Risk Factors for Cardiac Complications in Patients With Pheochromocytoma and Paraganglioma: A Retrospective Single-Center Study

Long-Term Cardiovascular Complications in Patients With Pheochromocytomas and Paragangliomas After Surgery: A Large Multi-Center Study

OBJECTIVE

The effects of pheochromocytomas and paragangliomas (PPGLs)-induced catecholamine overproduction on vascular and cardiac function are generally thought to be reversible after PPGLs removal. However, a sizable proportion of patients who were free of the recurrent disease still faced high risks of cardiovascular problems after successful surgery. We aim to identify incidence and risk factors for long-term cardiovascular complications in PPGLs patients after surgery.

DESIGN

We retrospectively reviewed 602 patients who underwent surgery for sporadic PPGLs at three centers between January 2012 and October 2022. Demographic characteristics and perioperative data were recorded. Multiple logistic regression was used to determine the risk factors for postoperative long-term cardiovascular complications.

RESULTS

Finally, a total of 602 patients were included in the analysis, comprising 460 (76.4%) patients with pheochromocytomas and 142 (23.6%) patients with paragangliomas. After a median follow-up of 64 months, 76 (12.6%) patients had developed long-term cardiovascular complications. Independent risk factors included pheochromocytomas (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.425-11.965, p = 0.009), had low preoperative left ventricular ejection fraction (LVEF, OR = 5.659, 95% CI: 2.141-14.955, p < 0.001), experienced intraoperative hemodynamic instability (HDI, OR = 2.498, 95% CI: 1.423-4.385, p = 0.001), suffered from postoperative in-hospital cardiovascular complications (OR = 5.723, 95% CI: 2.078-15.758, p = 0.001) and long-term persistent hypertension (OR = 3.552, 95% CI: 1.580-7.988, p = 0.002).

CONCLUSIONS

Long-term cardiovascular complications commonly occur in patients with surgical-cured PPGLs. Pheochromocytomas, had low preoperative LVEF, experienced intraoperative HDI, suffered from postoperative in-hospital cardiovascular complications, and persistent hypertension were determined as the risk factors for long-term cardiovascular complications. These findings may help to improve follow-up management.

Surgical anesthesia in a patient with a pheochromocytoma crisis supported by ECMO: a case report

Pheochromocytoma is rare in clinical practice, with patients typically presenting with headache, high blood pressure and sweating. Patients who develop a pheochromocytoma crisis are particularly rare. This report describes the case of a patient in a pheochromocytoma crisis who presented with severe cardiogenic shock, acute respiratory failure, and acute coronary syndrome. The patient underwent surgery under general anesthesia with ECMO support and was discharged in good health.

Cardiovascular Complications in Pheochromocytoma and Paraganglioma: Does Phenotype Matter?

BACKGROUND

Adrenaline-producing tumors are mostly characterized by a sudden release of catecholamines with episodic symptoms. Noradrenergic ones are usually less symptomatic and characterized by a continuous overproduction of catecholamines that are released into the bloodstream. Their effects on the cardiovascular system can thus be different. The aim of this study was to determine the prevalence of cardiovascular complications by catecholamine phenotype.

METHODS

We retrospectively analyzed data on the prevalence of cardiovascular events in 341 consecutive patients with pheochromocytoma and paraganglioma treated from 1995 to 2023. Biochemical catecholamine phenotype was determined based on plasma or urinary catecholamines and metanephrines.

RESULTS

According to the phenotype, 153 patients had noradrenergic pheochromocytoma and paraganglioma and 188 had adrenergic pheochromocytoma and paraganglioma. In the whole sample, the incidence of serious cardiovascular complications was 28% (95 patients), with no difference between the phenotypes or sexes. The noradrenergic phenotype had significantly more atherosclerotic complications (composite end point of type 1 myocardial infarction and symptomatic peripheral artery disease; odds ratio, 3.58 [95% CI, 1.59-8.83]; P=0.003), while the adrenergic phenotype more often had type 2 myocardial infarction and takotsubo-like cardiomyopathy (OR, 0.24 [95% CI, 0.09-0.57]; P=0.002). These changes remained even after adjustment for conventional risk factors of atherosclerosis.

