JKTA Journal of the Korean Thyroid Association J Korean Thyroid Assoc 2005-162X Korean Thyroid Association 10.11106/jkta.2013.6.1.64 jkta-6-64 Original Article Clinical Characteristics of Thyrotoxicosis Presented by Coronary Spasm KiwonKim SeWhan Lee SungWan Chun YeoJoo Kim SangJin Kim Division of Endocrinology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea Address reprint requests to Yeo Joo Kim, MD, Division of Endocrinology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 330-721, Korea Tel: 82-41-570-3685, Fax: 82-41-574-5762, E-mail: yeojoo@schmc.ac.kr 05 2013 03 05 2013 6 1 64 68 30 01 2013 06 03 2013 Copyright © 2013, the Korean Thyroid Association. All rights reserved. 2013 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background and Objectives

Cardiovascular symptoms are integral and often the most predominant clinical presentation in patients with thyrotoxicosis. In patients with known or suspected coronary artery disease, myocardial ischemia and angina-like chest pain may be presented due to increase in cardiac output and cardiac contractility as a result of thyrotoxicosis. In addition, coronary spasm may result in angina-like chest pain in thyrotoxicosis patients without any fixed coronary artery stenosis. However, there are few reports about clinical characteristics of thyrotoxicosis associated with coronary artery spasm.

 Materials and Methods

Coronary angiography, thyroid function test, and follow-up clinical data of patients were analyzed retrospectively.

 Results

Twelve patients with coronary artery spasm were included over 4.5 years (male : female, 5 : 7). The mean age of patients was 53.3 years (range, 27 to 68), and female patients were younger than male patients (mean, 56.2 vs. 51.2 years). Only 4 patients (33%) presented typical thyrotoxic symptoms. The causes of thyrotoxicosis were Grave's disease (75%) and painless thyroiditis (25%). On coronary angiography, severe coronary spasm was observed by provocation in 6 patients, and total occlusion of right coronary artery and left circumflex artery with chest pain developed in 2 of 6 patients. After antithyroid treatment, all patients became free of chest pain.

 Conclusion

Severe coronary artery spasm can be associated with thyrotoxicosis. Thyroid function test might be a differential diagnostic test in patients with coronary artery spasm. It should be considered that thyrotoxicosis can be presented by coronary artery spasm without typical symptom of thyrotoxicosis.

 Thyrotoxicosis Coronary vasospasm References Al JaberJHaqueSNoorHIbrahimBAl SuwaidiJThyrotoxicosis and coronary artery spasm: case report and review of the literatureAngiology201061880712 MasaniNDNorthridgeDBHallRJSevere coronary vasospasm associated with hyperthyroidism causing myocardial infarctionBr Heart J19957467001 KimJHA case of myocardial ischemia and myocardial injury caused by coronary vasospasm associated with hyperthyroidismKorean Circ J200030336972 ChoiYHChungJHBaeSWLeeWHJeongEMKangMGSevere coronary artery spasm can be associated with hyperthyroidismCoron Artery Dis20051631359 PatelRPetersonGRohatgiAGhayeeHKKeeleyECAuchusRJHyperthyroidism-associated coronary vasospasm with myocardial infarction and subsequent euthyroid anginaThyroid20081822736 IhmSHSeungKBChangKYJungHOKangDHChungWSMorphologic differences of vessel wall at sites of focal and diffuse coronary vasospasm by intravascular ultrasound (IVUS)Korean Circ J200131874956 BertrandMELaBlancheJMTilmantPYThieuleuxFADelforgeMRCarreAGFrequency of provoked coronary arterial spasm in 1089 consecutive patients undergoing coronary arteriographyCirculation19826571299306 YasueHNakagawaHItohTHaradaEMizunoYCoronary artery spasm–clinical features, diagnosis, pathogenesis, and treatmentJ Cardiol2008511217 YooSYShinDHJeongJIYoonJHaDCChoSWLong-term prognosis and clinical characteristics of patients with variant anginaKorean Circ J200838126518 LeeSCRhaSWLimDSLeeEMParkCGKimYHPharmacologically inducible coronary vasospastic changes in patient with ischemic heart diseases with normal angiogram or insignificant coronary lesion and its relationships with risk factorsKorean Circ J1996266115262 McAllisterRMGrossenburgVDDelpMDLaughlinMHEffects of hyperthyroidism on vascular contractile and relaxation responsesAm J Physiol19982745 Pt 1E94653 MakinoAWangHScottBTYuanJXDillmannWHThyroid hormone receptor-alpha and vascular functionAm J Physiol Cell Physiol20123029C134652 NapoliRBiondiBGuardasoleVMatarazzoMPardoFAngeliniVImpact of hyperthyroidism and its correction on vascular reactivity in humansCirculation200110425307680 ChudleighRADaviesJSGraves’ thyrotoxicosis and coronary artery spasmPostgrad Med J200783985e5 Figures and Tables

