# A case report of blood pressure fluctuation, inverted Takotsubo cardiomyopathy, and pulmonary embolism: searching for a link

## TL;DR

A rare case links blood pressure fluctuations, inverted Takotsubo cardiomyopathy, and pulmonary embolism to an undiagnosed adrenal tumor, highlighting the need for multidisciplinary care.

## Contribution

This case report adds to the limited literature on the co-occurrence of inverted Takotsubo cardiomyopathy, pulmonary embolism, and pheochromocytoma.

## Key findings

- A 68-year-old man was successfully treated for coexisting inverted Takotsubo cardiomyopathy, pulmonary embolism, and pheochromocytoma.
- Continuous volume expansion and selective α1-adrenergic blockade were effective in managing the patient's hemodynamic instability.
- Multidisciplinary care involving cardiologists, hypertension specialists, and surgeons is essential for managing this complex condition.

## Abstract

Alternating cycles of hypertension, sustained hypotension, and heart rate (HR) variability, manifesting as an inverted pattern of Takotsubo cardiomyopathy (ITC) and pulmonary embolism (PE) due to an underlying previously undiagnosed pheochromocytoma (Pheo), is a rare and complex clinical presentation. To date, only two previous reports have described this triad. Despite the absence of established guidelines for managing blood pressure (BP) and HR fluctuations in patients with Pheo, understanding the interplay between these conditions is crucial for improving patient outcomes and optimizing treatment strategies. This case report highlights the diagnostic challenges and the need for further investigation into effective management approaches in such patients.

We present a case of a 68-year-old man hospitalized for acute chest pain and BP and HR fluctuations. The clinical work-up revealed the coexistence of ITC, PE, and Pheo. The patient was successfully treated with continuous volume expansion and selective α1-adrenergic blockade, avoiding vasodilators and renin-angiotensin-aldosterone inhibitors. Perioperative administration of oral doxazosin and bisoprolol allowed a successful laparoscopic right adrenalectomy after 3-month anticoagulation.

Despite the lack of established recommendations for managing BP and HR fluctuations in patients with Pheo, the coexistence of PE further complicates the clinical management of this condition, suddenly modifying the haemodynamic status and increasing the risk of major bleeding events from the neoplastic mass. Patients presenting with ITC, PE, and Pheo require a multidisciplinary approach involving a cardiologist, hypertension specialist, and surgeon to resolve this intriguing clinical condition.