Graves' thyrotoxicosis and coronary artery spasm

Thyrotoxicosis-Related Left Main Coronary Artery Spasm Presenting As Acute Coronary Syndrome

Thyrotoxicosis can cause acute chest pain without ST changes in EKG due to coronary artery spasm. Its diagnosis can be particularly challenging as the symptoms may mimic acute coronary syndrome. The diagnosis of coronary artery spasm is confirmed by coronary angiography. The use of intracoronary nitroglycerin can relieve spasms and reveal the true extent of coronary artery disease. We present a case of a perimenopausal woman with newly diagnosed hyperthyroidism who presented with chest pain. Coronary angiography showed spasm of the left anterior descending artery which was relieved by intracoronary nitroglycerin. 

Hyperthyroidism is associated with a spectrum of cardiovascular manifestations ranging from relatively benign palpitations to cardiac arrest. Rarely, it has been associated with episodic angina which indicates myocardial ischemia secondary to coronary artery spasm. Thyrotoxicosis-induced coronary artery spasm is a rare condition. Coronary artery spasm might masquerade as acute coronary syndrome, and coronary angiography is usually necessary to rule out myocardial infarction. In patients with risk factors for developing thyrotoxicosis-induced coronary artery spasm, any stenosis found on coronary angiography must not be assumed to be coronary artery disease only, and the possibility of coronary artery spasm must be explored. Our case emphasizes the use of intraprocedural nitroglycerin in these patients, which can relieve the spasm and reveal the true extent of coronary artery disease. Restoration of euthyroidism is the cornerstone of management and abates the need for long-term coronary vasodilator medications. Early diagnosis and optimal management have a favorable prognosis in these patients. 

Cardiovascular Events in Patients with Thyroid Storm

CONTEXT

Thyroid storm can present as a multitude of symptoms, the most significant being cardiovascular (CV). It is associated with various manifestations such as cardiac arrhythmia, heart failure, and ischemia. However, the frequencies of events and characteristics associated with patients that experience these events are not known.

METHODS

Study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015. Total hospitalizations of thyroid storm were identified using appropriate ICD-9 diagnostic codes. The analysis was performed using SAS.

OBJECTIVE

To better understand the frequency and characteristics CV occurrences associated with thyroid storm, through a retrospective analysis of thyroid storm hospital admissions.

DESIGN

The study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015.

SETTING

Total hospitalizations of thyroid storm were identified using International Classification of Diseases (ICD)-9 diagnostic codes. The analysis was performed using Statistical Analysis System (SAS).

RESULTS

A total of 6380 adult hospitalizations were included in the final analysis, which includes 3895 hospitalizations with CV events (CEs). Most frequently associated CEs were arrhythmia (N = 3770) followed by acute heart failure (N = 555) and ischemic events (N = 150). Inpatient mortality was significantly higher in patients with CEs compared with those without CEs (3.5% vs 0.2%, P < 0.005). The median length of stay was also higher in patients with CEs compared with those without CEs (4 days vs 3 days, P < 0.0005). Atrial fibrillation was the most common arrhythmia type, followed by nonspecified tachycardia.

CONCLUSIONS

In patients who were hospitalized due to thyroid storm and associated CEs significantly increased in-hospital mortality, length of stay, and cost. Patients with obesity, alcohol abuse, chronic liver disease, and COPD were more likely to have CEs. Patients with CV complications were at higher risk for mortality. In-hospital mortality increased with ischemic events and acute heart failure. Further evaluation is needed to further classify the type of arrhythmias and associated mortality.

Fluctuations in Moyamoya Vasculopathy Associated with Basedow Disease Depending on Thyroid Hormone Status

A 31-year-old woman presented with sudden onset of weakness in her left upper limb. Magnetic resonance imaging revealed acute cerebral infarctions in the right frontal and parietal lobes. Magnetic resonance angiography showed stenosis in the proximal portions of the bilateral middle cerebral arteries and terminal portions of the bilateral internal carotid arteries. The patient also complained of thyrotoxic symptoms, such as tachycardia, goiter, and fine finger tremor. She was diagnosed with acute ischemic stroke due to moyamoya vasculopathy (MMV) associated with Basedow disease. The patient's thyroid hormone status normalized and intracranial artery stenosis gradually improved. However, after 6 months, she developed transient left hemiparesis during the 7th week of gestation. Her thyroid function deteriorated, and MMV progressed. Then, MMV improved again with the normalization of her thyroid function. This case shows that MMV associated with Basedow disease could worsen or improve depending on the thyroid hormone status.

