VASOSPATIC ANGINA IN GRAVES DISEASE

Abstract

Category A Thyroid hormones play a key role in the growth and metabolism of almost all tissues. Any abnormal increase or decrease of these hormones can cause impairment in functioning of almost all organ systems. Hyperthyroidism has been associated with a number of cardiac manifestations including tachycardia, cardiac arrhythmia especially AF, cardiomyopathy, angina or even myocardial infarction. Here we present a case of a 38 year old female with no known comorbidities who presented to medicine casualty with complaints of recurrent episodes of typical angina lasting 15–20 min or more. Her vitals showed mildly elevated blood pressure of 150/90 mmHg and tachycardia. An ECG taken immediately showed ST segment depression in the anterolateral leads. Cardiac biomarkers were negative. A provisional diagnosis of acute coronary syndrome was made and treatment started. Echo was found to be normal. Patient continued to have recurrent episodes of angina. Coronary angiography was normal. On detailed evaluation patient gave a history of palpitation, loss of weight, diarrhoea and increased sweating in the last 3 months. Detailed physical examination revealed a painless neck swelling. Laboratory tests showed Hb – 12 g/dl, serum K – 4.1 mmol/dl, Ca – 9.2 mg/dl, LFT and RFT normal, fT3 – 22.9, fT4 – 64.2, TSH <0.01 suggestive of hyperthyroidism. On further evaluation she was found to be positive for TSH receptor antibody and was diagnosed with Grave’s disease. She was started on anti-thyroid drugs and propranolol. Nitrates were stopped after 6 months and patient remains asymptomatic on treatment. Conclusion: Hyperthyroidism may present in numerous ways and may even be life threatening. This case highlights the importance of checking the thyroid status of patients, especially in the younger age group, with no obvious cause or risk factors presenting with angina. They may not always have classical symptoms of hyperthyroidism. A delay in diagnosis can result in undue complications and unnecessary interventions. Most of these patients were found to lead a normal life with proper medications once diagnosed.