Severe Reversible Heart Failure Enhanced by Sorafenib Treatment for Hepatocellular Carcinoma

The multitarget oral tyrosine kinase inhibitor sorafenib is an effective first-line treatment option in unresectable hepatocellular carcinoma. Through its mechanism of action, it has been associated with cardiotoxicity, mainly hypertension, which is usually low-grade and well-managed with behavioral changes and antihypertensor treatment adjustment, if needed. Acute, symptomatic heart failure is rarely described. We present the case of a patient with priors of arterial hypertension, dyslipidemia, type 2 diabetes mellitus, and non-alcoholic steatohepatitis-related cirrhosis of the liver, with the diagnosis of hepatocellular carcinoma treated with sorafenib, with previous excellent tolerability and stable disease. Dyspnea and detection of atrial fibrillation with severe reduction of left ventricular ejection fraction (26%), three years after the beginning of treatment, led to the diagnosis of acute heart failure with reduced ejection fraction and class IV New York Heart Association symptoms, confirmed to be enhanced by sorafenib, and partially reversible after its suspension and optimization of cardiological treatment. A multidisciplinary approach, prompt recognition, and aggressive treatment of this rare and severe toxicity are essential in determining a favorable outcome.