36 KUWAIT MEDICAL JOURNAL March 2002 Case Report Reversible Dilated Cardiomyopathy and Hyperthyroidism in a Patient with Ischeamic Heart Disease Rasha Kamel Ghaddar Department of Medicine, Al-Amiri Hospital, Kuwait Kuwait Medical Journal 2002, 34 (1): 36-38 ABSTRACT This article gives a clue about hyperthyroidism that manage such cases. may present as cardiomyopathy; how to diagnose and KEY WORDS: myocardial dysfunction, paroxysmal nocturnal dyspnea, thyroid function test INTRODUCTION ECG’s recorded persistent left bundle branch block. Thyrotoxicosis is a well known cause of high Chest X-ray showed cardiomegaly with left cardiac output failure and gives rise to arrhythmias. ventricular failure that cleared later. Serial cardiac In addition, it is a recognized, but rare, contributor enzymes were normal. For the next few days, she to dilated cardiomyopathy with severe impairment continued to complain of chest pain and shortness of left ventricular function. A full recovery of of breath. myocardial dysfunction is usually observed once She was kept on tridil and heparin infusions an euthyroid state is achieved . A 46-year-old plus enalapril, baby aspirin and diuretics. Gated female with severe impairment of myocardial blood pool study done on 17/3/1997 showed the function is presented. She had a co-existing same picture of dilated left ventricle with a left hyperthyroid state and coronary vessel disease. ventricle ejection fraction of 30%. However, following a spontaneous remission of her In view of her underlying risk factors and hyperthyroidism, which was possibly due to unstable condition, she was shifted to the chest transient thyroditis, her left ventricular function hospital for early coronary angiogram on improved dramatically. This article highlights 24/3/1997. The coronary angiogram reported a thyrotoxicosis as a potentially treatable and dilated left ventricle with global akinesia and a left reversible cause of heart failure. The mechanisms ventricle ejection fraction of 35%. The left main by which the thyroid hormones affect the stem artery was normal, left anterior descending cardiovascular system are elaborated[2-6]. Other showed a 50% distal stenosis. Ramus intermedius causes of reversible cardiomyopathy are also was large with 50% stenosis in two of its divisions, o u t l i n e d [ 7 - 1 2 ]. Literature on case reports left circumflex had a mid sigment stenosis and the demonstrating the association between right coronary artery was dominant with 99% mid thyrotoxicosis and low cardiac output failure are segmental stenosis. Percutaneous trans thoracic reviewed[13–19]. Finally, a brief outline on the coronary angioplasty of the right coronary artery treatment approach to such patients with left was attempted but failed and was postponed as ventricular dysfunction and hyperthyroidism is patient was quite tachycardic. Thyroid function given. report came back on 7/4/1997 with a picture of frank thyrotoxicosis with F-T4 of 63.21 pmol/l CASE REPORT (N.R.12-24 pmol/l) and thyroid stimulating A 46-year-old female was admitted to Amiri hormone (TSH) of 0.063 MIU/ml (N.R 0.23 - 5 Hospital Coronary Care Unit on 14/3/1997 MIU/ml). ESR was 60/hr. As she was clinically through the emergency room with acute stable, she was discharged on baby aspirin, isordil, pulmonary edema. She was suffering for the last enalapril, and furosemide and referred to thyroid month prior to admission from exertional shortness clinic for radioactive iodine treatment. of breath and attacks of paroxysmal nocturnal However, the lady decided not to visit the dyspnea. She was a diagnosed case of long- thyroid clinic and traveled to her native country for standing insulin dependent diabetes mellitus and four months leave without receiving any specific hypertension. She was a heavy smoker. Serial treatment. She reappeared in my medical Address correspondence to: Rasha Kamel Ghaddar, P.O. Box 5254, Hawally – 32083, Kuwait. Tel: (965) 254-9094 March 2002 KUWAIT MEDICAL JOURNAL 37 outpatient on 30/8/1997. She was symptom-free. underlying transient hyperthyroid condition. The Clinically she was euthyroid and had a palpable most probable diagnosis is a transient form of acute soft goiter. She apparently did not receive any thyroditis. She will definitely need regular follow specific anti thyroid treatment. No