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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00738-6
10.1016/j.radcr.2024.07.150
Case Report
Spontaneous multivessel coronary artery dissection associated with microaneurysms in a young women with thyroiditis background: Unusual case report
Lahmouch Nouhaila nouhaila_lahmouch@um5.ac.ma
⁎
Nafii Omar
Zarzur Jamila
Cherti Mohamed
Department of Cardiology B, Ibn Sina University Hospital, Mohammed V University, Faculty of Medicine and Pharmacy, Rabat, Morocco
⁎ Corresponding author. nouhaila_lahmouch@um5.ac.ma
21 8 2024
11 2024
21 8 2024
19 11 51095114
30 5 2024
24 7 2024
25 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Spontaneous coronary artery dissection (SCAD) is a rare condition that is frequently under-recognized. It has been connected to several triggers and predisposing factors. Interestingly, hypothyroidism has been linked to a higher likelihood of arterial dissections.

We present the case of a 49-year-old woman who was admitted for acute coronary syndrome. Coronary angiography revealed signs of SCAD affecting the distal left anterior descending artery and the right ventricular branch. Additionally, microaneurysms were detected in the distal circumflex artery, the main septal artery, and a branch of the distal right coronary artery. During her hospitalization, a goiter was identified, and further evaluation confirmed autoimmune thyroiditis. The patient was managed with conservative treatment. A follow-up angiogram 6 months later showed that the previously dissected coronary segments and microaneurysms had regressed.

This case highlights the possible role of hypothyroidism in increasing risk of SCAD and possibly microaneurysms which has been suggested in only isolated cases in the literature. It also demonstrates the effectiveness of a conservative treatment approach for this condition.

Keywords

Spontaneous multivessel coronary artery dissection
Coronary angiography
Coronary micro-aneurysms
Hypothyroidism
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pmcBackground

Spontaneous coronary artery dissection (SCAD) represents a critical and frequently underdiagnosed etiology of acute coronary syndrome (ACS). This condition is particularly prevalent among younger women who exhibit minimal cardiovascular risk factors, it is characterized by a rupture in the epicardial coronary arterial wall that is not associated with iatrogenic, atherosclerosis, or trauma causes [1]. It leads to myocardial ischemia by blocking coronary blood flow through 2 mechanisms: by creating a false channel through a tear in the coronary arterial intima-media or by compressing the artery with a deeper intramural hematoma [2].

The diagnostic of SCAD necessitates a thorough angiographic analysis and a high index of clinical suspicion. Jacqueline Saw [3] classified SCAD into 3 angiographic types, type 1: relatively easy to identify, characterized by typical contrast staining, type 2: Defined by long, smooth, diffuse narrowing, and type 3: presents focal or tubular stenosis.

The clinical presentation of SCAD can vary significantly, ranging from silent ischemia to acute coronary syndrome and sudden cardiac death. The underlying etiology of SCAD appears to be multifactorial, with contributing factors including pregnancy, peripartum and perimenopausal states, connective tissue disorders, fibromuscular dysplasia, coronary spasms, intense physical or emotional stress, and contraceptive use [4]. SCAD has also been linked to systemic autoimmune and inflammatory diseases, including hypothyroidism and autoimmune thyroiditis [5].

Thyroid hormones are essential for regulating cellular and tissue metabolism. The relationship between SCAD and hypothyroidism remains largely unexplored, although the link between hypothyroidism and noncoronary spontaneous arterial dissections is well-established.

Here, we present what we believe to be the first case involving a woman who experienced acute coronary syndrome (ACS) due to multivessel SCAD secondary to auto-immune thyroiditis with varying angiographic patterns. The present data may contribute to the investigation of the regression mechanisms and the long-term management of coronary artery spontaneous dissections and microaneurysms.

Case presentation

A 49-year-old woman with no known cardiovascular risk factors or prior medical history came to our emergency department with acute chest pain that lasted more than 30 minutes while at rest, without any obvious emotional or stress-related triggers.