Cardiorespiratory Failure in Thyroid Storm: Case Report and Literature Review

Thyroid storm is a potentially fatal manifestation of thyrotoxicosis. Cardiopulmonary failure is the most common cause of death in thyroid storm. Clinicians should keep in mind that thyroid storm complicated with cardiopulmonary failure can be the first presentation of thyrotoxicosis. As early intervention is associated with improved patient outcome, prompt diagnosis based on clinical grounds is of paramount importance in the management of thyrotoxicosis. A high index of suspicion and the ability of early recognition of impending thyroid storm depends on a thorough knowledge of both the typical and atypical clinical features of this illness. Herein, we report a case of thyroid storm presenting as cardiopulmonary failure in a 51-year-old woman with undiagnosed Grave’s disease. Additionally, we review the pathophysiology of cardiopulmonary failure associated with thyrotoxicosis and various treatment modalities for thyroid storm.

Severe Cerebral Vasospasm in Patients with Hyperthyroidism

Cerebral vasospasm associated with hyperthyroidism has not been reported to cause cerebral infarction. The case reported here is therefore the first of cerebral infarction co-existing with severe vasospasm and hyperthyroidism. A 30-year-old woman was transferred to our hospital in a stuporous state with right hemiparesis. At first, she complained of headache and dizziness. However, she had no neurological deficits or radiological abnormalities. She was diagnosed with hyperthyroidism 2 months ago, but she had discontinued the antithyroid medication herself three days ago. Magnetic resonance imaging and angiography showed cerebral infarction with severe vasospasm. Thus, chemical angioplasty using verapamil was performed two times, and antithyroid medication was administered. Follow-up angiography performed at 6 weeks demonstrated complete recovery of the vasospasm. At the 2-year clinical follow-up, she was alert with mild weakness and cortical blindness. Hyperthyroidism may influence cerebral vascular hemodynamics. Therefore, a sudden increase in the thyroid hormone levels in the clinical setting should be avoided to prevent cerebrovascular accidents. When neurological deterioration is noticed without primary cerebral parenchyma lesions, evaluation of thyroid function may be required before the symptoms occur.

Thyrotoxicosis-induced acute myocardial infarction due to painless thyroiditis

BACKGROUND

Thyrotoxicosis influences cardiovascular hemodynamics and can induce coronary vasospasm. Patients with thyrotoxicosis-induced acute myocardial infarction (AMI) are unusual and almost all reported cases have been associated with Graves' disease. Patients with painless thyroiditis show a thyrotoxic phase during the early stages. Here we describe a very rare case of thyrotoxicosis with painless thyroiditis-induced AMI.

SUMMARY

A 35-year-old Korean man visited the emergency room for a 2-hour duration of typical AMI chest pain. The patient did not have any coronary artery disease (CAD) risk factors. The electrocardiogram showed 3 mm of ST-segment elevation in leads II, III, and aVF, which is consistent with inferior AMI. We immediately treated the patient with aspirin, clopidogrel, and nitroglycerine and performed emergent coronary angiography. Coronary angiography showed normal coronary arteries without any stenotic lesions. Consistent with AMI, cardiac enzyme levels of serum creatine kinase (CK), CK-MB, and troponin-I were also elevated. Laboratory findings showed thyrotoxicosis without any thyroid autoantibodies. A 99m-technetium scintigraphy showed markedly decreased thyroid uptake compatible with thyroiditis. We treated the patient with calcium channel blockers and nitrates. The patient spontaneously recovered normal thyroid function after 6 weeks of observation and did not complain of chest pain.

CONCLUSION

Thyrotoxicosis due to painless thyroiditis provoked AMI in a young man who had no atherosclerotic coronary lesions and no CAD risk factors.

Lipid abnormalities and cardiometabolic risk in patients with overt and subclinical thyroid disease

Dyslipidemia is a common finding in patients with thyroid disease, explained by the adverse effects of thyroid hormones in almost all steps of lipid metabolism. Not only overt but also subclinical hypo- and hyperthyroidism, through different mechanisms, are associated with lipid alterations, mainly concerning total and LDL cholesterol and less often HDL cholesterol, triglycerides, lipoprotein (a), apolipoprotein A1, and apolipoprotein B. In addition to quantitative, qualitative alterations of lipids have been also reported, including atherogenic and oxidized LDL and HDL particles. In thyroid disease, dyslipidemia coexists with various metabolic abnormalities and induce insulin resistance and oxidative stress via a vice-vicious cycle. The above associations in combination with the thyroid hormone induced hemodynamic alterations, might explain the increased risk of coronary artery disease, cerebral ischemia risk, and angina pectoris in older, and possibly ischemic stroke in younger patients with overt or subclinical hyperthyroidism.

Thyrotoxicosis and Coronary Artery Spasm: Case Report and Review of the Literature

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.