Reversible Dilated Cardiomyopathy and Hyperthyroidism in a Patient by kzk85286


									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
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 [1]. 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[6].                                                           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[6]. 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;
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 [18].                       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 [19].                    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[6].                                 Heart J 1995; 129:1030-1032.
                                                               15.   Umpierrez GE, Challapalli S, Patterson C. Congestive heart
CONCLUSION                                                           failure due to reversible Cardiomyopathy in patients with
   Dilated cardiomyopathy is a rare clinical                         hyperthyroidism. Am J Med Sci 1995; 310:99-102.
                                                               16.   Jeyamalcer R, Chan SP. Areversible dilated Cardiomyopathy
disorder of thyrotoxicosis. Direct action of the                     due to Thyrotoxicosis. Interna J Cardiol 1995; 52:83-84.
thyroid hormone on the heart leading to                        17.   Safirstein SO, Santan O, Saagtston A. Thyrotoxicosis
disproportional structural and functional changes                    associated with reversible dilated cardiomyopathy. Am
may be responsible for dilated cardiaomyopathy                       Heart J 1994; 128:616-617.
that is reversible with treatment.                             18.   Shirani J, Barron MM, Marie Lydie Y. Louis P, Roberts WC.
                                                                     Congestive heart failure, dilated cardioventricles and
                                                                     sudden death in hyperthyroidism. Am J Cardiol 1993;
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                                                               19.   Ebisawa K Ikeda U. Murata M. Sekiguchi H. Nagai R.
1.   Polikar R, Burger AG, ursscherner, Nicol P. The Thyroid         Yazaki Y. Shimada K. Irreversible cardiomyopathy due to
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