Upon arrival, her vital signs were within normal ranges: blood pressure was 129/89 mmHg, heart rate was 67 beats per minute, and respiratory rate was 17 breaths per minute. There were no signs of congestive heart failure, and her cardiopulmonary examination was unremarkable. However, her thyroid examination revealed the presence of a goiter, though there were no other clinical signs associated with it.

The EKG (Fig. 1) showed a regular sinus rhythm with poor R-wave progression in the anterior-septal region and Q-wave in lead D3. Blood tests revealed elevated troponin levels at 550 ng/L, which is about 23 times the normal value, alongside high TSH levels and reduced T3 and T4 fractions, consistent with hypothyroidism. Other lab results were normal.Fig. 1 Electrocardiogram showing a regular sinus rhythm with anterior-septal poor R-wave progression and Q-wave in lead D3.

Fig 1:

Transthoracic echocardiography showed hypokinesia in the basal segments of the inferior and inferoseptal walls, but with a preserved left ventricular ejection fraction (LVEF = 69%). The patient was given a loading dose of aspirin, clopidogrel, and enoxaparin, then transferred to the catheterization lab for coronary angiography.

The angiography, performed through a right radial artery approach, revealed a long, diffuse lesion in the distal left anterior descending artery (consistent with a type 2 dissection) (Fig. 2A), a shorter lesion in the right ventricular branch (consistent with a type 3 dissection) (Fig. 2B), and microaneurysms (Fig. 3) in the distal circumflex artery, the main septal artery, and a branch of the distal right coronary artery.Fig. 2 Coronary angiography images showing 2 different patterns of SCAD in 2 different vessels: (A) Long diffuse stenosis in the distal left anterior descending artery LAD (Type 2 dissection). (B) Short focal stenosis in the distal right coronary artery RCA (Type 3 dissection).

Fig 2:

Fig. 3 Coronary angiography images showing microaneurysme of the distal circonflex artery (star) and the septal branch (arrow).

Fig 3:

Based on these angiographic findings and the absence of atherosclerotic stenosis in other coronary arteries, spontaneous coronary artery dissection SCAD was suspected. Notably, this case presented 2 different angiographic patterns in 2 different vessels, which is unusual.

Because the patient's chest pain subsided and there was a normal TIMI 3 flow in all involved arteries, a conservative approach was adopted. Further examination of the thyroid via ultrasound confirmed the presence of thyroiditis with positive thyroid peroxidase (TPO) antibodies, consistent with autoimmune thyroiditis.

The patient remained stable and was discharged with dual antiplatelet therapy (aspirin and clopidogrel), a beta-blocker, and proton pump inhibitors, with close medical follow-up. Further investigation for underlying vasculopathy, such as fibromuscular dysplasia, using CT angiography showed no abnormalities.

A follow-up coronary angiography conducted 6 months later showed that the microaneurysms had regressed (Fig. 4), and the coronary segments, including the previously dissected distal left anterior descending artery (Fig. 5A) and right ventricular branch (Fig. 5B), appeared normal.Fig. 4 Coronary angiography images showing the regression of the microaneurysm of the distal circonflex (star) and the septal branch (arrow).

Fig 4:

Fig. 5 Coronary angiography images showing the SCAD regression under conservative medical treatment after 6 months in the distal left anterior coronary artery LAD (star) and the distal right coronary artery (arrow).

Fig 5:

Discussion

Diagnosing SCAD requires detailed angiographic analysis. It was first discovered in 1931 during the autopsy of a 42-year-old woman. Types 2 and 3 can be particularly difficult to distinguish from atherosclerotic lesions, often necessitating intra-coronary imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) for more detailed visualization [5]. Although coronary CT scan is useful, its lower spatial resolution compared to traditional angiography might lead to underdiagnosis of dissections.

Thyroid hormones have a significant cardiovascular impact, influencing cholesterol levels, heart rate and ventricular function. Even minor changes in thyroid function can increase the risk of coronary heart disease and overall mortality [6].

