Coronary vasospasm associated with uncontrolled carcinoid tumour

Positional changes leading to transient ischaemia in a patient with neuroendocrine carcinoma of the lung

Coronary spasm in carcinoid heart disease has an incidence of 10%, but is rare in patients with neuroendocrine tumours without carcinoid heart disease. We present a rare case of right coronary artery spasm and ST elevations secondary to a neuroendocrine carcinoma of the lung, uniquely provoked by positional changes. Our patient is a 55-year-old man with recurrent ST-elevation myocardial infarction secondary to coronary vasospasm that was diagnosed with neuroendocrine carcinoma of the lung. We believe his positional coronary spasm episodes were likely due to intermittent tumour compression from changes in body position. Our case highlights positional coronary spasm as a previously unreported and potentially early manifestation of neuroendocrine carcinoma of the lung.

Perioperative management of a large, late presenting phaeochromocytoma

A 77-year-old man presenting to the emergency department with an acute coronary syndrome was later found to have a phaeochromocytoma. The lateness of this presentation was likely due to the protective α blocking effects of long-term terazosin therapy for his prostatism. α blockers such as terazosin are a well-recognised medical therapy in the perioperative optimisation of phaeochromocytoma because they treat the adrenergic effects of catecholamine release from the tumour such as hypertension. This patient was diagnosed with an ST elevation myocardial infarction (STEMI). A cardiac angiogram showed no evidence of vessel occlusion. A right adrenal mass of 9×8×9 cm was incidentally found and confirmed as a phaeochromocytoma with raised plasma metanephrines and normetanephrines. Following preoperative optimisation and multidisciplinary team involvement, an open right adrenalectomy was performed successfully some months later.

Carcinoid Syndrome-Induced Ventricular Tachycardia

Introduction. Carcinoid tumors are rare neuroendocrine malignancies that secrete multiple bioactive substances. These bioactive substances are responsible for the carcinoid syndrome characterized by diarrhea, flushing, syncope, and right-sided valvular heart disease. Previous case reports have described carcinoid syndrome associated with coronary vasospasm and the well-characterized carcinoid heart disease. Case. Our patient is a 73-year-old female with complex past medical history most notable for metastatic carcinoid tumors diagnosed in 2013-05. She initially presented in 2014-09 with syncope and dizziness associated with sinus pause on an event monitor. She received a pacemaker given normal left ventricular function and was discharged. However, she was readmitted with similar symptoms corresponding to multiple episodes of ventricular tachycardia. She was started on high-dose beta blockade and has had no recurrence of arrhythmia over a follow-up period of 12 months. Conclusion. We hypothesize that the patient's ventricular tachycardia was mediated by the multiple bioactive substances secreted by her carcinoid tumors. Her carcinoid tumor biomarkers were elevated and other explanations for arrhythmia were investigated and ruled out. To our knowledge, this is the first case of ventricular tachycardia mediated by carcinoid syndrome and suppressed by beta-blocker. Further investigation into this relationship is needed.