Clinical profiles of patients with coronary artery spasm associated with thyrotoxicosis

No. Sex/Age Clinical presentation Angiographic finding TFT Diagnosis Thyrotoxic symptoms
1 F/27 Exertional chest pain Pan–arterial, diffuse vasoconstriction T3: 4.83 ng/mLfT4: >7.77 ng/dLTSH : 0.006 uIU/mL Painless thyroiditis None
2 M/58 Resting chest pain p–mRCA spasm T3: 4.11 ng/mLfT4: 6.38 ng/dLTSH: 0.005 uIU/mL Graves’ disease None
3 M/55 Exertional chest pain I.C. ergonovine: RCA, diffuse vasoconstriction T3: 2.87 ng/mLfT4: 4.4 ng/dLTSH: 0.005 uIU/mL Graves’ disease Sweating, palpitation, fatigue, weight loss
4 M/38 Resting chest pain I.C. ergonovine: total occlusion of mid-RCA T3: 2.28 ng/mLfT4: 3.09 ng/dLTSH: 0.005 uIU/mL Painless thyroiditis None
5 M/62 Exertional chest pain LCA, diffuse intense vasoconstriction T3: 3.23 ng/mLfT4: 6.75 ng/dLTSH: 0.01 uIU/mL Graves’ disease Palpitation, weight loss
6 F/50 Resting chest pain I.C. ergonovine: RCA, diffuse vasoconstriction T3: 3.82 ng/mLfT4: 5.90 ng/dLTSH: 0.005 uIU/mL Graves’ disease Fatigue, palpitation
7 F/52 Resting chest pain I.C. ergonovine: RCA, diffuse vasoconstriction T3: 3.39 ng/mLfT4: 2.21 ng/dL Graves’ disease None
8 F/52 Resting chest pain Pan-arterial, diffuse vasoconstriction TSH: 0.005 uIU/mLT3: 7.18 ng/mLfT4: 5.88 ng/dL Graves’ disease None
9 F/63 Exertional chest pain Spasm of LCA TSH: 0.005 uIU/mLT3: 4.02 ng/mLfT4: 3.63 ng/dL Graves’ disease None
10 F/59 Resting chest pain Osteal left main spasm TSH: 0.05 uIU/mLT3: 3.47 ng/mLfT4: 2.94 ng/dLTSH: 0.021 uIU/mL Painless thyroiditis None
11 F/56 Resting chest pain Mid-RCA spasm T3: 2.03 ng/mLfT4: 2.02 ng/dLTSH: 0.005 uIU/mL Graves’ disease None
12 M/68 Resting chest pain syncope Total occlusion of LCX due to vasospasm and spasm of LAD, RCA T3: 3.85 ng/mLfT4: 6.86 ng/dLTSH: 0.005 uIU/mL Graves’ disease Fatigue, sweating, tremor, weight loss

F: female, I.C. : intracoronary, LAD: left anterior descending, LCA: left coronary artery, LCX: left circumflex artery, M: male, p-mRCA: proximal-mid right coronary artery, RCA: right coronary artery, TFT: thyroid function test

Angiograms showing the diffuse severe spasm that involved the left coronary artery (A). After an intracoronary nitroglycerin injection, the coronary arteries became fully dilated and they appeared normal (B).