Monday, November 25, 2013

Low-risk and high-risk pheo

Happy Thanksgiving! This will be the last piece for 2013. I wish everyone a great holiday season and a wonderful year of 2014!

When we, health care professionals and lay people alike, talk about pheo, we seem to assume all pheos are the same. In medical textbooks, pheo is mostly discussed in a way that gives the reader the impression that if one has a pheo, one will have all the classical signs and symptoms of pheo. In the lay communications, the heterogeneity of pheo is even less appreciated. One pheo, however, can be very different from another. I have written about clinically “silent” pheo, pheo associated with normal blood pressure, pheo that causes frank cardiovascular problems, small pheo, pheo caused by genetic mutations, etc. Understanding the heterogeneity of pheo is critical to tailor pheo management to an individual patient with a particular pheo.

Preoperative management of pheo has been controversial since the very beginning. I myself have advocated careful preoperative preparation for every patient with pheo. On the other hand, there are many different ways of preoperative preparation used by experts, all with similar excellent outcome. Recently, one review article proposes risk stratification for pheo, which may help reconcile the paradox.

The article divides pheos into 3 categories: low-, intermediate-, and high-risk, according to the risk of heart complications a particular pheo can impose on a patient. Low-risk pheos are those smaller than 3 cm in diameter. This article proposes that specific preoperative preparation is not needed for low-risk pheos. High-risk pheos are those that already cause obvious cardiovascular complications such as arrhythmia, heart attack, heart failure, or stroke. Careful preparation is needed for high-risk pheos and the doctors need to coordinate their care so that the preparation regimen is safe and effective. Intermediate-risk pheos are those that are none of the above. The preparation regimen should be individualized. The higher the relative risk of cardiovascular complications a pheo has, the more careful and longer the preparation it requires. 

It needs to be emphasized that this risk stratification is based on clinical observation and just a proposal. It has not been prospectively tested. What am I doing? I currently still carefully prepare everyone. If a patient does have a low-risk pheo, I am more relaxed with the regimen.


Dr. Pheo