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Širvys A, Baranauskas A, Budrys P. A Rare Encounter: Unstable Vasospastic Angina Induced by Thyrotoxicosis. J Clin Med 2024; 13:3130. [PMID: 38892840 PMCID: PMC11172422 DOI: 10.3390/jcm13113130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
Coronary artery vasospasm plays a crucial role in the prevalence of unstable angina. Despite common misdiagnosis, there is limited evidence on this topic. Here, we present a rare case of unstable vasospastic angina in a female with severe thyrotoxicosis. Case Report: A 62-year-old female patient was admitted to the cardiac intensive care unit due to crushing chest pain at rest. The patient exhibited ischemic changes on the ECG with a normal troponin I level. Recurrent chest pain prompted urgent coronary angiography, revealing generalized vasospasm of all coronary artery branches including the left main coronary artery. Intracoronary nitroglycerin injection partially alleviated the vasospasm; however, there was a persistent stenosis in the left main artery. Subsequent intravascular ultrasound demonstrated an anatomically normal left main artery. Post-procedure, laboratory tests revealed undetectable levels of thyroid-stimulating hormone and thyroid hormones above the detectable level. The patient was initiated on methimazole and discharged symptom-free, expecting a good prognosis under conservative management. Conclusions: Clinically significant coronary vasospasm triggered by thyrotoxicosis remains a rarity in clinical practice, often posing diagnostic challenges. This case emphasizes the significance of intracoronary nitroglycerin and intravascular ultrasound in discerning the etiology of coronary lesions seen on angiography. We advocate for these techniques to optimize invasive coronary artery diagnostics, enabling the selection of the appropriate treatment strategies and improving long-term prognosis.
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Affiliation(s)
- Artiomas Širvys
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (A.B.); (P.B.)
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Arvydas Baranauskas
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (A.B.); (P.B.)
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Povilas Budrys
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania; (A.B.); (P.B.)
- Cardiology and Angiology Center, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
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Iwahara N, Abe T, Nagai S, Yoshino M, Saito H, Okada H, Kikuchi H, Matsumoto R, Osawa T, Shinohara N. Postoperative thyroid storm after radical nephrectomy for renal cell carcinoma with inferior vena cava tumor thrombus. IJU Case Rep 2021; 4:330-332. [PMID: 34497996 PMCID: PMC8413219 DOI: 10.1002/iju5.12341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/02/2021] [Accepted: 06/15/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Thyroid storm is a rare life-threating condition. We report a case of thyroid storm after radical nephrectomy for renal cell carcinoma with inferior vena cava tumor thrombus. CASE PRESENTATION A 76-year-old man with a left renal tumor and tumor thrombus extending into the inferior vena cava underwent left radical nephrectomy and thrombectomy. After the surgery, his postoperative course rapidly deteriorated, including central nervous system disturbance, fever, tachycardia, congestive heart failure, and hepatic manifestation. Thyroid function test revealed perioperative hyperthyroidism. Corticosteroids and inorganic iodide improved his condition, suggesting that he developed thyroid storm after surgery. He was discharged 5 months after surgery and has been free from disease recurrence for more than 2 years. CONCLUSION Thyroid storm after surgery is rare. However, this postoperative complication is important because it is fatal if not diagnosed and treated properly.
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Affiliation(s)
- Naoya Iwahara
- Departments ofDepartment ofUrologyHokkaido University HospitalSapporoJapan
| | - Takashige Abe
- Departments ofDepartment ofUrologyHokkaido University HospitalSapporoJapan
| | - So Nagai
- Department ofEndocrinologyHokkaido University HospitalSapporoJapan
| | - Masanao Yoshino
- Department ofNeurologyHokkaido University HospitalSapporoJapan
| | - Hitoshi Saito
- Department ofAnesthesiology and Critical Care MedicineHokkaido University HospitalSapporoJapan
| | - Hiromi Okada
- Department ofSurgical PathologyHokkaido University HospitalSapporoJapan
| | - Hiroshi Kikuchi
- Departments ofDepartment ofUrologyHokkaido University HospitalSapporoJapan
| | - Ryuji Matsumoto
- Departments ofDepartment ofUrologyHokkaido University HospitalSapporoJapan
| | - Takahiro Osawa
- Departments ofDepartment ofUrologyHokkaido University HospitalSapporoJapan
| | - Nobuo Shinohara
- Departments ofDepartment ofUrologyHokkaido University HospitalSapporoJapan
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Yamazaki K, Minakata K, Nakane T, Kawatou M, Minatoya K, Sakata R. Thyroid storm after mitral valve repair in a patient with Becker muscular dystrophy. J Card Surg 2020; 36:739-742. [PMID: 33305858 DOI: 10.1111/jocs.15245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 11/26/2022]
Abstract
A 40-year-old male with Becker muscular dystrophy presented with severe mitral regurgitation and underwent mitral valve repair. Following the surgery, the patient became tachycardic and developed a continuous high-grade fever and hyperbilirubinemia. The patient's condition worsened and we eventually tested his thyroid levels and discovered abnormally high thyroid levels. After diagnosing a severe thyroid storm, the patient was treated with oral administration of Lugol's iodine and thiamazole, as well as an intravenous steroid, which led to an immediate improvement of symptoms. The incidence of thyroid storm after open-heart surgery is extremely rare but highly life-threatening if unrecognized.
