Endocrine Abstracts

A 54-year-old man presented to the heart attack centre with cardiac chest pain, vomiting and collapse. Biochemistry (troponin incremented from 117 to 315ng/l) and electrocardiogram confirmed a diagnosis of non-ST elevation myocardial infarction (NSTEMI). Past medical history included type 2 diabetes mellitus and hypertension (diagnosed 8 years previously), hypercholesterolaemia and a 20 pack year smoking history. Secondary prevention for MI was commenced and coronary angiography revealed critical triple vessel disease with urgent coronary artery bypass graft (CABG) suggested. To investigate iron deficiency anaemia, he underwent a CT scan of the abdomen which demonstrated a left 7cm heterogeneous adrenal mass. Further questioning revealed he had a history of the classic triad of phaeochromocytoma symptoms: headache, palpitations and diaphoresis. Plasma metadrenaline was elevated at 3554 (0-510 pmol/l) as was normetadrenaline at 6021 (0-1180 pmol/l). Alpha-blockade (phenoxybenzamine (PBZ)), beta blockade (bisoprolol) and antihyperglycaemic agents were titrated and volume status was restored. Detailed discussion took place regarding options for coronary vessel management (stent vs bypass) and the order of management (adrenalectomy vs coronary intervention). After effective blockade was achieved (PBZ 30mg QDS and bisoprolol 15mg OD), he proceeded to laparoscopic adrenalectomy with good peri- and intra-operative haemodynamic stability and made a rapid post-operative recovery. He is now under discussion by cardiology regarding further management of his coronary artery disease. Secretory phaeochromocytomata, leading to catecholamine excess, can cause life-threatening cardiovascular complications and mimic acute coronary syndrome. A multidisciplinary team carefully managed this complex case and we discuss the different potential approaches to this clinical scenario to achieve the best patient outcome. We highlight the importance of adequate alpha-blockade in restoring normal circulating volume and improvement in cardiac function as assessed by echocardiography.