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Gupta S, Goyal P, Idrees S, Aggarwal S, Bajaj D, Mattana J. Association of Endocrine Conditions With Takotsubo Cardiomyopathy: A Comprehensive Review. J Am Heart Assoc 2018; 7:e009003. [PMID: 30371307 PMCID: PMC6404898 DOI: 10.1161/jaha.118.009003] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Sonali Gupta
- Department of MedicineSt. Vincent's Medical CenterBridgeportCT
- The Frank H. Netter MD School of Medicine at Quinnipiac UniversityNorth HavenCT
| | - Pradeep Goyal
- The Frank H. Netter MD School of Medicine at Quinnipiac UniversityNorth HavenCT
- Department of RadiologySt. Vincent's Medical CenterBridgeportCT
| | - Sana Idrees
- Department of MedicineSt. Vincent's Medical CenterBridgeportCT
- The Frank H. Netter MD School of Medicine at Quinnipiac UniversityNorth HavenCT
| | - Sourabh Aggarwal
- Cardiology DivisionDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNE
| | - Divyansh Bajaj
- Department of MedicineSt. Vincent's Medical CenterBridgeportCT
- The Frank H. Netter MD School of Medicine at Quinnipiac UniversityNorth HavenCT
| | - Joseph Mattana
- Department of MedicineSt. Vincent's Medical CenterBridgeportCT
- The Frank H. Netter MD School of Medicine at Quinnipiac UniversityNorth HavenCT
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2
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Menichetti F, Orsini E, Delle Donne MG, Dini FL, Marzilli M. ST-segment elevation acute myocardial infarction associated with hyperthyroidism: beware of coronary spasm! J Cardiovasc Med (Hagerstown) 2018; 18:798-799. [PMID: 28858949 DOI: 10.2459/jcm.0b013e328365b8f5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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3
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Ugurlucan M, Zorman Y, Ates G, Arslan AH, Yildiz Y, Karahan Zor A, Cicek S. Takotsubo cardiomyopathy in a patient with multiple autoimmune disorders and hyperthyroidism. Res Cardiovasc Med 2013; 2:145-8. [PMID: 25478511 PMCID: PMC4253774 DOI: 10.5812/cardiovascmed.10023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 03/29/2013] [Accepted: 04/21/2013] [Indexed: 12/16/2022] Open
Abstract
Takotsubo cardiomypathy is a very rare cardiovascular syndrome leading to myocardial infarction and left ventricular dysfunction in the absence of a detectable coronary artery lesion. It is accepted as reversible left ventricular asynergy occuring typically after an intrinsic adrenergic hyperstimulation. In this report we present Takotsubo cardiomyopathy in a 75-year-old patient with multiple autoimmune disorders.
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Affiliation(s)
- Murat Ugurlucan
- Anadolu Medical Center Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Yilmaz Zorman
- University Hospitals Geneva, Division of Cardiovascular Surgery, Geneva, Switzerland
| | - Gursel Ates
- Anadolu Medical Center Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Ahmet H. Arslan
- Anadolu Medical Center Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Yahya Yildiz
- Anadolu Medical Center Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Aysegul Karahan Zor
- Anadolu Medical Center Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
| | - Sertac Cicek
- Anadolu Medical Center Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
- Corresponding author: Sertac Cicek, Anadolu Medical Center Hospital, Cumhuriyet Mahallesi, 2255 Sokak, No: 3, Gebze 41400, Kocaeli, Turkey, Tel: +90-2626785000, Fax: +90-2626540538, E-mail:
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4
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Vasospastic angina in a patient with hyperthyroidism. Herz 2012; 37:570-2. [PMID: 22407422 DOI: 10.1007/s00059-011-3572-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/20/2011] [Accepted: 11/24/2011] [Indexed: 10/28/2022]
Abstract
A 56-year-old man presented with typical angina pectoris lasting >20 min associated with precordial ST-segment elevation. Urgent coronary angiography showed critical stenosis in the proximal segment of the left anterior descending artery, which resolved with intracoronary nitrate application. He was subsequently diagnosed with hyperthyroidism secondary to exposure of iodinated contrast agent which is thought to be the cause of the coronary spasm. Symptoms resolved upon treatment with propylthiouracil, slow-release diltiazem, isosorbide mononitrate, and aspirin. This unusual case highlights the importance of considering hyperthyroidism in the differential diagnosis of chest pain and coronary artery spasm. We suggest routine thyroid function testing in patients with coronary spasm.
