A 71-year-old man with undifferentiated sarcoma was treated with palliative first-line regimen (epirubicin, anlotinib and penpulimab) for 6 cycles and maintained with anlotinib and penpulimab for 30 cycles. He was admitted to the hospital due to chest pain 25 months after the first treatment. The laboratory examination showed cardiac troponin T 1.26 ng·mL^-1, N terminal pro B type natriuretic peptide 8,545 pg·mL^-1, coronary computed tomography angiography (CTA) showed non-calcified plaque in the left proximal anterior descending branch, severe lumen stenosis, nearly complete occlusion. Emergency CTA was performed on the same day, showing 50% stenosis of the distal left main coronary artery (LMCA); 95% stenosis of the left anterior descending (LAD) branch ostium, the LAD branch was medium-sized and showed no stenosis; 50% stenosis of the left circumflex branch (LCx), and a cardiac stent was implanted into the LAD branch. The patient has recovered after coronary artery stent implantation. Naranjo's Assessment Scale was used to evaluate the association of suspected drugs, the acute myocardial infarction of this patient was likely associated with the combination of penpulimab and anlotinib. Myocardial infarction is a rare but severe adverse drug reaction of anti-tumor treatment. This article summarizes the related risks and treatment measures to provide a reference for clinical medication safety.

1.Fang ZW, Chen J, Teng S, et al. Analysis of soft tissue sarcomas in 1118 cases[J]. Chin Med J (Engl), 2009, 122(1): 51-53. https://pubmed.ncbi.nlm.nih.gov/19187617/

2.Yang Z, Zheng R, Zhang S, et al. Incidence, distribution of histological subtypes and primary sites of soft tissue sarcoma in China[J]. Cancer Biol Med, 2019, 16(3): 565-574. DOI:  10.20892/j.issn.2095-3941.2019.0041.

3.中国抗癌协会肉瘤专业委员会, 中国临床肿瘤学会. 软组织肉瘤诊治中国专家共识（2015年版）[J]. 中华肿瘤杂志, 2016, 38(4): 310-320. [Sarcoma Committee of Chinese Anti-Cancer Association, Chinese Society of Clinical Oncology. Chinese expert consensus on diagnosis and treatment of soft tissue sarcomas (Version 2015)[J]. Chinese Journal of Oncology, 2016, 38(4): 310-320.] DOI: 10.3760/cma.j.issn.0253-3766.2016.04.013.

4.Burningham Z, Hashibe M, Spector L, et al. The epidemiology of sarcoma[J]. Clin Sarcoma Res, 2012, 2(1): 14. DOI: 10.1186/2045 -3329-2-14.

5.Movva S, Avutu V, Chi P, et al. A pilot study of lenvatinib plus pembrolizumab in patients with advanced sarcoma[J]. J Clin Oncol, 2023, 41(Suppl 16): 11517. DOI: 10.1200/JCO.2023.41.16_suppl.11517.

6.Tawbi H, Burgess M, Bolejack V, et al. Pembrolizumab in advanced soft-tissue sarcoma and bone sarcoma (SARC028): a multicentre, two-cohort, single-arm, open-label, phase 2 trial[J]. Lancet Oncol, 2017, 18(11): 1493-1501. DOI: 10.1016/S1470-2045(17)30624-1.

7.Hu YB, Zhang Q, Li HJ, et al. Evaluation of rare but severe immune related adverse effects in PD-1 and PD-L1 inhibitors in non-small cell lung cancer: a Meta-analysis[J]. Transl Lung Cancer Res, 2017, 6(Suppl 1): S8-S20. DOI: 10.21037/tlcr.2017.12.10.

8.Naqash AR, Moey MYY, Cherie Tan XW, et al. Major adverse cardiac events with immune checkpoint inhibitors: a pooled analysis of trials sponsored by the National Cancer Institute-cancer therapy evaluation program[J]. J Clin Oncol, 2022, 40(29): 3439-3452. DOI: 10.1200/JCO.22.00369.

9.Dolladille C, Akroun J, Morice PM, et al. Cardiovascular immunotoxicities associated with immune checkpoint inhibitors: a safety Meta-analysis[J]. Eur Heart J, 2021, 42(48): 4964-4977. DOI: 10.1093/eurheartj/ehab618.

10.Gong B, Guo Y, Li Y, et al. Immune checkpoint inhibitors in cancer: the increased risk of atherosclerotic cardiovascular disease events and progression of coronary artery calcium[J]. BMC Med, 2024, 22(1): 44. DOI: 10.1186/s12916-024-03261-x.