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Affiliation(s)
- Kazuhiro Yamazaki
- Department of Cardiovascular Surgery, Graduate of School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Minakata
- Department of Cardiovascular Surgery, Graduate of School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeichiro Nakane
- Department of Cardiovascular Surgery, Graduate of School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahide Kawatou
- Department of Cardiovascular Surgery, Graduate of School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate of School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuzo Sakata
- Department of Cardiovascular Surgery, Graduate of School of Medicine, Kyoto University, Kyoto, Japan
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Lee JH. Thyroid storm after coronary artery bypass surgery: a case report. J Cardiothorac Surg 2020; 15:22. [PMID: 31948453 PMCID: PMC6964208 DOI: 10.1186/s13019-020-1044-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 01/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Thyroid storm is a rare, life-threatening disease triggered by an acute event or trauma, such as surgery of the thyroid or another area, and infection. However, recent studies have shown that irregular use or discontinuation of antithyroid drugs is the most common cause of thyroid storm. A cardiovascular event caused by thyroid storm following coronary artery bypass graft (CABG) is high output heart failure with extreme tachycardia, which can be fatal. Thyroid storm after nonthyroidal surgery, especially CABG, has been rarely reported, with only one reported case until now. Herein, we present a case of thyroid storm onset in a patient who underwent CABG. Case presentation A 74-year-old woman with a history of antithyroid medication discontinuation against medical advice underwent urgent CABG. The patient exhibited extreme tachycardia postoperatively, which is highly suggestive of thyroid storm. Although a higher infection risk is an important consideration, a high-dose steroid was used to control the intractable tachycardia that did not respond to beta-blocker administration. Despite appropriate antibiotic treatment, the patient’s condition was exacerbated, and she developed multiple organ failure resulting from adult respiratory distress syndrome progression, and she died on day 8 after surgery. Conclusions Risk factors for thyroid storm after CABG and its treatment outcomes are rarely reported. Patients with a history of inappropriate antithyroid medication prescription should be in a euthyroid state before surgery. If surgery is imminent, anticipating thyroid storm and its treatment as well as a euthyroid state can improve recovery outcomes postoperatively.
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Affiliation(s)
- Jae Hoon Lee
- Department of Thoracic and Cardiovascular Surgery, Sanggye Paik Hospital, Inje University School of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul, South Korea.
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Shoja MM, Nunez Lopez O, Okereke I. Acute Thyroid Storm Following Thymectomy: A Surprising Result of Undiagnosed Graves' Disease. Cureus 2018; 10:e3239. [PMID: 30410845 PMCID: PMC6209514 DOI: 10.7759/cureus.3239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Postoperative thyroid storm represents a diagnostic dilemma in patients with overlooked hyperthyroid state undergoing a nonthyroid surgery. We report a 30-year-old female with a history of mixed connective tissue disease who presented with an anterior mediastinal mass and underwent a thoracoscopic resection of the mass. On postoperative day 1, she had an acute change in mental status with fever, tachycardia and hypercapnic respiratory failure requiring intubation and mechanical ventilation. An elevated free thyroxine concentration and almost undetectable serum thyroid stimulating hormone suggested thyroid storm as the culprit. The patient was rendered euthyroid after initiation of therapy with propylthiouracil/methimazole, potassium iodide oral solution and systemic steroid. Histopathology of the resected anterior mediastinal mass showed thymic hyperplasia. In retrospect, the patient had hyperthyroid symptoms before surgery, but this diagnosis was overlooked. Non-thyroid surgeries can trigger thyroid storm in the setting of poorly controlled or overlooked hyperthyroidism. Although uncommon, thyroid storm should be considered in differential diagnosis of perioperative tachycardia and respiratory failure. We emphasize on the importance of preoperative thyroid workup in patients with tachycardia, palpitation, labile blood pressure, unexplained weight changes or poorly controlled anxiety. The significance of a proper preoperative assessment cannot be overestimated.