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McDonough RJ, Moul MS, Beckman D, Slim AM. Isolated right ventricular failure in hyperthyroidism: a clinical dilemma. Heart Int 2011; 6:e11. [PMID: 22049310 PMCID: PMC3205783 DOI: 10.4081/hi.2011.e11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 08/05/2011] [Accepted: 08/05/2011] [Indexed: 01/09/2023] Open
Abstract
We present a unique case of a 42-year-old gentleman with newly diagnosed Graves’ disease and isolated right ventricular failure. Extensive evaluation to include echocardiogram and cardiac catheterization were negative for significant pulmonary hypertension or coronary artery disease as potential etiologies. Hyperthyroid induced vasospasm is a rare but reported clinical entity that serves to be a clinical and diagnostic dilemma.
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Affiliation(s)
- Ryan J McDonough
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston
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6
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Mustafa C, Ozgül U, Zehra GC, Hülya C. Transient ST-segment elevation due to iatrogenic hyperthyroidism in a patient with normal coronary arteries. Intern Med 2011; 50:1595-7. [PMID: 21804288 DOI: 10.2169/internalmedicine.50.5099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 53-year-old man presented with angina pectoris and ST-segment elevation in V(1)-V(4) leads. Electrocardiogram changes and chest pain were completely resolved with nitroglycerine infusion. Coronary angiogram revealed normal epicardial vessels. These findings suggest that the acute myocardial ischemia was secondary to coronary vasospasm. From his medical history we learned that he was taking L-thyroxine and the dose had been increased two months previously. He was found to be in thyrotoxic state at admission. L-thyroxine treatment was withheld and diltiazem was given. He had no further symptoms. In conclusion we think that acute myocardial ischemia was likely secondary to L-thyroxine-induced coronary spasm.
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Affiliation(s)
- Cetìn Mustafa
- Department of Cardiology, Atatürk Chest Disease and Chest Surgery Education and Research Hospital, Sanatoryum caddesi, Turkey.
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7
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Kuboyama O, Tokunaga T, Kobayashi K, Iwai T, Osaka Y, Umemoto T. A case of asymptomatic patient with hyperthyroidism documented the onset of Takotsubo cardiomyopathy by Holter monitoring. Int J Cardiol 2010; 151:e82-4. [PMID: 20580453 DOI: 10.1016/j.ijcard.2010.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 05/30/2010] [Indexed: 11/16/2022]
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8
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Jaber JA, Haque S, Noor H, Ibrahim B, Al Suwaidi J. Thyrotoxicosis and Coronary Artery Spasm: Case Report and Review of the Literature. Angiology 2010; 61:807-12. [DOI: 10.1177/0003319710365146] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 51-year old Middle-Eastern man presented with recurrent chest pain associated with ST-segment elevation. The patient was treated with placement of a stent in the right coronary artery. He was subsequently diagnosed with severe hyperthyroidism secondary to Graves disease, which is thought to be the cause of the coronary spasm. The patient was treated with neomercazole and potassium iodide solution, and diltiazem, and nitrates with resolution of his symptoms. This unusual case highlights the importance of considering hyperthyroidism in the differential diagnosis of recurrent chest pain and coronary artery spasm. We suggest routine thyroid function testing in patients with coronary spasm.
