Undiagnosed Thyroid

Dysfunction as Comorbid in
Cardiovascular Disease
By: dr. Fikri

DIVISION OF CLINICAL CARDIOLOGY

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE
FACULTY OF MEDICINE UNIVERSITAS INDONESIA
NATIONAL CARDIOVASCULAR CENTER HARAPAN KITA
1
Outline

• Introduction
• Aim
• Case Illustration
• Discussion
• Conclusion

2
 Introduction

• Thyroid hormone affects virtually every anatomic and

physiologic component of the cardiovascular system.
• In the presence of heart disease, pericardial disease,
heart failure, or arrhythmias, overt or subclinical thyroid
dysfunction merits a high level of clinical suspicion.

Klein I, Danzi S. Thyroid Disease and The Heart. Curr Prob Cardiol. 2015(146): 1-28. 3
 Introduction
• Danish national registries
• 563,700 residents at least 18 years old who had thyroid
function tests run between 2000 and 2009.

1. Overt hyperthyroidism [0.6%]; Increasing risk of all-

cause mortality, MACE
2. Subclinical hyperthyroidism [1.06%]; and heart failure.
3. Euthyroidism/Normal [95.9%];
4. Subclinical hypothyroidism [0.9%]; Lowering all-cause
5. Overt hypothyroidism [0.3%]. mortality than those with
normal thyroid function
Braunstein C. Thyroid dysfunction and risk of death and cardiovascular events. Clinical
Thyroidology.2016(7):3-4. 4
 INTRODUCTION
Prevalence of hyperthyroid and heart disease in
NCCHK
Prevalence
80
69
70 62 62
60 53 The prevalence
50 44 showed tend to
40
decrease, but it seems
30
20
because of
10 undiagnosed ?
0
2011 2012 2013 2014 2015
5
Heart Failure Clinic. Heart failure registry. National Cardiovascular Center Harapan Kita. 2016.
 Aim

• To discuss thyroid dysfunction as comorbid in Cardiovascular Disease

in a serial case report.

6
Case Discussion

7
 Case Illustration

CASE 1 CASE 2
Mrs. AW, 53 years. Mr. AD, 46 years.
Chief Compliant: Chief Compliant:
• DOE, OP, PND since 3 • Chest pain since 1 day ago
days ago . • DOE, PND suffered since 1
• Risk Factor: HT, DM, year ago
menopause. • Risk Factor: HT, smoker.

8
 Case Illustration

CASE 1 CASE 2
Mrs. AW, 53 years. Mr. AD, 46 years.
1. CHF ec HHD 1. Acute coronary syndrome
2. Mitral 2. CHF ec HHD
Regurgitation
3. AF RVR
3. Diabetes Mellitus
type II

9
 Physical Examination
CASE 1 CASE 2
• BP: 151/122 HR: 77 x/m • BP: 160/92 HR: 125 x/m
regular RR: 24 x/m SpO2 irregular RR: 22 x/m SpO2
98% 98%
• JVP 5 + 3 cm H2 0 • JVP 5 + 2 cm H2 0
• Rales 1/3 base bilateral • Rales minimal
• S1-2 regular, PSM 3/6 apex • S1-2 regular
• Hepatomegaly • Warm extremity
• Pitting edema+/+
Bothextremity
• Warm this case shows characteristic of heart failure
10
 ECG CASE 1

SR, QRS rate 78x/min, axis N, wave P mitral, PR interval

0,04 s, QRS duration 0,08, QTc 588ms, ST-T changes (-). 11
 ECG CASE 2

Atrial Fibrillation Rate 130 x/min, Normal Axis, ST-T

changes No, poor R wave in V1-V4. 12
 Case 1 Case 2

• CTR 65%, normal segmen aorta&pulmonal, • CTR 70%, normal segmen aorta&pulmonal,
cardiac waist (+), apex lateral downward, cardiac waist (-), apex lateral downward,
sign of congestion (+), infiltrate (-). sign of congestion (+), infiltrate (-). 13
 Laboratory
CASE 1 CASE 2
Hb 11,3 gr/dl Hb 14,4 gr/dl
Ht 34 % Ht 43,4 %
Leuko 4380 /uL Leuko 7260 /uL
Trombo 169.000 Trombo 244.000
CRP 6, LED 42
INR 1,16
GDS= 467 mg/dl Keton 0,3
CKMB 36 HsTrop T 40
OSM 298,25
Ur 31,9 Cr 0,44 CCT 116 Ur 26,5 Cr 0,85 eGFR 93
Na 130 K 3,5 Cl 94 GDS 151
Ca T Mg 1,5 Na 139 K 3,9 Cl 103 Ca T 2,25
14
Mg 2,0
 Previously Drugs

