In a patient with pheochromocytoma, NEVER give pure beta-blockade. This would result in unopposed alpha activity from circulating catecholamines and could result in malignant hypertension.
Pheochromocytomas are rare tumors that produce catecholamines. The most common site is the adrenal medulla. Remember the rule of 10's - 10% are malignant, bilateral, extra-adrenal, calcified, pediatric, or familial. Symptoms are relapsing and remitting, causing episodic hypertension, pallor, perspiration, diaphoresis, headaches, and tachycardia. Diagnosis centers on clinical symptoms in conjunction with urinary metanephrines or vanillylmandelic acid and plasma catecholamines. Also recall the association with MEN 2A/2B. A tumor should be localized with CT or MRI and treated with alpha blockade first with or without beta blockade (often propranolol) and finally surgical resection.
Viera and Neutze discuss the diagnosis of secondary hypertension. A secondary etiology may be suggested by symptoms (e.g., flushing and sweating suggestive of pheochromocytoma), examination findings (e.g., a renal bruit suggestive of renal artery stenosis), or laboratory abnormalities (e.g., hypokalemia suggestive of aldosteronism). Secondary hypertension also should be considered in patients with resistant hypertension, and early or late onset of hypertension.
Shen and Yu discuss the perioperative management of pheochromocytoma. They note that while monitoring blood pressure is a key issue, one must also pay close attention to the risk of pheochromocytoma-induced cardiomyopathy. They classify pheochromocytomas into three groups according to the risk of developing clinical cardiomyopathy.
Illustration A depicts a pheochromocytoma on CT.
Answer 1: Use of an alpha blocker in conjunction with a beta blocker, like Propranolol, is also not contraindicated.
Answer 2: Nitrates, like nitroprusside, are not contraindicated.
Answers 4: Use of an agent with combined alpha and beta blockade, such as labetalol is not contraindicated.
Answers 5: Use of an ACE-inhibitor like lisinopril is not contraindicated.
Viera AJ, Neutze DM. Diagnosis of secondary hypertension: an age-based approach.Am Fam Physician. 2010 Dec 15;82(12):1471-8.
PMID:21166367 (Link to Abstract)
Shen J, Yu R. Perioperative management of pheochromocytoma: the heart of the issue. Minerva Endocrinol. 2013 Mar;38(1):77-93.
PMID:23435444 (Link to Abstract)