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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Elevated somatomedin C blood levels

  • Inability to suppress growth hormone to < 2 ng/mL during glucose tolerance test

  • Pituitary adenoma found on MRI

  • Biventricular hypertrophy with systolic and diastolic dysfunction

  • Hypertension, diabetes, and premature coronary artery disease

GENERAL CONSIDERATIONS

  • Acromegaly is caused by excessive growth hormone secretion from a pituitary adenoma

  • It is characterized by excess bone growth, organ enlargement, and premature death due to cardiorespiratory complications

  • Rarely other endocrine tumors can secrete growth hormone

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Headache, bitemporal hemianopsia from tumor growth

  • Impotence, galactorrhea or amenorrhea

  • Diaphoresis, hoarseness, polyuria, polydipsia

  • Carpal tunnel syndrome

  • Symptoms of:

    • – Heart failure, such as dyspnea

    • – Coronary artery disease, such as chest pain

PHYSICAL EXAM FINDINGS

  • Systemic hypertension

  • Thick lips, macroglossia, bulbous nose, protrusive lower jaw, frontal bossing, prominent cheek bones, and hollow temporal fossae

  • Joint swelling, kyphosis, barrel chest, spade-like hands with sausage-like digits

  • Left ventricular lift

  • Signs of congestive heart failure, such as pulmonary rales

DIFFERENTIAL DIAGNOSIS

  • Other causes of cardiomyopathy and heart failure

  • Other causes of hypertension

  • Other causes of premature coronary artery disease

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Growth hormone, somatomedin C, and insulin-like growth factor-1 levels

  • Growth hormone during a glucose tolerance test

  • Hyperglycemia, hypertriglyceridemia

  • Hyperphosphatemia

ELECTROCARDIOGRAPHY

  • Left ventricular hypertrophy

  • Atrial and ventricular tachyarrhythmias

  • Nonspecific ST-T changes and intraventricular conduction defects

IMAGING STUDIES

  • Chest x-ray: cardiomegaly

  • Echocardiography: eccentric left ventricular hypertrophy or asymmetric hypertrophy and left ventricular systolic dysfunction

  • Doppler echocardiography: diastolic dysfunction

DIAGNOSTIC PROCEDURES

  • Stress cardiac imaging or cardiac catheterization may be indicated to diagnose coronary artery disease

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected cardiac disease

  • Difficult to control hypertension

HOSPITALIZATION CRITERIA

  • Heart failure

  • Acute coronary syndromes

  • Planned surgery

MEDICATIONS

  • Pharmacologic therapy with somatostatin analogs, eg, octreotide 200–500 μg/day SC, or Sandostatin LAR (octreotide) Depot 10–40 mg IM every 4 weeks, or lanreotide 60–120 mg SC every 4 weeks, or dopamine agonists, eg, bromocriptine 5–30 mg/day PO (start at 2.5 mg/day)

  • Heart disease treated conventionally

THERAPEUTIC PROCEDURES

  • Cardiac catheterization and angioplasty may be required

SURGERY

  • Surgical removal of the pituitary tumor with postoperative radiation therapy

MONITORING

  • ECG monitoring in hospital as appropriate

DIET AND ACTIVITY

  • Low-sodium, low-saturated-fat diet

  • Activity restriction if heart disease present

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution ...

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