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Affiliation(s)
- Jihad A. Jaber
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Saiful Haque
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hassam Noor
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Centre, Manama, Bahrain
| | - Buthina Ibrahim
- Internal Medicine (Endocrinology), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Jassim Al Suwaidi
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar,
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Abstract
The cases of two patients with hyperthyroidism and acute left ventricular (LV) dysfunction with segmental wall motion abnormalities resulting in heart failure are reported. Both had electrocardiographic changes mimicking ischemic coronary artery disease. Treatment with antithyroid medications, beta blockers, and angiotensin-converting enzyme inhibitors rapidly restored LV function. The rapid reversibility suggests a role for myocardial stunning, an important entity to recognize in hyperthyroidism since this form of LV dysfunction can be reversed with appropriate treatment.
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Affiliation(s)
- N Pereira
- Harvard Medical School, Boston, Massachusetts, USA
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Patel R, Peterson G, Rohatgi A, Ghayee HK, Keeley EC, Auchus RJ, Chang AY. Hyperthyroidism-associated coronary vasospasm with myocardial infarction and subsequent euthyroid angina. Thyroid 2008; 18:273-6. [PMID: 18279027 DOI: 10.1089/thy.2007.0131] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A 40-year-old African-American woman presented with atypical chest pain, an acute non-ST segment elevation myocardial infarction, and angiographic evidence for severe ostial vasospasm of the left main and right coronary arteries. Subsequently, she was diagnosed with hyperthyroidism and treated with antithyroid therapy and oral nitrates. Repeat angiography revealed resolution of the vasospasm; however, the chest pain recurred in the euthyroid state. Hyperthyroidism-associated coronary vasospasm is a rare disorder that characteristically causes angina in young Asian women and resolves with correction of hyperthyroidism. We present an atypical case of an African-American woman presenting with a myocardial infarction who developed recurrent angina while euthyroid.
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Affiliation(s)
- Rupa Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9066, USA
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11
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Lee SM, Jung TS, Hahm JR, Im SI, Kim SK, Lee KJ, Lee JM, Chung SI. Thyrotoxicosis with coronary spasm that required coronary artery bypass surgery. Intern Med 2007; 46:1915-8. [PMID: 18057764 DOI: 10.2169/internalmedicine.46.0472] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe a 47-year-old woman with severe coronary vasospasm induced by hyperthyroidism. The patient complained of anginal chest pain without specific characteristics of thyrotoxicosis. Coronary arteriography was performed and revealed 90% stenosis of both the left and right coronary os. She was treated with emergent coronary artery bypass graft surgery. Postoperatively, she exhibited a comatose mentality. Severe thyrotoxicosis was indicated on thyroid function tests and thyrotoxic storm was diagnosed. Nineteen days after the surgery and following the initiation of propylthiouracil treatment, coronary arteriography revealed entirely normal coronary arteries.
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Affiliation(s)
- Sang Min Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
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12
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Basso MC, Flores PC, de Azevedo Marques A, de Souza GL, D'Elboux Guimarães Brescia M, Campos CR, de Cleva R, Saldiva PHN, Mauad T. Bilateral extensive cerebral infarction and mesenteric ischemia associated with segmental arterial mediolysis in two young women. Pathol Int 2005; 55:632-8. [PMID: 16185293 DOI: 10.1111/j.1440-1827.2005.01881.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Segmental arterial mediolysis (SAM) is a rare non-atherosclerotic non-inflammatory vascular disease that affects mainly muscular arteries of the splanchnic and cerebral territories. Reported herein are two cases of SAM in young women with fatal outcome. One of the patients had an atypical form of the disease, which primarily affected small intestinal submucosal and subserosal arteries, and resulted in acute mesenteric ischemia. The other had bilateral brain infarction with SAM of internal carotid arteries (ICA). Pathological examination of both cases did not reveal the cause of blood flow disturbance: large mesenteric branches of the former and ICA of the latter were free of either dissection or thrombosis; in addition, small intestinal arteries of the first patient did not show signs of vasculitis. These findings suggest that unusual pathways of arterial occlusion and dissection may occur in the context of SAM.
