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

Abstract

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.

A Rare Encounter: Unstable Vasospastic Angina Induced by Thyrotoxicosis

“…Similar occurrences have been documented in previous reports. Coronary vasospasm can often mimic acute coronary syndrome stemming from an atherosclerotic event, exhibiting typical ECG changes, and sometimes even elevated high sensitivity troponin levels, coupled with persistent chest pain, thus posing challenges in clinical differentiation prior to the coronary angiography [ 9 , 10 ]. Also, vasospasm can clinically resemble ST-elevation myocardial infarction, manifesting with consistent ECG findings and elevated troponin levels [ 11 , 12 ].…”

“…Also, vasospasm can clinically resemble ST-elevation myocardial infarction, manifesting with consistent ECG findings and elevated troponin levels [ 11 , 12 ]. Therefore, during coronary angiography, the administration of intracoronary nitroglycerin serves as a valuable diagnostic tool in distinguishing vasospasm from atherosclerotic coronary artery disease and avoiding unnecessary stenting [ 9 , 10 , 11 ]. Thyrotoxicosis-induced coronary vasospasm may lead to severe outcomes, including cardiac arrest and necessitating resuscitation, as reported by Omar et al [ 13 ].…”

“…In the literature, intracoronary nitroglycerin is consistently recognized as a vital diagnostic tool during coronary angiography especially when coronary vasospasm is suspected [ 9 , 10 , 11 , 12 , 24 ]. Moreover, IVUS plays a crucial role in optimizing the diagnostic process and averting unnecessary stenting particularly in cases of refractory coronary artery spasm resistant to nitroglycerin [ 12 , 24 , 42 ].…”

“…Akin to vasospastic angina, thyrotoxicosis is more common among females [ 4 , 8 ]. Clinically significant coronary vasospasm triggered by thyrotoxicosis remains a rarity in clinical practice, and it often poses diagnostic challenges [ 9 ]. Despite its significance and the prevalence of misdiagnoses, evidence on this topic remains scant, and it is largely limited to case reports and retrospective studies.…”