Thursday, October 16, 2008

Cardiogenic shock in a young woman

A previously healthy 38 year old woman presented with shock, elevated cardiac markers and low ejection fraction. I don’t usually link to case reports from journals but this one, which recently appeared in Laboratory Medicine, is rich. It contains important lessons and much food for thought.

You’ll test scads of patients for pheochromocytoma who don’t have the disease. If you finally do encounter it the textbook features you’ve been taught may be buried in a morass confusing findings and mimics.

The patient presented with a picture of cardiogenic shock and elevated cardiac markers. Although there was myocardial damage it wasn’t a territorial myocardial infarction due to coronary artery disease. One red flag against the diagnosis of classical myocardial infarction was the presence of cardiogenic shock and a profound drop in the ejection fraction despite only a mild troponin leak. Something else was going on. Although the article didn’t mention this red flag it did provide a nice discussion on the differential diagnosis of troponin elevation due to conditions other than classical myocardial infarction.

Buried in this constellation of findings was the triad we were all taught: headache, palpitation and diaphoresis. The authors noted:

Headache, palpitations, and diaphoresis are the most frequent symptoms of pheochromocytoma. If all 3 present together, the specificity of this combination of symptoms for the diagnosis of pheochromocytoma is greater than 90%.

Pretty astounding given the ubiquity of those symptoms.

Perhaps more telling was the patient’s left ventriculogram, which showed a markedly reduced ejection fraction and mid ventricular ballooning closely resembling the left ventriculograms in this series of patients with Takotsubo cardiomyopathy. Pheochromocytoma cardiomyopathy is physiologically similar to Takotsubo cardiomyopathy. I suspect that had this patient had a myocardial biopsy it would have shown contraction band necrosis.

Speaking of Takotsubo cardiomyopathy---will we see a spike following the Wall Street meltdown?

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