Myxedema, which indicates severe hypothyroidism, is characterized by the deposition of hydrophilic mucopolysaccharides, accumulation of water and sodium in the vascular wall, elevated hyaluronic acid synthesis by fibroblasts, and reduced hyaluronic acid degradation. Some researchers suggest that these changes may contribute to systemic inflammation, and endothelial dysfunction which could explain the association between hypothyroidism and SCAD [7], potentially resulting in thrombus formation at the interface between the media and adventitia but the precise pathophysiological link is not fully understood. However, further research is essential to fully understand the underlying mechanisms.

The connection between thyroid disease and noncoronary arterial dissection in various territories, such as the aorta, carotid, and vertebral arteries, is well established. In a series involving 101 patients with aortic dissection, Rosenmann et al. [8] discovered a 22% prevalence of hypothyroidism, in contrast to 8% in the control group. Moreover, Pezzini et al. [9] compared 29 patients who had a stroke secondary to cervical artery dissection with 29 patients who had a stroke without dissection. They found that the group with cervical artery dissection was more likely to have antithyroid antibodies. While there is evidence linking arterial dissections at various levels to thyroid abnormalities, the relationship between hypothyroidism and SCAD has only been suggested in isolated cases in the literature.

Santiago Jesus et al. [10] studied 73 patients with SCAD and compared their clinical characteristics and thyroid function abnormalities with those of patients who had ACS without SCAD. They found a high prevalence of hypothyroidism in SCAD patients, particularly among women, who also tended to have more frequent distal dissections in tortuous vessels, similar to the findings in our patient. However, it is important to note that while an association was identified, this study alone cannot establish causation.

The most recent scientific statement on SCAD [11] suggests revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) for patients with occluded blood flow or worsening clinical status. However, conservative therapy as the preferred initial strategy for stable patients who are hemodynamically and clinically stable. A large Swiss cohort with follow-up up to 22 years, included 105 patients with SCAD and were treated mainly with conservative methods. Follow-up angiograms after a median of 6 months showed that most dissections had healed. Over a median follow-up of 7.5 years, there were only 15 major cardiovascular events (MACE), including deaths and recurrent SCAD [12]. The medical treatment involves antiplatelet therapy, β-blockers, and statins if indicated [13]. While systemic anticoagulation with heparin can reduce thrombus burden, it should not be routinely used in SCAD and carries a risk of extending the intramural hematoma unless there is another indication. Additionally, several studies have demonstrated an elevated risk of complications associated with PCI in patients with SCAD. A series from the Mayo Clinic, were Tweet et al. reported an unsuccessful PCI rate of 53% in SCAD patients, with 13% requiring emergency CABG [14]. Therefore, treatment options for SCAD patients should be chosen with careful consideration.

Conclusion

SCAD is a rare condition that often goes undiagnosed. It has been linked to various triggers and predisposing factors. However, hypothyroidism has been associated with an increased risk of arterial dissections in noncoronary arteries. This case emphasizes the possible role of hypothyroidism in increasing risk of SCAD and possibly microaneurysms. Individuals with this condition tend to be women, often experience more distal and diffuse dissections, and are more likely to receive conservative treatment. The present data may contribute to the investigation of the regression mechanisms and the long-term management of coronary artery aneurysms and dissections. Prospective studies to evaluate these data are warranted.

Author contributions

NL: Study concept, Data collection, Data analysis, Writing the paper.

ON: Study concept, Data collection, Data analysis, Writing the paper.

JZ: Supervision and data validation.

MC: Supervision and data validation.

All authors reviewed the final manuscript.

Availability of data and materials

All relevant data generated and analyzed during this study are included in this published article. If it needs any additional information, it is available from the corresponding author on reasonable request.

Patient consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Competing Interests: The authors declare that they have no competing interests.

Acknowledgments: We thank all the people who contributed to the realization of this work.

Funding: This study had no funding from any resource.
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