The paroxysms of profound hypertension with associated reflex bradycardia are highly suggestive of an underlying phaeochromocytoma. This diagnosis is compatible with the patient’s longstanding history of anxiety and previous presentation to secondary care with dyspnoea, palpitations and headaches. This presentation represents a decompensation with acute pulmonary oedema secondary to left ventricular failure. This is likely to have been precipitated by the commencement of propranolol (a non-selective β-blocker). Blockade of β2 mediated peripheral vasodilation worsens the hypertension caused by excessive circulating catecholamines (α-agonists). In addition the negative effect on β1 activity further impairs myocardial function in face of severely raised systemic vascular resistance, precipitating cardiac failure4.
