First Things First: CABG during Thyroid Storm

Introduction: In sole appearance, acute coronary syndrome and thyroid storm are life-threatening conditions. Hereby, thyrotoxicosis usually represents a contraindication for any surgery. If both coincidence, the physician finds himself between a rock and a hard place, which life-threatening condition should be treated first and how?

Case Report: Herein we report a 68-years old woman presenting with unstable angina. ECG and laboratory testings revealed a NSTEMI and the patient urgently underwent coronary angiography, revealing a severe left-main and three-vessel CAD. Subsequently, contrast agent induced a severe hyperthyreosis resulting in a thyroid storm. Ad admission, the patient was febrile (37.5°C), tachyarrhythmic (149 bpm), hypertensive (155/80 mm Hg) and dyspneic with a respiratory rate of 29/min. Thyroid stimulating hormone (TSH) was completely suppressed and free thyroxine (fT4) dramatically increased with >100 pmol/l (reference 11.5–19.6 pmol/L). Clinical symptoms and laboratory testings resulted in a Burch and Wartofsky Score of 65. Immediately, treatment with propranolol, methimazole and potassium perchlorate was initiated. Additionally, glucocorticoids were administered to stop conversion from T3 to fT4. For prevention of thromboembolic events, therapeutic anticoagulation was begun. Despite adequate treatment, the clinical condition aggravated and the patient reported angina at rest, coming along with progressive ST-segment elevation resulting in short CPR. For those reasons, the patient underwent immediate CABG. The procedure itself was uneventful. A couple of hours, a total thyroidectomy was performed by visceral surgeons. Afterwards, the clinical condition steadily improved and fT4 significantly decreased (26.5 pmol/l) within three days. The patient fully recovered after an uneventful hospital course.

Discussion: Thyroid storm by itself is a life threatening condition, being associated with a high mortality up to 30%. The same is true for ST-elevation myocardial infarction. If both come together, developing an adequate treatment strategy is challenging. A short staged approach consisting of optimized medical treatment, CABG, total thyroidectomy was associated with an excellent outcome in this case.