SUN-272 - Catecholamine-Induced Cardiomyopathy in Pheochromocytoma: Contrasting Two Divergent Clinical Outcomes

Catecholamine-induced cardiomyopathy is a rare but potentially life-threatening and difficult to manage complication of pheochromocytoma. Cardiovascular manifestations include systemic vasoconstriction, coronary vasospasm, arrythmias, severe left ventricular dysfunction, and congestive heart failure. We present two clinical cases of incidentally identified pheochromocytomas with divergent cardiac outcomes to highlight clinical and biochemical factors influencing catecholamine-mediated cardiomyopathy.

Case 1: A 37-year-old male with hypertension, type 2 diabetes, and a previously identified 2.7cm left adrenal nodule lost to follow-up for 13 years presented with acute onset chest pain, nausea, diaphoresis, extremity numbness, and self-reported systolic blood pressure exceeding 220mmHg. For the past several years, he reported episodic headaches, palpitations, and anxiety. During hospitalization, troponin peaked at 5,904, and electrocardiogram demonstrated NSTEMI. Echocardiogram revealed newly reduced ejection fracture (40%) with inferior wall motion abnormalities. Left heart catheterization showed mild non obstructive coronary disease. Plasma and urine metanephrines were elevated fivefold above the upper limit of normal. CT imaging revealed enlargement of the left adrenal mass to 12 cm. Patient received traditional neurohormonal blockade and doxazosin. Two weeks later he underwent open left adrenalectomy with pathology confirming pheochromocytoma. Postoperatively, symptoms resolved and repeat echocardiogram demonstrated improvement in ejection fraction and wall motion abnormality.

Case 2: A 62-year-old male with Hashimoto’s hypothyroidism, prior pulmonary embolism/DVT on warfarin, and bilateral adrenal masses not followed for 3 years presented with perioperative supraventricular tachycardia and hypertension (systolic >220 mmHg). For the past year, he reported palpitations followed by tremulousness but attributed these episodes to anxiety. Echocardiogram demonstrated ejection fraction 60% without wall motion abnormalities. Plasma and urine metanephrines were elevated more than twice the upper limit of normal. CT imaging demonstrated 4.9 cm left adrenal mass and a 2.4 cm right adrenal nodule. DOTATATE PET/CT confirmed left pheochromocytoma. He received traditional neurohormonal blockade and doxazosin. Two months later, he underwent left adrenalectomy. Postoperative, symptoms resolved with blood pressure within normotensive range.

The mechanisms and management of catecholamine included cardiomyopathy remain under investigation. These cases compare and contrast the widely variable cardiac outcomes that patients can present with. Early recognition, appropriate diagnostic evaluation, timely surgical intervention, and continued surveillance are essential to prevent irreversible myocardial injury.

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