Hypothyroidism and Spontaneous Coronary Artery Dissection Following Kayaking: Dual Pathology or a Unifying Diagnosis?

A 54-year-old woman presented with an episode of chest pain and collapse, 30 minutes after river kayaking.She was a smoker and was prescribed levothyroxine for hypothyroidism, which she had not taken for the previous week.On examination, she was haemodynamically stable, her blood pressure was 130/74 mmHg, heart rate 54 beats per minute, and oxygen saturation and random glucose were normal.Electrocardiography showed sinus rhythm with ST-segment elevation in the lateral leads (I and AVL) with reciprocal ST-segment depression in the inferior leads (II, III and AVF, see Figure 1).The left main stem, circumflex, and right coronary arteries were normal.Emergency coronary angiography was suggestive of coronary artery dissection, with associated thrombus in the left anterior descending (LAD) artery (Panel B).High-sensitivity troponin T peaked at 390 ng/L, and biomarkers showed TSH:85.68 mU/L and T4:3.5 pmol/L.She was managed conservatively and received aspirin 75 mg daily and ticagrelor 90 mg twice daily following initial loading doses.In view of the high suspicion of intraluminal thrombus at angiography.she also received low-molecular-weight heparin (1 mg/kg twice daily).Echocardiography showed mild left ventricular systolic impairment with hypokinesia of the apical anterior, lateral and true apical segments.