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      Utility of Alpha-Blockade in a Hypotensive Pheochromocytoma Patient with Myocardial Infarction

      case-report

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          Abstract

          Objective

          The aim of this case study is to emphasize the importance of α-blockade in managing a rare complication of an untreated pheochromocytoma.

          Clinical Presentation and Intervention

          A 41-year-old man with previous bilateral pheochromocytoma presented with chest pain. He was suffering from cardiac failure and persistent hypotension requiring an inotrope. Cardiac markers, an electrocardiogram and an echocardiogram confirmed acute myocardial infarct with poor ejection fraction and global hypokinesia. An 18F-fluorodeoxyglucose PET/CT scan showed progressive left suprarenal and organ of Zuckerkandl pheochromocytomas. Blood pressure stabilisation proved challenging but was achieved by titrating an incremental dose of α-blocker against a tapering inotropic dose.

          Conclusion

          This case showed the efficacy of an α-blocker despite persistent hypotension in a patient with pheochromocytoma-induced cardiomyopathy.

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          Cardiovascular manifestations of phaeochromocytoma.

          Aleksander Prejbisz, Jacques Lenders, Graeme Eisenhofer … (2011)
          Clinical expression of phaeochromocytoma may involve numerous cardiovascular manifestations, but usually presents as sustained or paroxysmal hypertension associated with other signs and symptoms of catecholamine excess. Most of the life-threatening cardiovascular manifestations of phaeochromocytoma, such as hypertensive emergencies, result from a rapid and massive release of catecholamines from the tumour. More rarely, patients with phaeochromocytoma present with low blood pressure or even shock that may then precede multisystem crisis. Sinus tachycardia, with palpitations as the presenting symptom, is the most prevalent abnormality of cardiac rhythm in phaeochromocytoma, but tumours can also be associated with more serious ventricular arrhythmias or conduction disturbances. Reversible dilated or hypertrophic cardiomyopathy are well established cardiac manifestations of phaeochromocytoma, with more recent attention to an increasing number of cases with Takotsubo cardiomyopathy. This review provides an update on the cause, clinical presentation and treatment of the cardiovascular manifestations of phaeochromocytoma. As the cardiovascular complications of phaeochromocytoma can be life-threatening, all patients who present with manifestations that even remotely suggest excessive catecholamine secretion should be screened for the disease.
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            Cardiovascular complications in patients with pheochromocytoma: a mini-review.

            Fabio Galetta, Ferdinando Franzoni, Giampaolo Bernini … (2010)
            Phaeochromocytomas are rare neuroendocrine tumours secreting high levels of catecholamines, able to exert serious metabolic and cardiovascular effects. The serious and potentially lethal cardiovascular complications of these tumours are due to the potent effects of secreted catecholamines, especially noradrenaline, the main transmitter released from sympathetic nerve terminals. Hypertension, tachycardia, pallor, headache and anxiety, usually dominate the clinical presentation. Occasionally, patients with predominantly epinephrine-secreting tumours present hypotension or even shock. Other cardiovascular complications of pheochromocytoma include ischaemic heart disease, acute myocardial infarction, cardiac arrhythmias, heart failure due to toxic cardiomyopathy, or pulmonary edema. Catecholamines have been shown to influence the extracellular matrix with collagen deposition and subsequent fibrosis in the arterial wall and in the myocardium. These morphofunctional changes of the myocardium and of arterial wall can be emphasized by ultrasound imaging. Indeed, ultrasound imaging of the myocardium and arterial wall not only identifies wall thickness but also contains information on texture that may be revealed by acoustic tissue characterization. The latter can be quantified through videodensitometric analysis of echographic images or through ultrasonic integrated backscatter signal analysis. This paper reviews cardiovascular complications in patients with pheochromocytoma and utility of the new ultrasound technique as backscatter signal. It is useful for evaluating preclinical pathological morphofunctional changes of the myocardium and arterial wall, characterized by increased collagen content in pheochromocytoma patients. The recognition of early catecholamine-induced alterations in patients with pheochromocytoma, is important to prevent at least morbidity and mortality, before surgical treatment.
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              Prevalence and Patterns of Left Ventricular Dysfunction in Patients with Pheochromocytoma

              Jae-Hyeong Park, Kyu Seop Kim, Ji-Young Sul … (2011)
              Background Excessive catecholamine release in pheochromocytoma is known to cause transient reversible left ventricular (LV) dysfunction, such as in the case of pheochromocytoma-associated catecholamine cardiomyopathy. We investigated patterns of clinical presentation and incidence of LV dysfunction in patients with pheochromocytoma. Methods From January 2004 to April 2011, consecutive patients with pheochromocytoma were retrospectively studied with clinical symptoms, serum catecholamine profiles, and radiologic findings. Patterns of electrocardiography and echocardiography were also analyzed. Results During the study period, a total of 36 patients (21 males, 49.8 ± 15.8 years, range 14-81 years) with pheochromocytoma were included. In the electrocardiographic examinations, normal findings were the most common findings (19, 52.8%). LV hypertrophy in 12 cases (33.3%), sinus tachycardia in 3 (8.3%), ischemic pattern in 1 (2.8%) and supraventricular tachycardia in 1 (2.8%). Echocardiographic exam was done in 29 patients (80.6%). Eighteen patients (62.1%) showed normal finding, 8 (27.6%) revealed concentric LV hypertrophy with normal LV systolic function, and 3 (10.3%) demonstrate LV systolic dysfunction (LV ejection fraction < 50%). Three showed transient LV dysfunction (2 with inverted Takotsubo-type cardiomyopathy and 1 with a diffuse hypokinesia pattern). Common presenting symptoms in the 3 cases were new onset chest discomfort and dyspnea which were not common in the other patients. Their echocardiographic abnormalities were normalized with conventional treatment within 3 days. Conclusion Out of total 36 patients with pheochromocytoma, 3 showed transient LV systolic dysfunction (catecholamine cardiomyopathy). Pheochromocytoma should be included as one of possible causes of transient LV systolic dysfunction.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Med Princ Pract
                Journal ID (iso-abbrev): Med Princ Pract
                Journal ID (publisher-id): MPP
                Title: Medical Principles and Practice
                Publisher: S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.ch )
                ISSN (Print): 1011-7571
                ISSN (Electronic): 1423-0151
                Publication date (Print): January 2015
                Publication date (Electronic): 22 November 2014
                Publication date PMC-release: 22 November 2014
                Volume: 24
                Issue: 1
                Pages: 96-98
                Affiliations
                [1] aDepartment of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
                [2] bDepartment of Molecular Imaging and Nuclear Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
                Author notes
                *Dr. Norasyikin A. Wahab, Department of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Jalan Yaacob Latif, Cheras, Kuala Lumpur 56000 (Malaysia), E-Mail naw8282kt@ 123456gmail.com
                Article
                Publisher ID: mpp-0024-0096
                DOI: 10.1159/000369021
                PMC ID: 5588189
                PubMed ID: 25428406
                SO-VID: d8da9081-055f-45b2-b4d2-b8c804b04b13
                Copyright © Copyright © 2014 by S. Karger AG, Basel
                License:

                This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.

                History
                Date received : 3 July 2014
                Date accepted : 13 October 2014
                Page count
                Figures: 1, References: 7, Pages: 3
                Categories
                Subject: Case Report

                Keywords: pheochromocytoma,cardiomyopathy,myocardial infarction,α-blocker,noradrenaline
                Data availability:
                Keywords: pheochromocytoma, cardiomyopathy, myocardial infarction, α-blocker, noradrenaline

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