Reversibility of end-stage acromegalic cardiomyopathy: a long way to recovery

Background. Acromegalic cardiomyopathy is a significant cardiovascular complication associated with acromegaly, primarily caused by excessive growth hormone production from a pituitary adenoma. The clinical presentation can range from an initial asymptomatic stage to congestive heart failure. The diagnosis often comes many years after the initial onset of endocrine changes. Clinical case. We present the case in a 47-year-old man who sought a routine cardiac evaluation. He reported experiencing shortness of breath upon exertion and occasional chest discomfort over the past 3 months. Additionally, he noted increased sweating, fatigue, and gradual changes in his facial features, as well as enlargement of his hands and feet over the past few years. Patient had no family history of cardiovascular disease. Among traditional cardiovascular risk factors, he was a smoker and had a history of mild hypertension for the past five years. A month before examination, he had noted a tendency towards hypotension. The laboratory analysis revealed moderate microcytic iron deficiency anemia, dyslipidemia, prediabetes, increased growth hormone and insulin-like growth factor 1. Transthoracic echo revealed thickening of the left ventricular (LV) wall, dilation of the left chambers, and a reduced ejection fraction (35 %). There was also impaired LV relaxation and mild mitral insufficiency. These data indicated acromegalic cardiomyopathy in an intermediate to advanced stage, resembling hypertensive cardiomyopathy in a burn-out phase. On magnetic resonance imaging (MRI), there was thickened skull and frontal bossing. Left-sided 9-mm T2 low signal intensity lesion (microadenoma) abuts medial dural reflection of cavernous sinus, it caused focal contour bulge of the gland superior margin, mild sagging of the sellar floor and mild deviation of the stalk to the right side. Patient was referred to neurosurgery consultation. Due to the presence of heart failure with reduced ejection fraction and moderate iron deficiency anemia, the surgery was postponed. He received recommendations for lifestyle modifications and was also prescribed treatment with octreotide and therapy for heart failure, iron supplements. In a two-month follow-up, there were no significant changes in echocardiogram or laboratory markers, except increased hemoglobin and ferritin. At a six-month follow-up, the patient reported a general improvement in well-being. Blood pressure was within normal ranges, and there were no signs of heart failure. The echocardiogram revealed positive changes, including a decrease in LV size and improvement in ejection fraction up to 52 %. The patient subsequently underwent neurosurgery, and the pituitary adenoma was excised via transsphenoidal nasal access. No post-surgical residues were detected during a follow-up MRI of the brain conducted three months after operation. Conclusions. Cardiovascular complications are the most significant concerns for patients with acromegaly, profoundly affecting their quality of life and survival. Early diagnosis is crucial to reverse the progression of cardiac complications and improve overall prognosis. Multidisciplinary team involving endocrinologists, cardiologists, and neurosurgeons is essential.