What is the best course of action for a patient with a history of lymphoma (lymphoma) experiencing weekly chest tightness with a normal sinus rhythm (NSR) on electrocardiogram (EKG)?

Workup and Management of Weekly Chest Tightness in a Lymphoma Patient with Normal Sinus Rhythm

This patient requires immediate evaluation for cardiac lymphoma infiltration and chemotherapy-induced cardiotoxicity, as both can present with chest symptoms despite a normal baseline ECG, and lymphoma can directly infiltrate cardiac tissue causing life-threatening complications. 1

Immediate Diagnostic Evaluation

Cardiac Imaging and Monitoring

• Obtain echocardiography urgently to evaluate for cardiac masses, pericardial effusion, ventricular dysfunction, or infiltrative disease, as lymphoma can directly infiltrate the heart and present with chest pain even when the ECG shows normal sinus rhythm 2, 1, 3
• Perform continuous cardiac monitoring or serial ECGs, as conduction abnormalities from lymphomatous infiltration can fluctuate rapidly and may not be captured on a single ECG 1, 4
• Check cardiac biomarkers including troponin, as elevated levels can indicate myocardial involvement even with normal ECG findings 2, 4

Advanced Imaging

• Obtain chest CT with contrast to identify cardiac masses, mediastinal lymphadenopathy, or infiltration of the atria or AV node, which occurs in lymphoma patients and can cause arrhythmias 1, 5, 6
• Consider cardiac MRI if echocardiography is non-diagnostic but clinical suspicion remains high for cardiac involvement 1

Risk Stratification Based on Findings

High-Risk Features Requiring Urgent Intervention

• If imaging reveals a cardiac mass or infiltration: Initiate urgent chemotherapy, as this is the definitive treatment for lymphomatous cardiac involvement and can reverse conduction abnormalities 1, 4
• If troponin is elevated or pericardial effusion is present: Admit for continuous monitoring and evaluate for myopericarditis, which requires hospitalization even with normal sinus rhythm 2, 4
• Do not place a permanent pacemaker if new conduction abnormalities develop, as these typically resolve with chemotherapy for lymphomatous infiltration 1, 4

Chemotherapy-Related Cardiotoxicity Assessment

• Review all current and prior chemotherapy agents, particularly anthracyclines (doxorubicin), alkylating agents (cisplatin), taxanes (paclitaxel), mitoxantrone, and 5-fluorouracil, which cause both tachyarrhythmias and cardiomyopathy 2, 1, 7
• If the patient is on ibrutinib for chronic lymphocytic leukemia, recognize this causes atrial fibrillation in 3% of patients typically 3-8 months after initiation 1
• Assess for heart failure symptoms (dyspnea, edema, exercise intolerance) as chemotherapy-induced cardiomyopathy can present with chest discomfort before overt heart failure develops 2, 7

Differential Diagnosis Considerations

Exclude Lyme Carditis Only If Epidemiologically Appropriate

• Do not routinely test for Lyme disease unless the patient has acute myocarditis/pericarditis of unknown cause AND lives in or has traveled to an endemic area 2, 4
• Lyme carditis presents with dyspnea, palpitations, lightheadedness, chest pain, or syncope, but requires epidemiologic exposure to warrant testing 2, 4
• The guidelines explicitly recommend against routine Lyme testing in patients with chronic cardiomyopathy or non-specific symptoms without epidemiologic support 2, 4

Other Causes to Evaluate

• Check electrolytes (potassium, magnesium) as cancer patients frequently have abnormalities that exacerbate cardiac symptoms 2, 1
• Assess for pulmonary embolism, particularly if the patient has active malignancy and risk factors for thrombosis 1
• Evaluate oxygenation status, as hypoxemia can cause chest tightness and is common in lymphoma patients with mediastinal involvement 1

Critical Pitfalls to Avoid

• Do not dismiss weekly chest tightness as "just anxiety" or "cancer-related stress" without obtaining echocardiography and cardiac biomarkers, as you may miss life-threatening cardiac lymphoma or chemotherapy-induced cardiomyopathy 2, 1
• Do not rely on a single normal ECG to exclude cardiac involvement, as lymphomatous infiltration can cause intermittent symptoms and conduction abnormalities may not be present at the time of initial evaluation 1, 4
• Do not use multiple QT-prolonging medications (ondansetron, domperidone, antiemetics, antidepressants) simultaneously with cardiotoxic chemotherapy, as this increases arrhythmia risk 2, 1
• Do not assume the chest tightness is angina and pursue coronary angiography first without ruling out infiltrative disease, as lymphoma patients are more likely to have direct cardiac involvement than coronary disease as the cause of chest symptoms 1, 3, 6