Endocrine Abstracts

Background: Spontaneous coronary artery dissection (SCAD) is a rare condition, which is sometimes underdiagnosed in patients with chest pain and presumably normal coronaries. There have been a few case reports of patients with thyroid dysfunction and arterial dissections.

Case: We present a 20 year old female with recent diagnosis of Graves’ thyrotoxicosis managed with methimazole. She initially presented in South Korea with shortness of breath on exertion and was diagnosed with hyperthyroidism. She then presented to A&E with thyrotoxicosis, constant central chest pain radiating down her left arm, worsening shortness of breath and reduced exercise tolerance. Past medical history includes iron deficiency anaemia, polycystic ovarian syndrome and atrial septal defect repair. Investigations revealed suppressed TSH (<0.01 mU/l), raised thyroid hormones (free T4 31.2 pmo/l, free T3 14.1 pmo/l), and initial troponin 2,452ng/l and D dimer 907ng/mL. ECG showed sinus rhythm and inferior T wave inversion. TSH receptor and TPO antibodies were positive. She also had detectable IgG and IgM for Parvovirus B19. A preliminary diagnosis of myocarditis was made, secondary to viral illness, and felt unlikely to be associated with mild thyrotoxicosis. Urgent echocardiogram showed dilated left ventricle with severely impaired systolic function and ejection fraction of 41%. She was urgently transferred to the cardiac centre for angiography, which showed SCAD affecting mid to distal LAD. She was then transferred to the cardiothoracic unit for specialist monitoring.

Conclusion: Cardiac sounding chest pain should not be dismissed in young individuals, especially those with autoimmune thyroid disease. Studies have concluded that there is a high prevalence of autoimmune thyroid dysfunction in patients with SCAD. These patients are more frequently women, more frequently have distal dissections like our patient, and are managed with a conservative medical strategy.