CASE 1 CASE 2

Ramipril Cedocard Captopril

1x10mg 3x5mg 2 x 25 mg
Bisoprolol Simarc 1x2mg Cardioaspirin
1x5mg Glimepirid 1x 100 mg
Furosemid 1x4mg
1x40mg Insulin 2x35 Beside the patient has the
Spironolakton Unit SC treatment of Diabetes, but
1x25mg there is no Metformin in Case I
15
 Echocardiography

Case 1 Case 2
EDD 48 EDD 55 mm
ESD 26 ESD 47 mm
EF 69% EF 45%
TAPSE 2 cm TAPSE 1,8 cm
Global normokinetik E/A >2, fusi (AF)
Katup mitral regurgitasi Hipokinetik anteroseptal
severe, TR mild
IVC 23/18

16
 Case I Asses Thyroid function
700
TSH <0,065
fT4: 7,54
600
561 mg/dl Hyperthyroidism
524 mg/dl
Blood Sugar

500
Well Controlled
400 Blood Sugar 3 days
after PTU drug
300 256 mg/dl 481 mg/dl started
200

100 9 Days-Poorly Controlled Blood Sugar Before Thyroid Treatment

0
98 mg/dl
27-Jun 28-Jun 29-Jun 30-Jun 1-Jul 2-Jul 3-Jul 4-Jul 5-Jul 6-Jul 7-Jul 8-Jul 9-Jul

Prophyltiouracyl (Anti Thyroid Drug)

Insulin Drips Basal bolus+ Diabetes
Drugs Basal
Insulin drips +
bolus+Diabetes
17
Drugs
 Case II
TSH <0,005, fT4 3,25 Patient
Nocturnal Blood sugar 196 Discharged with
mg/dl PTU, Metformin,
HYPERTHYROID AND DM Bisoprolol
130 bpm
Heart Rate

EMG
90 bpm
AF RVR
CVC
60 bpm
AF RVR
WARD
AF NVR
Day1 Day2 Day 3-5

Cordarone PTU 3x100mg

Bisoprolol 1x1.25mg
Metformin 3x 500 mg

18
Physiology of Thyroid Hormone
Hypotalamus

Pituitary The HPA axis effect systemic

on Target Tissue especially
TSH Heart organ.

19
Guyton AC, Hall JE (ed). Textbook of medical physiology 11th ed. Philadelphia. 2006
Effects of Thyroid Hormones on Cardiomyocyte

Thyroid Activity:
1. Genomic: simpathetic
overdrive
2. Non-genomic :
activation T4 into T3

Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007; 116:1725-35 20
 Effects of Thyroid Hormones on
Cardiovascular Hemodynamics
Increased Tissue Decreased Systemic
Thermogenesis Vascular Resistance

Decreased Effective
Arterial Filling Volume
TriiodoThyronine (T3)
Increased Renal
Sodium
Reabsorption

Increased Increased Blood

Cardiac Volume
Increased Cardiac Inotrophic and Chronotropic
Output
21
 Anti Thyroid Drug Role
Cardiomyocyte T4
Plasma PTU
Membrane

Atrial fibrillation, tachyarythmia,

endhotelial dysfunction, Ischemia
Myocardial, Thyrotoxic
PTUMyocellular
prevent Oxidation and Deiodination,
Cardiomyopathy
Contraction
so that T3 lower.
β-AR
ROS
Inotropic and
Chronotropic HR >
22
Ertek S, Cicero AF et al. Hyperthyroidism and cardiovascular complications: A narrative review on the basis of pathophysiology.
Arch Med Sci.2013;9(5):944-952. doi:10.5114/aoms.2013.38685.
Hyperthyroid Effect to Cardiac
Dysfunction