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Abstract
The heart is a major target organ for thyroid hormone action, and marked changes occur in cardiac function in patients with hypo- or hyperthyroidism. T(3)-induced changes in cardiac function can result from direct or indirect T(3) effects. Direct effects result from T(3) action in the heart itself and are mediated by nuclear or extranuclear mechanisms. Extranuclear T(3) effects, which occur independent of nuclear T(3) receptor binding and increases in protein synthesis, influence primarily the transport of amino acids, sugars, and calcium across the cell membrane. Nuclear T(3) effects are mediated by the binding of T(3) to specific nuclear receptor proteins, which results in increased transcription of T(3)-responsive cardiac genes. The T(3) receptor is a member of the ligand-activated transcription factor family and is encoded by cellular erythroblastosis A (c-erb A) genes. T(3) also leads to an increase in the speed of diastolic relaxation, which is caused by the more efficient pumping of the calcium ATPase of the sarcoplasmic reticulum. This T(3) effect results from T(3)-induced increases in the level of the mRNA coding for the sarcoplasmic reticulum calcium ATPase protein, leading to an increased number of calcium ATPase pump units in the sarcoplasmic reticulum.
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Affiliation(s)
- George J Kahaly
- Departmrent of Medicine I, Endocrine Unit, Gutenberg-University Hospital, D-55101 Mainz, Germany
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Choi YH, Chung JH, Bae SW, Lee WH, Jeong EM, Kang MG, Kim BJ, Kim KW, Park JE. Severe coronary artery spasm can be associated with hyperthyroidism. Coron Artery Dis 2005; 16:135-9. [PMID: 15818081 DOI: 10.1097/00019501-200505000-00001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Coronary artery spasm is not infrequently seen in Korea. Most of the patients with coronary spasm show a focal spasm in coronary angiography. However, the cause of the disease is not well known. There have been a few anecdotal case reports of coronary artery spasm associated with hyperthyroidism, but there has not been a report concerning a large series of such patients. Over a period of 5 years and 8 months, we experienced eight patients having the diffuse or severe type of coronary artery spasm in association with hyperthyroidism. METHODS We investigated the characteristics of the patients with coronary artery spasm, which was diagnosed by coronary angiography or by provocation with an intracoronary injection of acetylcholine or ergonovine. The demographic data, coronary angiographic findings, thyroid function test results, and the follow-up clinical data of the eight patients having coronary artery spasm associated with hyperthyroidism were analyzed. RESULTS All eight patients had Graves' disease. In six patients, the coronary arterial vasoconstriction developed during the coronary angiography without an injection of ergonovine. In three patients, the left main stem coronary artery was involved in the spasm. Among these eight patients, five were female, and all of these female patients were < or = 51 years old. All of the patients were treated with anti-thyroid medications, calcium channel blockers, and long-acting nitroglycerines; they all remained free of chest pain during the median follow-up period of 5 years. CONCLUSIONS A severe form of coronary artery spasm could be associated with hyperthyroidism. A high level of suspicion and the thyroid function study should be mandatory for patients with coronary artery spasm, especially for the young female patients.
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Affiliation(s)
- Yoon-Ho Choi
- Division of Cardiology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea
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Miyazaki S, Kamiishi T, Hosokawa N, Komura M, Konagai H, Sagai H, Takamoto T. Reversible left ventricular dysfunction "takotsubo" cardiomyopathy associated with hyperthyroidism. ACTA ACUST UNITED AC 2004; 45:889-94. [PMID: 15557732 DOI: 10.1536/jhj.45.889] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Myocardial stunning with hyperthyroidism is rare. A 79-year old woman with hyperthyroidism was admitted to our hospital complaining of palpitations due to paroxysmal atrial fibrillation. An echocardiogram showed akinesis of the apical wall which was not observed 2 weeks before admission. Cardiac catheterization performed in the acute phase showed normal coronary arteries and no evidence of provocative spasms. The wall motion abnormality disappeared entirely after 1 week in hospital. We report a case of transient left ventricular dysfunction, so called "takotsubo" cardiomyopathy, associated with hyperthyroidism.
