonaduce D, Marone G, Tocchetti CG. Cardiotoxicity of immune checkpoint inhibitors. ESMO Open. 2017 Oct 26;2(4):e000247.
  2. Frigeri M, Meyer P, Banfi C, Giraud R, Hachulla AL, Spoerl D, Friedlaender A, Pugliesi-Rinaldi A, Dietrich PY. Immune Checkpoint Inhibitor-Associated Myocarditis: A New Challenge for Cardiologists. Can J Cardiol. 2018 Jan;34(1):92.e1-92.e3.
  3. Tarrio ML, Grabie N, Bu DX, Sharpe AH, Lichtman AH. PD-1 protects against inflammation and myocyte damage in T cell-mediated myocarditis. J Immunol. 2012 May 15;188(10):4876-84.

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