Acute coronary syndrome as a rare manifestation of cardiac metastasis in melanoma: a case report

Introduction: Cardiac tumor manifestations are non-specific and can mimic various cardiovascular diseases. Melanoma is one of the most common sources of secondary cardiac tumors. Diagnosing cardiac metastasis in melanoma is challenging due to its predominantly asymptomatic course. We present a rare case of melanoma manifesting as acute myocardial infarction.

Case Description: A 51-year-old male, who underwent cutaneous melanoma excision, lymphadenectomy, and nivolumab immunotherapy 5 years prior, was admitted to the intensive care unit with intense chest pain. Admission electrocardiogram showed atrial fibrillation and ST-segment elevation in leads V2-V5. Laboratory tests revealed elevated high-sensitivity troponin levels. Coronary angiography showed no significant coronary artery stenosis. Cardiac magnetic resonance (CMR) revealed multiple intramyocardial masses in the walls of both ventricles, suggestive of metastatic involvement. Positron emission tomography/computed tomography (PET/CT) confirmed the diagnosis of metastatic melanoma with cardiac involvement. The patient was started on combined immunotherapy with nivolumab and ipilimumab. Follow-up examination (cardiac MRI, PET/CT) at 3 months demonstrated significant regression in size and metabolic activity of tumor foci both in the heart and other organs. No serious adverse events were observed during therapy; the patient continued maintenance monotherapy with nivolumab.

Conclusions: Despite its typically asymptomatic course, cardiac metastasis in melanoma can present with chest pain, ST-segment changes, and elevated troponin levels, mimicking acute coronary syndrome. CMR is a clue in the differential diagnosis of myocardial injury in patients without obstructive coronary artery disease. This case demonstrates an efficacy of immunotherapy in regression of melanoma metastases in the heart and other organs.

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