Vol. 4 No. 2, 2011.pmd


Introduction:
Patients with acromegaly have been reported to have about
30% higher mortality rate, and cardiovascular disease
accounts for 60% of the deaths. We are reporting a case of
a patient with acromegaly who was diagnosed with severe
cardiac failure at the time of diagnosis and had marked
clinical improvement after the successful resection of the
pituitary adenoma. Immediate diagnosis and treatment are
required for better control of acromegalic heart failure.

Case Report:
A 70 years old lady presented with a short history of
dyspnoea (NYHA IV). On query she admitted that she
noticed   progressive enlargement of acral parts,
coarsening and enlargement of face for 7 years, orthopnoea
and palpitation for 3 months and new onset of diabetes
mellitus and hypertension  for 1 month . She also had
excessive sweating and knee joint arthalgia but gave no
history of headache, visual impairment, nasal discharge
or any limb weakness. Clinical examination revealed
acromegalic facies, enlarged acral parts, thyromegaly,
features of cardiomegaly with mitral regurgitation,
controlled B.P (with medication), and husky voice. Fundus
examination and visual evaluation were unremarkable.
Serum GH level was 15.0 ng/ml at basal level, and serum
prolactin, TSH, FT4 were within normal limit. X-ray skull
showed apparently normal size sella without any erosion
but MRI of pituitary gland showed pituitary
microadenoma. X ray hand showed increased soft tissue
shadow with enlargement of hand bones with tufting of
terminal phalanges with periarticular osteopenia. X ray

Acromegaly Presenting As Cardiac Failure - A Case Report
Shohael Mahmud Arafat1, Mahammad Abul Kalam Azad2,  Rezwanur Rahman3, Mehruba Alam Ananna4 , Ahmed
Manzurul Aziz5, Quazi Mamtazuddin Ahmed6, Muhammad Khaled Hasan 7,  ABM Abdullah8
1Associate Professor, 2Medical officer, 3Resident, Department of Medicine, BSMMU, Dhaka.4Registrar , BIRDEM  5Medical Officer,
Singair Health Complex6Assistant Professor, Department of Medicine,7Medical officer. Department of Neurolgy, 8 Professor and Dean,
Department of Medicine, BSMMU, Dhaka.

Abstract:
Acromegaly is characterized by chronic hypersecretion of growth hormone (GH) and is associated with increased
mortality rate because of the potential complications such as cardiovascular disease, respiratory disease, or malignancy,
which are probably caused by the long-term exposure of tissues to excess GH, for at least 10 years, before diagnosis and
treatment. Here we are reporting a case of acromegaly who initially presented with features of left ventricular failure for
which she got herself admitted in CCU and was treated conservatively. Later on, after clinical examination and investigations
she was diagnosed as a case of mitral regurgitation due to cardiomyopathy caused by acromegaly. After the successful
transsphenoidal resection of the pituitary microadenoma, the level of GH was normalized and heart failure improved.

Key words: acromegaly, heart failure, Pituitary microadenoma.

[BSMMU J 2011; 4(2): 122-124]

Address of correspondence: Dr Shohael Mahmud Arafat, Dept
of Medicine,BSMMU, Dhaka  E mail: arafatdr@yahoo.com

foot shows increased heel pad thickness. CXR revealed
cardiomegaly with scoliosis. Echocardiography showed
systolic dysfunction with E.F 40% with moderate mitral
regurgitation. After confirmation of the diagnosis of
acromegaly due to pituitary microadenoma transsphenoidal
endoscopic pituitary surgery was done following
stabilization of cardiac function. After successful surgery
tissue was sent for histopathology which showed pituitary
neoplasm composed of fairly uniform polygonal cells
arranged in sheets. The cells had abundant eosinophilic
cytoplasm and supporting connective tissue stroma was
scarce. Post operative growth hormone level came down
to normal with uneventful postoperative recovery. The
patient was discharged at home on 9th post operative day.

Fig.-1:X ray foot shows increased heel pad thickness.



Discussion:
Acromegaly is a consequence of chronic growth hormone
(GH) excess, due in the majority of cases to a GH-secreting
pituitary adenoma, and occurring with a population
prevalence of 60 per million and an incidence of 3-4 per
million per year1. Males and females appear to be equally
affected with an average age of presentation of 44 years1.

