Abstract Body (Do not enter title and authors here): Case: A 38-year-old woman with a history of migraine headaches, a stable intracranial aneurysm, no recent stressors and a prior normal echocardiogram and ECG presented with 2 years of episodic headaches, palpitations, chest pain and worsening dyspnea. She was found to be hypertensive and electrocardiogram showed inferolateral ST segment depressions, QT interval prolongation, and elevated troponins concerning for myocardial infarction. She underwent cardiac catheterization which revealed normal coronary arteries and left ventricular basal hypokinesis with apical hyperkinesis, suggestive of reverse Takotsubo cardiomyopathy (rTTC). This left ventriculogram was confirmed with an echocardiogram and cardiac MRI. In addition, computed tomography revealed a 3 cm adrenal nodule and 24-hour urine metanephrine levels were greater than eight times the upper limit of normal, concerning for pheochromocytoma (PCC). Follow-up abdominal MRI a few days later showed the nodule had shrunk to 2.3 cm, with hemorrhagic contents. 2 weeks later, catecholamines normalized. Adrenalectomy was deferred. Repeat echocardiogram 6 months later showed normalized LV wall motion. Repeat abdominal CT showed marked adrenal mass reduction with findings consistent with nodule hemorrhage. She remains asymptomatic with normal catecholamines.

Discussion: rTTC is characterized by transient basal LV hypokinesis with apical hyperkinesis and no coronary obstruction. It is attributed to catecholamine surges causing myocardial stunning. PCCs, though rare, have been documented as reversible triggers of rTTC. In this case, elevated metanephrines and an adrenal mass suggested PCC-induced rTTC that resolved after tumor hemorrhage. Early recognition and treatment of PCC is vital. Rarely, PCCs may auto-infarct or hemorrhage, becoming nonfunctional—a scenario that can shift management strategy and avoid unnecessary surgery. While rTTC is often reversible, its 10% recurrence rate underscores the importance of addressing underlying causes and ensuring appropriate follow-up.