Hypertensive Heartbreak

This Clinical Problem-Solving article presents the diagnostic and therapeutic journey of a 61-year-old man scheduled for elective knee arthroplasty who experienced sudden cardiovascular collapse postoperatively. Initially diagnosed with essential hypertension and managed with hydrochlorothiazide, he developed severe postoperative hypertension (BP 216/99 mm Hg), tachycardia, and asymmetric pulmonary edema, progressing to cardiogenic shock, multiorgan failure, and death. Cardiac workup revealed stress cardiomyopathy with basilar hypokinesis and preserved apical contraction (inverted Takotsubo pattern), left ventricular dysfunction (EF 25%), and normal coronary arteries. Postmortem findings uncovered a large left adrenal pheochromocytoma (280 g, 11 cm) with markedly elevated plasma and urinary metanephrines. Autopsy showed hypertensive cardiomegaly, multifocal myocyte necrosis, ischemic hepatitis, acute kidney injury, and gastrointestinal hemorrhage. The case underscores pheochromocytoma’s elusive presentation, perioperative vulnerability, and potential for lethal catecholamine-induced crisis mimicking stress cardiomyopathy.

This Clinical Problem-Solving article presents the diagnostic and therapeutic journey of a 61-year-old man scheduled for elective knee arthroplasty who experienced sudden cardiovascular collapse postoperatively. Initially diagnosed with essential hypertension and managed with hydrochlorothiazide, he developed severe postoperative hypertension (BP 216/99 mm Hg), tachycardia, and asymmetric pulmonary edema, progressing to cardiogenic shock, multiorgan failure, and death. Cardiac workup revealed stress cardiomyopathy with basilar hypokinesis and preserved apical contraction (inverted Takotsubo pattern), left ventricular dysfunction (EF 25%), and normal coronary arteries. Postmortem findings uncovered a large left adrenal pheochromocytoma (280 g, 11 cm) with markedly elevated plasma and urinary metanephrines. Autopsy showed hypertensive cardiomegaly, multifocal myocyte necrosis, ischemic hepatitis, acute kidney injury, and gastrointestinal hemorrhage. The case underscores pheochromocytoma’s elusive presentation, perioperative vulnerability, and potential for lethal catecholamine-induced crisis mimicking stress cardiomyopathy.