thyroid scan up of her thyroid function. was done during her hyperthyroid state, as she The aim of this case review is to discuss the failed to seek medical advice. direct relationship of hyperthyroidism with I decided to reevaluate her. Arepeated ECG was reversible cardiomyopaty. Thyrotoxicosis has been completely normal. Chest X-ray was within associated commonly with high cardiac output normal. ESR was 20/hr. Repeated thyroid function failure but reports that caused dilated were entirely normal (F T4 14 Pmol/l and TSH: 0.33 cardiomyopathy are rare. MIU/ml). A thyroid scan reported a diffuse goiter Excess thyroid hormones can lead to direct with normal uptake and thyroid antibodies were cardiac disease through different potential negative. A 24-hour ECG record was normal with mechanism, either at the cellular level through a no record of bundle branch block. A repeated echo nuclear-receptor mediated effect; at extranuclear on 4/10/1997 showed a normal global left ventricle sites, and affecting plasma membrane function. systolic function with left ventricle ejection fraction Other mechanisms include direct interaction with of 60%. Activated gated blood pool study done at the sympathetic nervous system, a direct the same time showed a normal left ventricle with chronotropic effect independent of catecholamine's left ventricle ejection fraction of 68%. effect[1-2]. Different studies have also demonstrated She was continued on her antianginal and that thyroid hormones have a direct effect on antihypertensive medication (B. aspirin, Diltiazim myocardial contractility and left ventricle diastolic 60 mg x 3, Enalapril 20 mg x l) and was doing quite function. Hyperthyroidism also has its potential well. effects on the peripheral circulation with I re-referred the patient to the chest hospital for documented increase in the blood volume, decrease re-evaluation of her coronary vessels and need for in the peripheral resistance, increase in the mean any further intervention. Regular checkup of blood pressure and proven increase in the atrial thyroid function will be needed. natriuretic factor [3-6]. Chronic tachycardia and arrhythmia, e.g., AF, have been reported as causes DISCUSSION of cardiomyopathy[7-8]. This lady evidently had a transient form of Reversible cardiomyopathy has been commonly thyroiditis associated with hyperthyroidism which reported in the literature. Endocrine dysfunction, presented as frank low cardiac output failure apart from thyroid dysfunction, includes case confirmed by Echocardiogram, gated blood pool reports of association of reversible cardiomyopathy study and coronary angiogram. As she became with Addisson’s disease, Phaeochromocytoma, euthyroid, she was clinically free apart from effort congenital adrenal hyperplasia, growth hormone stable angina explained by her underlying coronary deficiency and hyperparathyroidism[9-12]. vessel disease. However, she definitely retained her It is essential to remember that heart failure can normal systolic cardiac function (as documented by be the only manifestation of thyrotoxicosis and Echocardiogram and gated blood pool study) underlying heart disease may be absent. Clinical without receiving any definite therapy for her data support the existence of a reversible underlying coronary vessel disease. cardiomyopathy in hyperthyroid patients, however, A delay in the diagnosis of her hyperthyroid reports are rare but they all show that most if not all, state had probably led to premature referral of the of the cardiac abnormalities return to normal once patient for coronary angiogram and thus the failure an euthyroid state has been achieved. The factors of the balloon angioplasty. She definitely needed to involved, as explained earlier, include decreased left treat her thyrotoxic state before proceeding with ventricle contractile reserve, left ventricle any definite invasive coronary intervention which hypertrophy with impaired left ventricle filling, could have been quite hazardous to the patient. A existence of atrial fibrillation, decreased peripheral thyrotoxic crisis could have been precipitated by vascular resistance and increased blood volume injecting contrast material containing iodine. I do (usually factors in high cardiac output failure) and not deny that her underlying coronary vessel finally