Clinical Characteristics of Thyrotoxicosis Presented by Coronary Spasm

Kim Kiwon; Whan Lee Se; Wan Chun Sung; Joo Kim Yeo; Jin Kim Sang

doi:10.11106/jkta.2013.6.1.64

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Kiwon, Se, Sung, Yeo, and Sang: Clinical Characteristics of Thyrotoxicosis Presented by Coronary Spasm

Original Article

J Korean Thyroid Assoc 2013;6(1):64-68.

Published online: 3 May 2013

DOI: https://doi.org/10.11106/jkta.2013.6.1.64

Clinical Characteristics of Thyrotoxicosis Presented by Coronary Spasm

Kim Kiwon, Whan Lee Se, Wan Chun Sung, Joo Kim Yeo, Jin Kim Sang

¹Division of Endocrinology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea

²Division 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

Received 30 January 2013 Accepted 6 March 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.

Keywords: Thyrotoxicosis, Coronary vasospasm

References

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Table 1.

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/mL fT4: >7.77 ng/dL TSH : 0.006 uIU/mL	Painless thyroiditis	None
2	M/58	Resting chest pain	p–mRCA spasm	T3: 4.11 ng/mL fT4: 6.38 ng/dL TSH: 0.005 uIU/mL	Graves’ disease	None
3	M/55	Exertional chest pain	I.C. ergonovine: RCA, diffuse vasoconstriction	T3: 2.87 ng/mL fT4: 4.4 ng/dL TSH: 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/mL fT4: 3.09 ng/dL TSH: 0.005 uIU/mL	Painless thyroiditis	None
5	M/62	Exertional chest pain	LCA, diffuse intense vasoconstriction	T3: 3.23 ng/mL fT4: 6.75 ng/dL TSH: 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/mL fT4: 5.90 ng/dL TSH: 0.005 uIU/mL	Graves’ disease	Fatigue, palpitation
7	F/52	Resting chest pain	I.C. ergonovine: RCA, diffuse vasoconstriction	T3: 3.39 ng/mL fT4: 2.21 ng/dL	Graves’ disease	None
8	F/52	Resting chest pain	Pan-arterial, diffuse vasoconstriction	TSH: 0.005 uIU/mL T3: 7.18 ng/mL fT4: 5.88 ng/dL	Graves’ disease	None
9	F/63	Exertional chest pain	Spasm of LCA	TSH: 0.005 uIU/mL T3: 4.02 ng/mL fT4: 3.63 ng/dL	Graves’ disease	None
10	F/59	Resting chest pain	Osteal left main spasm	TSH: 0.05 uIU/mL T3: 3.47 ng/mL fT4: 2.94 ng/dL TSH: 0.021 uIU/mL	Painless thyroiditis	None
11	F/56	Resting chest pain	Mid-RCA spasm	T3: 2.03 ng/mL fT4: 2.02 ng/dL TSH: 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/mL fT4: 6.86 ng/dL TSH: 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

Fig. 1.

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).

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