11.Drobni ZD, Alvi RM, Taron J, et al. Association between immune checkpoint inhibitors with cardiovascular events and atherosclerotic plaque[J]. Circulation, 2020, 142(24): 2299-2311. DOI: 10.1161/CIRCULATIONAHA.120.049981.

12.Masson R, Manthripragada G, Liu R, et al. Possible precipitation of acute coronary syndrome with immune checkpoint blockade: a case report[J]. Perm J, 2020, 24: 1. DOI: 10.7812/TPP/20.037.

13.Zhang N, Cheng S, Geng X. Red flag on electrocardiogram findings in a patient with lung cancer[J]. JAMA Intern Med, 2023, 183(7): 724-725. DOI: 10.1001/jamainternmed.2023.0346.

14.Cancela-Díez B, Gómez-De Rueda F, Antolinos Pérez MJ, et al. Acute coronary syndrome and recurrent colitis as immune-related adverse events in a lung cancer patient[J]. J Oncol Pharm Pract, 2020, 26(1): 252-255. DOI: 10.1177/1078155219865596.

15.Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions[J]. Clin Pharmacol Ther, 1981, 30(2): 239-245. DOI: 10.1038/clpt.1981.154.

16.Chen YC, Huang CY, Lien LM, et al. Cardiovascular toxicity of angiogenesis inhibitors among patients with cancer in Taiwan: a nested case-control study[J]. J Am Heart Assoc, 2024, 13(1): e030263. DOI: 10.1161/JAHA.123.030263.

17.Shen W, Jing C, Tian W, et al. Anlotinib in patients with recurrent platinum resistant/refractory ovarian cancer: a prospective, single arm, phase II study[J]. Int J Gynecol Cancer, 2023, 33(11): 1764-1770. DOI: 10.1136/ijgc-2023-004777.

18.赵亚伟, 刘康, 孙明壮, 等. 安罗替尼续接放化疗致急性心肌梗死一例[J]. 中华老年多器官疾病杂志, 2022, 21(7): 538-539. [Zhao YW, Liu K, Sun MZ. A case of acute myocardial infarction caused by anlotinib with radiotherapy and chemotherapy[J]. Chinese Journal of Multiple Organ Diseases in the Elderly, 2022, 21(7): 538-539.] DOI: 10.11915/j.issn.1671-5403.2022.07.115.

19.谭喜莹, 孙程, 李莲静. 维莫非尼联合安罗替尼致心肌梗死1例[J]. 医药导报, 2022, 41(9): 1380-1382. [Tan XY, Sun C, Li LJ. A case of myocardial infarction caused by the combination of vimafenib and anlotinib[J]. Herald of Medicine, 2022, 41(9): 1380-1382.] DOI: 10.3870 /j.issn.1004-0781.2022.09.024.

20.Liu G, Chen T, Ding Z. Anlotinib-induced acute myocardial infarction: a case report and literature review[J]. Exp Ther Med, 2020, 20(4): 3203-3207. DOI: 10.3892/etm.2020.9041.

21.Dong M, Yu T, Tse G, et al. PD-1/PD-L1 blockade accelerates the progression of atherosclerosis in cancer patients[J]. Curr Probl Cardiol, 2023, 48(3): 101527. DOI: 10.1016/j.cpcardiol. 2022.101527.

22.Poels K, van Leent MMT, Boutros C, et al. Immune checkpoint inhibitor therapy aggravates T cell-driven plaque inflammation in atherosclerosis[J]. JACC Cardio Oncol, 2020, 2(4): 599-610. DOI: 10.1016/j.jaccao.2020.08.007.

23.Guo K, Chen M, Li J. PD-1 inhibitor-induced thyrotoxicosis associated with coronary artery spasm and ventricular tachycardia[J]. Cardiovasc Toxicol, 2022, 22(10-11): 892-897. DOI: 10.1007/s12012-022-09756-4.

24.Abdel-Qadir H, Ethier JL, Lee DS, et al. Cardiovascular toxicity of angiogenesis inhibitors in treatment of malignancy: a systematic review and Meta-analysis[J]. Cancer Treat Rev, 2017, 53: 120-127. DOI: 10.1016/j.ctrv.2016.12.002.

25.Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes[J]. Eur Heart J, 2023, 44(38): 3720-3826. DOI: 10.1093/eurheartj/ehad191.

26.中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 非ST段抬高型急性冠脉综合征诊断和治疗指南（2024） [J]. 中华心血管病杂志, 2024, 52(6): 615-646. [Chinese Society of Cardiology, Chinese Medical Association, Editorial Board of Chinese Journal of Cardiology. Guidelines for the management of non-ST elevation acute coronary syndromes (2024) [J]. Chinese Journal of Cardiology, 2024, 52(6): 615-646.] DOI: 10.3760/cma.j.cn112148-20240107-00014.