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Affiliation(s)
| | | | - Ikenna Okereke
- Surgery, University of Texas Medical Branch, Galveston, USA
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Baladi IH, Rai AA, Ahmed SM. ECG changes in patients with primary hyperthyroidism. Pan Afr Med J 2018; 30:246. [PMID: 30627307 PMCID: PMC6307920 DOI: 10.11604/pamj.2018.30.246.12244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 05/25/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Thyroid hormones plays key role in regulating cardiovascular system. Its imbalance leads to various electrophysiological changes in cardiovascular system. This study was done to determine the frequency of electrocardiographic (ECG) changes in patients with primary hyperthyroidism. METHODS It was a descriptive cross-sectional study conducted in the Department of Medicine, Medical Unit III, Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from October 2013 to April 2014. A total of 103 patients newly diagnosed with primary hyperthyroidism were included in this study. Venous blood samples were collected for T3, T3, TSH analyzed by radioimmunoassay. ECG was performed. Outcome variables were the ECG changes i.e. sinus tachycardia and atrial fibrillation. RESULTS The average age of the patients was 30.09±5.57 years (95%CI: 29 to 31.18). Out of 103 cases, 19 (18.45%) were male and 84 (81.55%) were female. Sinus tachycardia was observed in 60.19% (62/103) patients whereas atrial fibrillation was found in 11.65 (12/103) of cases. CONCLUSION In this study frequency of electrocardiographic changes in term of sinus tachycardia was high. This report has emphasized the importance of thyrotoxicosis as a cause of cardiac morbidity and mortality in patients with thyrotoxicosis. These cardiac complications are readily reversible if timely optimal treatment is offered.
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Affiliation(s)
- Ishtiaque Hussain Baladi
- Department of Medicine, Medical Unit III, Ward 7, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Ayesha Aslam Rai
- Department of Medicine, Medical Unit III, Ward 7, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Syed Masroor Ahmed
- Department of Medicine, Medical Unit III, Ward 7, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
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Hyperthyroidism-associated coronary spasm: A case of non-ST segment elevation myocardial infarction with thyrotoxicosis. J Geriatr Cardiol 2012; 8:258-9. [PMID: 22783313 PMCID: PMC3390094 DOI: 10.3724/sp.j.1263.2011.00258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/10/2011] [Accepted: 08/17/2011] [Indexed: 01/14/2023] Open
Abstract
Hyperthyroidism is associated with many heart diseases. Thyrotoxic state has a relationship with coronary spasm. We present a case of a non-menopausal woman with hyperthyroidism who complained of chest pain. The diagnosis of coronary spasm was confirmed by coronary angiography (CAG). She is treated well with anti-thyrotoxicosis and anti-anginal medication. We recommend not use CAG as the first diagnostic choice among the patients with medication-uncontrolled hyperthyroidism and chest pain.
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Abstract
This review presents current knowledge about the thyroid emergencies known as myxedema coma and thyrotoxic storm. Understanding the pathogenesis of these conditions, appropriate recognition of the clinical signs and symptoms, and their prompt and accurate diagnosis and treatment are crucial in optimizing survival.
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Affiliation(s)
- Joanna Klubo-Gwiezdzinska
- Division of Endocrinology, Department of Medicine, Washington Hospital Center, Washington, DC 20010-2910, USA
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Deegan RJ, Furman WR. Cardiovascular Manifestations of Endocrine Dysfunction. J Cardiothorac Vasc Anesth 2011; 25:705-20. [DOI: 10.1053/j.jvca.2010.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Indexed: 01/27/2023]
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Thyroid storm after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2010; 140:e67-9. [DOI: 10.1016/j.jtcvs.2010.06.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 06/15/2010] [Accepted: 06/29/2010] [Indexed: 11/19/2022]
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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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The Vanishing Stenosis: ST Elevation Myocardial Infarction and Rhythm Disturbance due to Coronary Artery Spasm-Case Report and Review of the Literature. Case Rep Med 2010; 2010:132902. [PMID: 20368774 PMCID: PMC2846340 DOI: 10.1155/2010/132902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2009] [Accepted: 02/08/2010] [Indexed: 12/03/2022] Open
Abstract
A 62-year-old lady was admitted with clinical and electrocardiograph features of acute myocardial infarction. Urgent coronary arteriography was performed, demonstrating a single discrete stenosis of one coronary artery. Following intracoronary injection of GTN, this stenosis completely resolved, as the symptoms did. The causes of acute myocardial infarction with normal coronary arteries are reviewed.
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