Heart attack traced to tear in artery wall may link to Cushing’s disease

Hypercortisolism can affect heart, but coronary artery damage is unusual

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by Andrea Lobo |

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A 46-year-old woman with a history of Cushing’s disease had a heart attack from an unusual cause — a tear in the coronary artery not due to trauma — and her disease may have contributed to the attack, scientists reported.

A spontaneous tear, or dissection, in the wall of coronary artery, a condition known as SCAD, can lead to a heart attack, as it limits the oxygen-rich blood that the coronary artery delivers to the heart.

“This association [between Cushing’s and SCAD] may be of clinical relevance, and patients presenting with SCAD, particularly women, may [need to] be tested for overt or even subclinical forms of hypercortisolism” or high cortisol levels, the researchers wrote.

The study, “Spontaneous Coronary Artery Dissection in a Patient With Cushing’s Disease,” was published in the journal Cureus.

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SCAD is not common, having a prevalence in the general population of 1% to 5%. It can affect both sexes, but 90% of SCAD patients are women ages 47 to 53. Although its causes are poorly understood, studies suggest an association exists between SCAD and the period immediately after childbirth (postpartum), connective tissue disorders, inflammatory conditions, hormonal therapy, and a few other conditions.

In people with Cushing’s syndrome, excess levels of the hormone cortisol — hypercortisolism — may lead to cardiovascular complications. Research has associated Cushing’s with other types of artery dissections, but not SCAD.

Scientists in Portugal described the case of a 46-year-old woman with a previous history of Cushing’s disease, who had a heart attack caused by SCAD.

She came to their hospital in Porto complaining of chest pain that started while she was cooking. The pain radiated to the left arm, lasted for 30 minutes, and was accompanied by nausea and sweating.

An initial exam showed she had high blood pressure, and a normal heart rate and blood-oxygen levels. Blood tests came back normal, except for an increase in high-sensitivity cardiac troponin I, indicative of a heart attack (myocardial infarction).

An ultrasound showed enlargement of the left ventricle, the heart’s lower left chamber that pumps oxygen-rich blood to the body. The other heart chambers were of normal size, and there were no abnormalities in heart valves.

Tests also indicated that the percentage of blood pumped from the heart was at the lower limit of normal. The patient was diagnosed with a heart attack caused by a reduction in oxygen supply and admitted to the hospital.

She had a history of obesity and high blood pressure since age 25. She didn’t smoke and had no other cardiovascular risk factors or history of cardiovascular disease.

She had been diagnosed with Cushing’s disease caused by a pituitary tumor, for which her disease was surgically treated 12 years earlier. She had not taken corticosteroid supplements for several years and reported no Cushing’s-related symptoms.

While in the emergency room, her chest pain returned and did not ease with standard treatment. A coronary angiography, given to analyze blood flow through heart arteries, detected SCAD and partial blood flow obstruction.

She was treated conservatively with anticoagulation therapy while in the hospital, and further examinations found no common causes for SCAD or familial history of the condition.

Chest pain recurred twice during hospitalization, without changes in heart function or troponin I levels. She was discharged after seven days and instructed to take medications to treat high blood pressure and chest pain.

At a follow-up visit one month later, she reported chest pain. Again, no significant changes in heart function were found. An MRI scan revealed a residual pituitary tumor, with no signs of hypercortisolism.

Scientists suggested that her previous Cushing’s disease might have contributed to SCAD, although Cushing’s is not considered a typical risk factor for tears in this particular artery.

But both hypercortisolism and treatment with high-dose corticosteroids are associated with “aortic and vertebral arterial dissections,” the scientists noted. And while “the aorta differs structurally from coronary arteries, many of the components of the arterial wall, such as elastic and collagen fibers, are similar.”

As such, a connection between SCAD and Cushing’s is possible.

“As there are reported cases of arterial dissections associated with [Cushing’s] and common causes of SCAD were excluded, we hypothesized that the patient’s past medical history may have contributed to SCAD,” they wrote.

Treatment with high-dose corticosteroids also has been associated with SCAD, making plausible the connection between Cushing’s and SCAD.

“To the best of our knowledge, there are no other reported cases in the literature of Cushing’s syndrome associated with SCAD,” the scientists added.