CASES OF THE WEEK – “Graves disease with acute myocardial infarction and normal coronary arteries” by Dr Shekhar Shikare, Consultant & HOD, Nuclear Medicine

CASES OF THE WEEK – “Graves disease with acute myocardial infarction and normal coronary arteries” by Dr Shekhar Shikare, Consultant & HOD, Nuclear Medicine

Graves disease with acute myocardial infarction and normal coronary arteries

47 years old male with h/o epigastric pain of severe in nature three days prior to admission in ICU. He was treated with proton pump inhibitors, H2 blockers and antacid along with narcotics. He did not respond to treatment and pain persisted.

ECG done and showed acute anterior wall infarction with QS with convex St elevation and T inversion in V2-V4 leads (treated with clexane nitroglycerine, aspirin and atenolol). He was not thrombolysed, since it was a completed infarct with pain of 3 days duration. Cardiac enzymes CK, MB Troponin T were elevated.

2 days later he had severe pain in left lower chest and epigatsric region, repeat ECG showed fresh ST elevation in 1AvL, 2,3AvF, V5, V6 and cardiac enzymes were further elevated. He was thrombolysed with actilyse and his ST segment in 1AVL, 2,3AVF, V5 and V6 regressed and his pain subsided. ECG showed extensive antero-lateral wall infarction.

2D-Echo-Mild dilatation of LV, akinetic distal half of IVS and adjacent anterior wall, apex and distal third of lateral wall. LVEF 39%) Risk Factors-Heavy smoking.

STRESS MYOCARDIAL PERFUSION SCAN (Pharmacological)

Predominantly fixed perfusion defect in apex, distal third of septum, distal half of anterior and inferio-medial wall of the myocardium at stress (as shows in pictures)

Coronary angiography shows normal coronary arteries without stenosis (as shown in pictures).

Subsequently noticed bilateral exophthalmos, tremors, Diffuse goiter with bruie His thyroid functions tests found to abnormal {FT3 10.94 pg/ml (2.6-5.4), FT4 2.55 ng/dl (0.7-1.55), TSH ND mciu/ml (0.25-5.0)}.

99m Techentium thyroid scan showed- Mild-moderate toxic diffuse goiter. Tc- uptakes 17.9% ( 0.4% to 30%) as shown in pictures.

Started on Neomercazole but developed sore throat and agranulo-cytopenia and hence subsequently treated with RADIOACTIVE IODINE THERAPY ABLATION DOSE and patient become hypothyroid and doing fine with replacement therapy.

Acute myocardial infarction (AMI) is a scarce but fatal complication in Graves' disease (GD). The potential mechanisms for AMI with angiographically normal coronary arteries in the setting of hyperthyroidism may be attributed to the hyper-metabolic state due to thyrotoxicosis, severe vasospasm in coronary artery, coagulation abnormalities, and the inflammatory/autoimmune milieu. myocarditis. Graves' disease was confirmed by exophthalmos and elevated titers of T3 and T4 thyroid hormones. Cardiac catheterization studies Thyroid hormone may directly influence myocardial oxygen supply and demand and, by some unknown mechanism, cause a critical imbalance in coronary circulation resulting in myocardial infarction.

GRAVES DISEASE WITH MYOCARDIAL INFARCTION AND NORMAL CORONARY ARTERIES

Unique Cases 092a Unique Cases 092b

Coronary angiography- Normal coronaries.

Unique Cases 092c Unique Cases 092d