β-blocker ACEI or ARB

Martinez F et al. Thyroid hormones and heart failure. Heart Fail Rev. 2016:1-4.
23
Klein I, Danzi S et al. Thyroid disease and the heart. Circulation. 2007;116(15):1725-35.
Hyperthyroidism & Atrial Fibrillation

24
ESC Guidelines for management of atrial fibrillation. 2016
 25
ESC Guidelines for management of atrial fibrillation. 2010
January CT et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
26
Hyperthyroid dan Atrial Fibrillation

Treat the comorbid factor

Optimal management

Preventive & Curative

Arythmia Ischemia Myocardium Heart Failure

27
ESC guidelines 2016. atrial fibrilation
 ESC Guideline on HF

The Guideline recommend to asses Thyroid Function examination.

Voors A, Anker D, Bueno H, et al. 2016 Guideline on Acute and Chronic Heart Failure. European Society of
Cardiology.
28
Research Thyroid and ACS

Lamprou V, Varvarousis D, Polytarchou. The Role of Thyroid Hormones in Acute Coronary

Syndromes. Clinical Cardiol. 2017 29
ESC Guideline on ACS

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation 30
 Thyroid and Diabetes Control

• NHANES III study:

• Hyperthyroidism: Overt 1,3 % and Subclinical 2%
• Hypothyroidism : Overt 4,6% and 8,5 %.
• The prevalence of thyroid disorder in diabetic population was
reported to be 13.4%.
• The prevalence of thyroid dysfunction in T2DM patients was
reported to be 12.3% in Greece and 16% in Saudi Arabia.

Wang C et al. The Relationship between Type 2 Diabetes Mellitus. J Diabetes Res.
2013;2013:1-9. doi:10.1155/2013/390534 31
Hyperthyroid Effect in Glucose Control

Biguanides,
ex: Metformin

Hypertiroid Poorly controlled blood sugar

Wang C et al. The Relationship between Type 2 Diabetes Mellitus. J Diabetes Res. 2013;2013:1-9. doi:10.1155/2013/390534
32
Zolk O. Current understanding of the pharmacogenomics of Metformin. . Clinical Pharmacology and Therapeutics. 2009;86:595-8.
 Hyperthyroid Effect in Glucose Control

Thyroid Hormone effects in increasing Blood Sugar.

Wang C et al. The Relationship between Type 2 Diabetes Mellitus. J Diabetes Res. 2013;2013:1-9. doi:10.1155/2013/390534
33
Hyperthyroidism Algorithm

Normal Value
TSH = 0.270 - 4.200 uIU/mL
fT4 = 0.93 - 1.70 ng/dL

Diagnosing and Managing Thyroid Disease. JAMDA. Volume 9,

Issue 1 , Pages 9-17, January 2008
34
 Management of
Hyperthyroid Heart Disease

• GOAL : to restore thyroid hormone levels to normal (normal TSH)

• Antithyroid drug such as PTU and Methimazole restore to euthyroid.

• Propranolol  decrease the peripheral conversion of T4 to T3

• If symptoms and signs of heart failure (+)  cardio-selective β-

blocker

Vargas-Urichoecha H, Bonelo-Perdomo A, Sierra-Torres CA. Effects of thyroid hormones on the heart. Clin Invest Arterioscl. 2014;26(6):296---309
35
Douglas R, Burch B, Cooper D. Guideline for Diagnosis and Treatment of Hyperthyroidism. American Throid Association. 20016(26(:1343-1418)
 Resume

This two case reports show the importancy of thyroid

function assesment in management of cardiovascular
disease. In case I shows that management of
hyperthyroidism will lead the outcome into well - controlled
blood sugar. And then in case II shows that the heart rate
control is better after management of hyperthyroidism.

36
 Take home message

• Metabolic factors such as thyroid dysfunction, diabetes

have a part in prevent progression of cardiovascular
disease.
• Thyroid have been recently studied, and formally written
in the guideline of Heart Disease (HF and ACS).
• We should begin study about thyroid and heart disease, so
that we can manage the disease better.

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THANK YOU

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