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Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiology, Hokushin General Hospital, Nagoya 383-8505, Japan
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Sakaki T, Fujioka Y, Akagami T, Masai M, Shimizu H, Sakoda T, Tsujino T, Ohyanagi M. Cardiac Wall Motion Abnormalities Observed in a Patient With Transient Hyperthyroidism. ACTA ACUST UNITED AC 2004; 45:1071-7. [PMID: 15655284 DOI: 10.1536/jhj.45.1071] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A 74-year-old woman, with a history of hypertension and hyperlipidemia, was admitted to our hospital. She was found to have a sinus tachycardia with ST-segment elevations in leads II, III, (a)V(F), and V(3) through V(6) in electrocardiography, hypokinesis of the left ventricular apex by echocardiography, and normal findings on coronary angiography. Blood analysis revealed an increase in the creatine kinase MB fraction, a significant positive detection in troponin T, and transient elevations in the concentrations of free triiodothyronine, free thyroxine, thyroid globulin antibody, and thyroid peroxidase antibody. Defects in myocardial perfusion and fatty acid metabolism in the apical area were also demonstrated by myocardial scintigraphy. These data suggest that tako-tsubo syndrome or myocardial infarction may be induced in patients with mild and transient hyperthyroidism.
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Affiliation(s)
- Takatoshi Sakaki
- Department of Internal Medicine, Division of Coronary Heart Disease, Hyogo College of Medicine, Japan
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Abstract
Under physiologic conditions, epicardial arteries contribute minimally to coronary vascular resistance. However, in the presence of endothelial dysfunction, stimuli that normally produce vasodilation may instead cause constriction. Examples include neural release of acetylcholine or norepinephrine, platelet activation and production of serotonin and thrombin, and release of local factors such as bradykinin. This shift from a primary endothelial-mediated vasodilator influence to one of endothelial dysfunction and unchecked vasoconstriction is precisely the milieu in which coronary vasospasm is observed. This condition, which typically occurs during periods of relatively sedentary activity, is associated with focal and transient obstruction of an epicardial arterial segment resulting in characteristic echocardiographic changes and symptoms of myocardial ischemia. This review highlights the current understanding of mechanisms regulating the coronary circulation during health and examines the pathophysiologic changes that occur with coronary spasm. Genetic and other predisposing conditions are addressed, as well as novel therapies based on recent mechanistic insights of the coronary contractile dysfunction associated with coronary spasm.
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Affiliation(s)
- Srilakshmi Konidala
- Department of Medicine, Cardiovascular Center, General Clinical Research Center, Milwaukee, WI 53226, USA
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Emdin M, Pratali L, Iervasi G. Abolished vagal tone associated with thyrotoxicosis triggers prinzmetal variant angina and paroxysmal atrial fibrillation. Ann Intern Med 2000; 132:679. [PMID: 10766696 DOI: 10.7326/0003-4819-132-8-200004180-00024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Masani ND, Northridge DB, Hall RJ. Severe coronary vasospasm associated with hyperthyroidism causing myocardial infarction. Heart 1995; 74:700-1. [PMID: 8541184 PMCID: PMC484140 DOI: 10.1136/hrt.74.6.700] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A 48 year old woman presented with angina after an anterior myocardial infarction and was found to be hyperthyroid. Coronary angiography showed a stenosis of the left coronary os and a long, severe stenosis of the left anterior descending artery which was partially relieved by glyceryl trinitrate. Three months later, after radioactive iodine treatment had rendered her euthyroid, repeat coronary angiography showed entirely normal coronary arteries. This unusual case establishes an association between hyperthyroidism and coronary vasospasm resulting in myocardial infarction.
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Affiliation(s)
- N D Masani
- Department of Cardiology, University Hospital of Wales, Cardiff
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Abstract
Despite earlier recognition and treatment of hyperthyroidism, thyroid storm remains a life-threatening, although fortunately rare, medical emergency. Prompt recognition and aggressive treatment employing a multifaceted approach are generally effective at correcting the homeostatic decompensation that is the hallmark of thyroid storm. Research is furthering understanding of the cellular actions of thyroid hormone and may lead to additional, even more effective treatment modalities in the future.
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Affiliation(s)
- S T Tietgens
- Division of Endocrinology and Metabolism, Albany Medical College, New York
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