Cushing’s heart failure case shows need for early diagnosis
Case report says doctors should recognize overlapping symptoms
A woman with Cushing’s disease developed overlapping heart symptoms, a case researchers said highlights the need for early diagnosis and coordination between cardiologists and endocrinologists.
The woman had cortisol-induced heart failure with preserved ejection fraction, meaning her heart pumped normally but was too stiff to fill properly. The heart symptoms overlapped with infiltrative cardiomyopathy, where toxic deposits build up in the heart muscle.
“Recognition of this overlap is crucial to avoid misdiagnosis and to ensure timely endocrine and cardiovascular management,” the researchers wrote in a case report.
The report, “Global Longitudinal Strain Reduction With Apical Sparing in Cushing Syndrome-Related Heart Failure With Preserved Ejection Fraction (HFpEF): A Case Report,” was published in Cureus.
Cushing’s disease is caused by a tumor in the pituitary gland, a small gland at the base of the brain. The tumor produces excessive amounts of a hormone that stimulates the adrenal glands, located above the kidneys, and releases too much cortisol. This overproduction of cortisol, known as hypercortisolism, leads to the symptoms associated with Cushing’s.
High blood pressure, headache at hospital visit
The first-line treatment for Cushing’s disease is surgery to remove the pituitary tumor. If the tumor cannot be fully removed or returns, doctors use medication to keep cortisol under control. However, some symptoms may persist even after cortisol levels return to normal.
The researchers reported the case of a 56-year-old woman in Lebanon who arrived at the hospital with very high blood pressure and a severe headache. She had a history of pituitary adenoma, a benign (noncancerous) pituitary tumor, which had been operated on twice. She also had coronary artery disease and type 2 diabetes.
Tests showed no brain bleeding or other acute problems. The woman showed signs typical of hypercortisolism, such as a round face, fat accumulation around the trunk, and swelling in her legs.
Doctors began treatment with antihypertensive medications to lower her blood pressure and suspected Cushing’s disease. A dexamethasone suppression test, which measures whether cortisol is suppressed after taking dexamethasone (a lab version of cortisol), revealed her cortisol levels stayed high, confirming the diagnosis.
A heart ultrasound revealed thickening of the heart muscle and reduced global longitudinal strain, a measure of how well the heart muscle contracts. The heart also had a normal ejection fraction, meaning it could still pump blood effectively. These findings pointed to heart failure with preserved ejection fraction.
This means that the heart is stiff and cannot relax properly between beats, even though it still pumps a normal amount of blood with each contraction. This leads to symptoms of heart failure, such as shortness of breath and leg swelling. In the woman’s case, the cause was likely high cortisol, damaging the heart muscle over time.
The doctors also tested for amyloidosis, a disease in which abnormal proteins accumulate in the heart and cause it to stiffen. Because the heart imaging pattern looked somewhat similar to amyloidosis, tests were needed to confirm the difference. Blood and urine studies were negative, ruling out that possibility.
Further brain imaging showed that the woman’s pituitary tumor had returned, explaining the persistent excess cortisol. She was referred to a neurosurgeon for another evaluation and potential surgery. Meanwhile, doctors gave her medication aimed at reducing cortisol levels.
The woman’s blood pressure was gradually brought under control during her hospital stay, and her swelling improved with diuretics. Her physical strength and ability to move returned to normal levels.
“This case underscores the multisystem burden of endogenous [having an internal cause] hypercortisolism, with particular cardiovascular susceptibility,” the researchers wrote. Early diagnosis and a coordinated approach between endocrinology and cardiology can prevent complications and improve patient outcomes, they said.
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