Can fluconazole (antifungal medication) cause chest pain?

Fluconazole and Chest Pain

Fluconazole can cause chest pain in rare cases, particularly related to cardiac side effects such as QT prolongation and arrhythmias like torsade de pointes. 1

Cardiac Side Effects of Fluconazole

• Fluconazole has been associated with QT interval prolongation, which can lead to torsade de pointes, a potentially life-threatening ventricular arrhythmia that may present with chest pain 1
• There is a documented case of a patient developing torsade de pointes after 8 days of fluconazole therapy, with symptoms resolving after discontinuation of the medication 1
• The mechanism appears to be depression of rapidly activating delayed rectifier potassium currents, which affects cardiac repolarization 1

Risk Factors for Fluconazole-Related Chest Pain

• Pre-existing cardiac conditions such as coronary artery disease, cardiomyopathy, or congestive heart failure may increase risk 1
• Electrolyte abnormalities, particularly hypokalemia or hypomagnesemia, can potentiate cardiac effects 1
• Concurrent use of other medications that prolong QT interval can increase risk 1
• Critical illness may predispose patients to adverse effects of fluconazole 2

Clinical Approach to Chest Pain in Patients on Fluconazole

• For patients on fluconazole who develop chest pain:

  • Obtain an ECG to evaluate for QT prolongation or arrhythmias 1
  • Check electrolyte levels, particularly potassium and magnesium 1
  • Consider discontinuation of fluconazole if QT prolongation is present 1
  • Monitor cardiac rhythm until symptoms resolve 1

• For high-risk patients receiving fluconazole:

  • Consider baseline ECG before starting therapy 1
  • Implement serial electrocardiographic monitoring during treatment 1
  • Maintain vigilance for symptoms such as palpitations, dizziness, or chest pain 1

Alternative Antifungal Options

• If fluconazole must be discontinued due to chest pain or cardiac effects, alternative antifungal options include:
  • Echinocandins (caspofungin, micafungin, anidulafungin) for candidemia 3
  • Lipid formulation amphotericin B for severe fungal infections 3
  • Voriconazole for aspergillosis (note that voriconazole can also cause QT prolongation) 3

Other Notable Adverse Effects of Fluconazole

• Fluconazole can also cause adrenal insufficiency in critically ill patients, which requires monitoring 2
• Gastrointestinal side effects are common but generally less severe than with other antifungals 4
• Hepatotoxicity can occur and may require monitoring of liver function tests 3

Clinical Pearls

• Fluconazole is generally well-tolerated compared to amphotericin B, with fewer adverse events (13% vs 81%) 4
• Despite potential cardiac effects, fluconazole remains an important first-line agent for many fungal infections due to its efficacy and overall safety profile 3
• The risk of serious cardiac events appears to be low in patients without predisposing factors 4
• When chest pain occurs in a patient on fluconazole without other clear etiology, consider drug-related cardiac effects 1