Background
Thyroid storm is a rare condition with well-known cardiovascular manifestations including tachycardia, atrial fibrillation, heart failure, and myocardial infarction (MI). Several uncommon conditions that can mimic MI are associated with thyrotoxicosis and discussed in this case.
Case summary
A 23-year-old previously healthy male presented after the onset of generalized weakness and inability to rise from bed in the setting of 35 kg of unintentional weight loss, and was found to have profound hypokalaemia, elevated thyroid hormone, and suppressed thyroid-stimulating hormone consistent with thyrotoxicosis secondary to Grave’s disease. Following hospital admission, he developed worsening tachycardia with dynamic anteroseptal ST-segment elevations and elevated cardiac biomarkers concerning for MI. He was treated with aspirin, ticagrelor, and a heparin infusion, but was unable to tolerate beta-blockade acutely due to hypotension. Echocardiography demonstrated a severely dilated left ventricle (left ventricular end-diastolic volume index 114 mL/m2) and severely reduced systolic function (ejection fraction 23%) with global hypokinesis. Following initiation of propylthiouracil, iodine solution, and stress-dosed steroids his tachycardia and ST-elevations resolved. Computed tomography (CT) coronary angiography demonstrated no evidence of coronary stenosis. He was discharged on methimazole, metoprolol, and lisinopril and found to have recovered left ventricular systolic function at 2-month follow-up.
Discussion
Thyrotoxicosis can rarely cause coronary vasospasm, stress cardiomyopathy, and autoimmune myocarditis. These conditions should be suspected in hyperthyroid patients with features of MI and normal coronary arteries. Workup should include laboratory evaluation, electrocardiography (ECG), echocardiography, and non-invasive or invasive ischaemic evaluation.
Background
It is unclear how to geographically distribute percutaneous coronary intervention (PCI) programs to optimize patient outcomes. The Washington State Certificate of Need program seeks to balance hospital volume and patient access through regulation of elective PCI.
Methods and Results
We performed a retrospective cohort study of all non‐Veterans Affairs hospitals with PCI programs in Washington State from 2009 to 2018. Hospitals were classified as having (1) full PCI services and surgical backup (
legacy
hospitals, n=17); (2) full services without surgical backup (
new certificate of need [CON]
hospitals, n=9); or (3) only nonelective PCI without surgical backup (
myocardial infarction [MI] access
hospitals, n=9). Annual median hospital‐level volumes were highest at
legacy
hospitals (605, interquartile range, 466–780), followed by
new CON
, (243, interquartile range, 146–287) and
MI access
, (61, interquartile range, 23–145). Compared with
MI access
hospitals, risk‐adjusted mortality for nonelective patients was lower for
legacy
(odds ratio [OR], 0.59 [95% CI, 0.48–0.72]) and
new‐CON
hospitals (OR, 0.55 [95% CI, 0.45–0.65]).
Legacy
hospitals provided access within 60 minutes for 90% of the population; addition of
new CON
and
MI access
hospitals resulted in only an additional 1.5% of the population having access within 60 minutes.
Conclusions
Many PCI programs in Washington State do not meet minimum volume standards despite regulation designed to consolidate elective PCI procedures. This CON strategy has resulted in a tiered system that includes low‐volume centers treating high‐risk patients with poor outcomes, without significant increase in geographic access. CON policies should re‐evaluate the number and distribution of PCI programs.
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