Considerable evidence suggests acromegaly can cause
specific type of cardiomyopathy which can result in
structural and functional abnormalities resulting in heart
failure. This may be partially reversed by effective reduction
in GH and IGF-1 levels 2, The patient in this report had
massive cardiomegaly with a cardiothoracic ratio of <0.9.
In acromegaly, cardiac enlargement is a consistent finding
and seems to be disproportionate, compared with the
increase in size of other internal body organs.2 An
increased frequency of systemic hypertension and

premature coronary artery disease have also been
described. 2

Epidemiological study showed that in patients with
acromegaly, valvular abnormalities are more prevalent than
in control subjects, who were individually matched for left
ventricular function, age, sex, and the presence of
hypertension3. In addition, it has been found that in
acromegalic cardiomyopathy myocardial hypertrophy with
interstitial fibrosis, lymphomononulear infiltration, and
areas of monocyte necrosis resembling myocarditis are
prominent histopathological features. These changes
often result in increased left ventricular mass and
concentric hypertrophy. 2, 4

Left ventricular hypertrophy occurs first, often leading to
slow deterioration of diastolic function early in the
disease.5,6 This finding has been reported in acromegalic
patients even  with disease duration shorter than five
years. 7.8Our patient developed overt heart failure at the
age of 70 years with clinical features  of acromegaly for
almost  seven years. Then she suddenly developed heart
failure.

Clinically evident congestive heart failure may develop
when the disease is untreated or unsuccessfully treated.7
Our patient sought medical attention because of severe
symptoms of congestive heart failure. Data are limited on
clinically evident heart failure in acromegalics.
Damganovics et al reported high-output failure in 10% of
patients, while Hayward et al found only 7 out of 256
patients (<1%) with clinically evident heart failure. 9.10

Echocardiographic findings in this patient showed
significant increase in end-systolic and end-diastolic
dimensions, reduction in the ejection fraction and fractional
shorting, and reversal of the E/A ratio, in the presence of
severe signs of congestive heart failure. These
echocardiographic features have been documented in
young acromegalics without any clinical evidence of
cardiac impairment. 7

Cardiac dysrhythmias have been documented in a few
reports, due to the left ventricular remodeling that occur
in this disease.11, 12

However, our patient did not present with any form of
ventricular arrythmia. In the absence of other causes of
heart failure and mitral regurgitation in this case, we think
that her heart failure was caused by acromegalic
cardiomyopathy, although we couldn’t confirm it by
myocardial biopsy.

Treatment of acromeagly presenting with heart failure is
aimed at removing the source of GH hyper secretion or at

Fig.-2:  X ray hand showing increased soft tissue shadow
with bony enlargement and tufting of terminal phalanges.

Fig.-3:  Histopathological examinationshowing pituitary
neoplasm composed of fairly uniform polygonal cells
arranged in sheets.

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suppressing its activity along with other supportive
treatment for heart failure.  Somatostatin analogues are
effective as first-line therapy and have a success rate of
45%– 65%.13, 14. Besides this, surgery and local irradiation
are other options of treatment. Our patient was, however,
treated surgically which made a good symptomatic
recovery of her heart failure.

Conclusion:
Though classically acromegaly patients commonly
presents with progressive enlargement of limbs and
coarsening of faces but rarely it may present with obvious
heart failure caused by cardiomyopathy. So we need to
look for endocrine cause of heart failure like acromegaly
when there is no other overt cause of failing heart.

References:
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Pituitary. 1999 Jun; 2 (1):29-41 

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Endocrine Rev. 1994; 15:555–573.

3 . Sjoerd W. van Thiel, Alberto M. Pereira, Jonathan R. Lindner,
Ferdinand Roelfsema, Ernst E. van der Wall, Hans Morreau et
al. Increased Prevalence of Regurgitant Valvular Heart Disease
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4 . Frustaci A, Chimenti C, Setoguchi M, et al.Cell death in
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6 . Colao A, Cuocolo A, Marzullo P, et al. Impact of patient’s age
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8 . olao A, Baldelli R, Marzullo P, et al. Systemic hypertension
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9 . Damjanovics SS, Neskovic AN, Petakov MS, et al. High output
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1 0 . Hayward RP, Emanuel RW, Nabarro JDN. Acromegalic heart
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11.  Rodrigues EA, Caruana MP, Lahiri A, Nabarro JDN, Jacobs HS,
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1 2 . Kahaly G, Olshausen KV, Mohr–Kahaly S, et al. Arrythmia
profile in acromegaly. Eur Heart J. 1992;13:51–56.

1 3 . Abs R, Verhelst J, Maiter D, et al. Carbergoline in the treatment
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1 4 . Chanson P, Leselbaum A, Blumberg J, et al. Efficacy and
tolerability of long-acting somatostatin analogue lanreotide
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patients. Pituitary. 2000; 2:269–276.

Acrmegaly Presenting As Cardiac Failure - A Case Report Arafat et al

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