Graves’ Disease-Induced Coronary Vasospasm

JACC: CARDIOVASCULAR INTERVENTIONS

VOL.

ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

-, NO. -, 2016

ISSN 1936-8798/$36.00

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http://dx.doi.org/10.1016/j.jcin.2016.08.028

IMAGES IN INTERVENTION

Graves’ Disease-Induced Coronary Vasospasm Naddi Marah, MD, Keisha Bryant, MD, Salman Haq, MD, Muhammad Khan, MD

A

51-year-old woman presented to the emer-

of 20, indicated a low likelihood of thyrotoxicosis, she

gency department with a 3-week history of

was started on methimazole and propanolol. Euthyr-

intermittent palpitations, dyspnea, and sub-

oidism was restored thereafter, as well as symptomatic

sternal chest pain lasting 5 to 10 min with sponta-

relief with the attenuation of her adrenergic drive.

neous resolution. She remained hemodynamically

Multiple hypothetical pathophysiological path-

stable, and an electrocardiogram showed a 1.5-mm

ways have been proposed for the mechanism of

ST-segment elevation in lead V 2 along with sinus

thyroid hormone–induced coronary vasospasm. In a

tachycardia. Given the persistence of her symptoms,

Korean study of 6,923 subjects undergoing coronary

she underwent diagnostic angiography. Upon coro-

angiography for evaluation of chest pain, the inci-

nary vessel engagement with the coronary catheter,

dence of coronary vasospasm was 5%, with 29%

there was severe left main and right coronary ostial

occurring in women under 50 years of age (1). During

vasospasm, with dampening of the blood pressure

a thyrotoxic state, hypersensitivity to vasoconstric-

tracings, both subsequently relieved with the admin-

tive agents, decreased vasodilation, and general

istration of sublingual and intracoronary nitroglyc-

hypermetabolic

erin (Figure 1).

between blood supply and oxygen demand (2). Con-

state

precipitates

an

imbalance

Further investigation revealed an elevated serum-

trolling thyroid activity is in itself curative, obviating

free thyroxine of 7.22 ng/dl (range: 0.76 to 1.46

the need for unnecessary mechanical interventions

ng/dl),

and further antianginal therapy.

suppressed

thyroid-stimulating

hormone

of <0.005 mIU/ml (range: 0.36 to 3.74 mIU/ml), elevated thyroid peroxidase antibody titer of 87 (normal value

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

is <9 m IU/ml) IU/ml, and thyroid-stimulating immu-

Naddi Marah, Department of Medicine, New York

noglobulin of 341 (normal value is <140), confirming

Methodist Hospital-Weill Cornell Medicine, 506 6th

the diagnosis of Graves’ disease. Although her clinical

Street, Brooklyn, New York 11215. E-mail: nbm9004@

assessment, supported by a Burch-Wartofsky score

nyp.org.

From the Department of Medicine, New York Methodist Hospital-Weill Cornell Medicine, Brooklyn, New York. All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received August 9, 2016; accepted August 11, 2016.

2

Marah et al.

JACC: CARDIOVASCULAR INTERVENTIONS VOL.

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Graves’ Disease-Induced Coronary Vasospasm

F I G U R E 1 Diagnostic Left Heart Catheterization of the Left and Right Coronary Vessels

(A) Left main coronary artery vasoconstriction (blue arrow). (B) Left main coronary vasodilation after intracoronary and sublingual nitroglycerin. (C) Right coronary artery vasoconstriction. (D) Right coronary artery vasodilation after intracoronary and sublingual nitroglycerin.

REFERENCES 1. Choi YH, Chung JH, Bae SW, et al. Severe coronary artery spasm can be associated with hyperthyroidism. Coron Artery Dis 2005;16:135–9.

2. Jung CH, Rhee EJ, Shin HS, et al. Higher serum free thyroxine levels are associated with coronary artery disease. Endocrine J 2008;55:819–26.

KEY WORDS coronary vasospasm, Graves’ disease, hyperthyroidism, methimazole, nitroglycerin, thyroid peroxidase antibody, thyroid-stimulating immunoglobulin