CONCLUSIONS

We found a 28% incidence of cardiovascular complications in a consecutive group of patients with pheochromocytoma and paraganglioma. Patients presenting with a noradrenergic phenotype have a higher incidence of atherosclerotic complications, while the adrenergic phenotype is associated with a higher incidence of acute myocardial damage due to takotsubo-like cardiomyopathy.

Pheochromocytoma/paraganglioma-associated cardiomyopathy

Pheochromocytoma/paraganglioma (PPGL) are neuroendocrine tumors that frequently produce and release catecholamines. Catecholamine excess can manifest in several cardiovascular syndromes, including cardiomyopathy. PPGL-induced cardiomyopathies occur in up to 11% of cases and are most often associated with an adrenal pheochromocytoma (90%) and rarely with a paraganglioma derived from the sympathetic ganglia (10%). PPGL-associated cardiomyopathies can be chronic or acute, with takotsubo cardiomyopathy being the most often reported. These two types of PPGL-induced cardiomyopathy seem to have different pathophysiological backgrounds. Acute catecholaminergic stress inundates myocardial β-adrenoceptors and leads to left ventricle stunning and slight histological apoptosis. In chronic cardiomyopathy, prolonged catecholamine exposure leads to extended myocardial fibrosis, inflammation, and necrosis, and ultimately it causes dilated cardiomyopathy with a low ejection fraction. Sometimes, especially in cases associated with hypertension, hypertrophic cardiomyopathy can develop. The prognosis appears to be worse in chronic cases with a higher hospital mortality rate, higher cardiogenic shock rate at initial presentation, and lower left ventricular recovery rate after surgery. Therefore, establishing the correct diagnosis at an early stage of a PPGL is essential. This mini-review summarizes current data on pathophysiological pathways of cardiac damage caused by catecholamines, the clinical presentation of PPGL-induced cardiomyopathies, and discusses treatment options.

Effects of Metabolic Syndrome on Cardiovascular Outcomes of Psoriatic Patients with Coronary Artery Disease: A Single Center Retrospective Cohort Study

BACKGROUND

Psoriasis is associated with an increased prevalence of cardiovascular risk factors, including metabolic syndrome (MetS). To date, it is unclear whether MetS causes differences in cardiovascular outcomes in psoriatic patients with coronary artery disease.

METHODS

We conducted a retrospective cohort study to determine the effects of MetS in psoriatic patients with coronary artery disease. Comparisons were made between patients with and without MetS. Cox regression analysis and Kaplan-Meier survival analysis were used to evaluate the association between variables.

RESULTS

Of the 307 psoriatic patients with coronary artery disease, 94 met criteria (30.6%) for MetS. Individuals with MetS were more likely to be female (p <0.001). Levels of platelet counts and high-sensitivity C-reactive protein were higher in the MetS group (p = 0.038 and 0.005, respectively). After a mean follow-up of 35.32 months, major adverse cardiovascular events (MACEs) and non-fatal myocardial infarction were more likely in the MetS than the non-MetS group (33.3% vs 20.6%, p = 0.02; 26.4% vs 15.7%, p = 0.032, respectively). Kaplan-Meier estimates showed the same trend. Cox regression analysis showed that MetS (hazard ratio 1.738; 95% confidence interval 1.045-2.891; p = 0.033) and left ventricular ejection fraction (hazard ratio 0.968; 95% confidence interval 0.945-0.991; p = 0.006) were associated with an increased risk of MACEs.

CONCLUSION

In psoriatic patients with coronary artery disease, MetS independently predicted MACEs. In addition, left ventricular ejection fraction was negatively associated with an increased risk of MACEs. To reduce the cardiovascular disease risk, it is necessary to increase awareness of MetS in psoriatic patients with coronary artery disease.