increased myocardial O22 demand. disease was significant and acute coronary I have come across few reports of documented ischemia could not be ruled out as another adding clinical cases of thyrotoxicosis that presented as low factor to her low cardiac output state. cardiac output failure. These include around 11 Unfortunately, a thyroid uptake scan was not done patients who had documented hyperthyroid state during the hyperthyroid state which made it and left ventricle systolic dysfunction proven by difficult to establish the exact pathology of her 2D-Echocardiogram. All were managed by 38 Reversible Dilated Cardiomyopathy and Hyperthyroidism in a Patient with Ischeamic Heart Disease March 2002 antifailure and antithyroid drugs. They improved 2. Elian D, Harpaz D, Sucher E, Kaplinsky E, Motro M, rapidly and were follow up by echoes once Ve red Z. Reversible Catecholamine - induced cardiomyopathy presenting as acute pulmonary oedema euthyroid, done 6-12 months after, showed in a patient with Phaeochromocytoma. Cardiology 1993; restoration of most if not all of the left ventricle 83:118-120 normal function[13-17]. 3. Forfar JC, Muir Al-Sawers SA, Toft AD, Abnormal left There were autopsy reports of two clinical cases ventricular function in hyperthyroidism: evidence for a of thyrotoxic ladies, who were admitted with acute possible reversible cardiomyopathy. N Eng J Med 1982; 307:1165-1170. pulmonary edema and expired. The autopsy 4. Forfar JC, Caldwel GC. Hyperthyroid heart disease. Clinics reported enlarged hearts, with normal coronaries, Endocrinology & Metabolism 1985; 14:491-508. dilated ventricles with histopathology report of 5. Thoman MR, Mc Gregor AM, Jewitt DE. Left ventricle myocyte hypertrophy and myocardial edema . filling abnormality prior to and following treatment of There was only one report of four cases of Thyrotoxicosis. Eur Heart J 1993; 14: 662-668 6. Woeber KA. Thyrotoxicosis and Heart. N Eng J Med 1992; thyrotoxicosis associated with irreversible July:95-98. cardiomyopathy. They were diagnosed between the 7. Packer DI, Brady GH, Worley SJ, Smith MS, Cobb FR, years 1978-1992. Their thyroid functions normalized Coleman RE, Gallagher JJ, German LD. Tachycardia but they remained in low cardiac output failure. induced cardiomyopathy: a reversible from of left They all had coronary angio that showed normal ventricular dysfunction. Am J Cardio 1986; 75:563-570 8. Dhala A, Thomas TP. Images in cardiovascular medicine. coronaries with high left ventricle end diastolic Reversible tachycardia - induced cardiomyopathy. volume and low left ventricle ejection fraction. A Circulation 1997; 95:2327-2378. myocardial biopsy was reported normal . 9. Derish M, Eckert K, Chin C. Reversible cardiomyopathy in Once transient thyroiditis has been ruled out, a child with Addisson's disease. Intensive Care Med 1996; patients with thyrotoxicosis can be offered 22: 460-463. 10. Quigg RJ. OMA. Reversal of severe cardiac systolic radioactive iodine ablation, antithyroid drugs or dysfunction caused by phaechromocytoma in a heart. surgical intervention. However, in the subgroup of Transplant candidate. J Heart Lung Transplant 1994; 13:525- thyrotoxic patients who present with low cardiac 532. output failure, the recommended approach is to 11. Frustaci A, Perone GA, Gentiloni N, Runo MA. Reversible start them on antithyroid drugs for 4-8 weeks and dilated cardiomyopathy due to growth hormone deficiency. Am J Clin Pathol 1992; 97:503-511. then to stop for 3-5 days, followed by ablation with 12. Giles TD, Iteld BJ, Rives KL. The Cardiomyopathy of radioactive iodine. Ablation is indicated because of hypoparathyroidism. Another reversible from of heart the increased risk of recurrent cardiac disease if muscle disease. Chest J 1981; 79:225-229. thyrotoxicosis recurred. Heart failure is usually 13. Reversible cardiomyopathy due to Thyrotoxicosis (Letter, treated with diuretics and high dose of Digoxin-B- comment) American Journal of Cardiology. 1992; 70:132. 14. Kantharia BK, Richards HB, Battaghia J. Reversible dilated blockers should be introduced later once the patient Cardiomyopathy: an unusual case of Thyrotoxicosis. Am is not in frank clinical failure. Heart J 1995; 129:1030-1032. 15. Umpierrez GE, Challapalli S, Patterson C. 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