Spontaneous Coronary Artery Dissection, Apical Thrombus and Unknown Hyperthyroidism: A Clinical Case

Background: Spontaneous coronary artery dissection (SCAD) is a rare non-atherosclerotic cause of acute coronary syndrome (ACS), and recent studies have shown a significant involvement in young women with few or no cardiovascular risk factors. The pathogenesis is multifactorial, possibly related to genetic causes, hormonal imbalances or peripartum. Methods and results: A 45-year-old woman was admitted to the emergency room for anterior myocardial infarction. Coronary angiography showed a long, diffuse tapering involving mid to distal left anterior descending (LAD) segments, with haziness in the mid-LAD. Intravascular ultrasound was used, highlighting the presence of intramural hematoma and leading to medical management. Hematological samples revealed a diagnosis of hyperthyroidism; this detection prompted an evaluation of a possible association with SCAD. Echocardiography revealed a preserved ejection fraction with akinetic apex and a sessile thrombus leading to anticoagulant with warfarin. Discussion: SCAD is a rare cause of ACS, difficult to recognize and whose physiopathology is not fully understood. In our case report we highlight the possible link between SCAD and hyperthyroidism. The lack of specific guidelines, the concomitant presence of hyperthyroidism and apical thrombus forced us toward a multidisciplinary management approach, with a meticulous evaluation of risks and benefits to offer the best therapeutic option.