CHEST Guidelines-A-59-Year-Old-Woman-With-Shortness-of-Breath-and-C

A-59-Year-Old-Woman-With-Shortness-of-Breath-and-C

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A 59-year-old woman presented to the emergency department with syncope, progressive shortness of breath, and chest pain. She had a history of heart failure with preserved ejection fraction, well-controlled severe obstructive sleep apnea, past deep vein thrombosis and pulmonary embolism, chronic myeloid leukemia treated with dasatinib, and a smoking history. In the emergency department, she was hemodynamically stable but exhibited signs of cardiac distress.<br /><br />Diagnostic investigations showed a normal ECG with nonspecific ST-segment changes, unremarkable CBC, renal, and liver function tests, but elevated BNP levels. Imaging revealed an enlarged pulmonary conus, right ventricular, and pulmonary artery enlargement without pulmonary embolism, and echocardiography highlighted significant right ventricular pressure overload indicative of severe pulmonary hypertension.<br /><br />The diagnosis was dasatinib-induced pulmonary arterial hypertension (PAH), a rare complication of the tyrosine kinase inhibitor dasatinib used in chronic myeloid leukemia treatment. Right heart catheterization confirmed severely elevated pulmonary pressures with maintained left ventricular ejection fraction. The first step in management was the discontinuation of dasatinib, and the patient was transitioned to nilotinib. Additionally, she received dual pulmonary artery vasodilator therapy with tadalafil and macitentan.<br /><br />The therapeutic changes resulted in significant symptomatic improvement and reduction in pulmonary hypertension. Echocardiographic follow-up after 11 months showed near-normalization of right heart strains, and the patient's chronic myeloid leukemia remained in remission. This case highlights the importance of recognizing dasatinib's potential to induce PAH and the necessity of a systematic evaluation and management strategy, including drug discontinuation and vasodilator therapy.

Keywords

pulmonary arterial hypertension

dasatinib

chronic myeloid leukemia

tyrosine kinase inhibitor

right ventricular pressure overload

vasodilator therapy

heart failure

syncope

pulmonary conus enlargement

nilotinib