Rechallenge decision and outcomes after fluoropyrimidine related chest pain: real-world data from a cardio-oncology centre

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ID: 323407
2026
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Abstract
Abstract Background Chest pain is a frequent type of cardiotoxicity during fluoropyrimidine treatment and may lead to permanent discontinuation of the treatment, with a potential negative impact on cancer prognosis. However, the evidence behind current recommendations is mainly limited to small case series, and data on fluoropyrimidine rechallenge remains scarce. Purpose To assess rechallenge decision and outcomes after fluoropyrimidine related chest pain in a real-world cohort. Methods We performed a retrospective cohort study including all patients referred to a cardio-oncology service for chest pain during fluoropyrimidine treatment between 2021 – 2025. Demographic and cancer related factors were assessed, as were details of the chest pain episode and final diagnosis. Rechallenge recommendations, preventive strategies and outcomes were analysed. Results Forty patients were included (mean age 62yo and 38% females). Nineteen received 5-fluorouracil and twenty-one received capecitabine. 6 were diagnosed with likely or confirmed vasospasm, in 6 an alternative cardiac cause was identified, in 24 the cause of pain was indeterminate, and in 4 there was a non-cardiac cause. After cardio-oncology assessment and multidisciplinary team discussion, fluoropyrimidine rechallenge was considered feasible if clinically indicated in 32 patients (80%). Concomitant preventive strategies targeting chest pain and coronary vasospasm were heterogeneous (Figure 1). In 12 patients, no specific preventive therapy targeting coronary vasospasm was recommended. In some patients, management focused on optimization of underlying coronary artery disease was done; in others, short-acting nitrates were prescribed only on an as-needed basis. No specific intervention was done when chest pain was not considered cardiac or had resolved. Ultimately, 23 patients underwent rechallenge (figure 2). After rechallenge, recurrent chest pain occurred in 8 patients (35%) however, the rate of significant complications was low (acute myocardial infarction (1), arrythmia (0), death (0)) and in 5 (63%) treatment was still continued safely. Conclusions In a real-world cardio-oncology setting, fluoropyrimidine re-challenge, after chest pain, is commonly recommended and can be safely implemented in some selected patients following careful risk-benefit consideration and concomitant initiation of cardioprotective strategies. However, rechallenge strategies remain heterogeneous and further studies are warranted to better identify patients who are at risk of developing chest pain, as well as to build the evidence base for the appropriate cardiac and oncological strategies to enable successful rechallenge.Recommended rechallenge strategies Rechallenge decisions and outcomes
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Authors A Pons Riverola, L Ruane, A R Lyon, S Nazir
Journal European heart journal supplements : journal of the European Society of Cardiology
Year 2026
DOI
10.1093/eurheartjsupp/suag097.187
URL
https://doi.org/10.1093/eurheartjsupp/suag097.187
Keywords Keywords not found

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