CONGRESS ABSTRACT

A 36-year-old patient presented to the emergency department of a spoke center in June 2022 with an episode of hypertension (200/100 mmHg). The patient underwent a cardiology evaluation and was started on antihypertensive therapy with angiotensin-converting enzyme (ACE) inhibitors and amlodipine. In June 2023, the patient was admitted to the same spoke center for heart failure. A prognostic therapy for heart failure with reduced ejection fraction (HFrEF) was initiated. Echocardiography revealed a hypertrophic phenotype with severe ejection fraction (EF) reduction. Coronary computed tomography (CT) ruled out significant coronary stenosis, while cardiac magnetic resonance imaging (MRI) demonstrated a non-dilated left ventricle with concentric hypertrophy and severe EF reduction (30%) due to diffuse hypokinesia. No abnormalities were identified on tissue characterization. The right heart chambers appeared normal. After three months of therapy, implantable cardioverter defibrillator (ICD) implantation was proposed to the patient; however, he sought a second opinion at our cardiomyopathy clinic. During physical examination, the patient exhibited obesity, a moon-shaped face, and striae rubrae (Figure 1). Electrocardiography was normal. Given the suspicion of Cushing syndrome, the patient was referred to an endocrinologist. Biochemical testing showed elevated 24-hour urinary free cortisol (UFC) and late-night salivary cortisol levels. Plasma ACTH levels were also increased, and the low-dose dexamethasone suppression test (LDDST) was positive. Pituitary MRI revealed no findings consistent with a pituitary adenoma. However, high-resolution chest CT revealed a 10-mm nodular lesion in the left lung. Positron emission tomography (PET) imaging was negative, and subsequent biopsy confirmed a typical ACTH-producing carcinoid tumor. Preoperative echocardiography before thoracic surgery showed improved left ventricular EF and reduced hypertrophy. In October 2024, the patient underwent successful surgical lobectomy (Figure 2). This case highlights a rare but fully reversible cause of HFrEF and underscores the critical role of a multidisciplinary team in achieving optimal diagnosis and treatment outcomes. A careful physical examination helped to reach the final diagnosis and to avoid an ICD implantation.