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Hyperthyroid Heart Disease

Hyperthyroid Heart Disease. Alterations in Cardiac Parameters.  resting heart rate  myocardial contractility  left ventricular muscle mass predisposition to atrial arrhythmias. Molecular and Cellular Mechanisms. Action of thyroid hormones on the heart

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Hyperthyroid Heart Disease

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  1. Hyperthyroid Heart Disease medslides.com

  2. Alterations in Cardiac Parameters •  resting heart rate •  myocardial contractility •  left ventricular muscle mass • predisposition to atrial arrhythmias medslides.com

  3. Molecular and Cellular Mechanisms Action of thyroid hormones on the heart • direct effect on the transcription of specific and nonspecific cardiac genes • non-genomic action on plasma membranes, mitochondria, and the sarcoplasmic reticulum medslides.com

  4. Cardiac Manifestations • Classical symptoms • heat intolerance, irritability, nervousness, emotional the ability, muscle weakness,menstrual abnormalities, weight loss • Cardiovascular symptoms • tachycardia (90%), palpitation (85%), dyspnea on exertion and fatigue (50%), angina pectoris is uncommon • Physical findings • bounding peripheral pulses, wide pulse pressure, active precordium, systolic ejection murmur (50%), Means-Lerman scratch (rubbing of the hyperdynamic pericardium against the pleura, mimicking pericarditis),an increased incidence of mitral valve prolapse medslides.com

  5. tachycardia 90 palpitations 85 exercise intolerance 65 bounding pulses 75 wide pulse pressure 75 hyperactive precordium 75 Prevalence of Symptoms and Signs dyspnea on exertion 50 fatigue 50 systolic murmurs 50 systolic hypertension 30 atrial fibrillation 15 angina pectoris 5 medslides.com

  6. Rhythm Disturbances • Atrial fibrillation • the most common complication of hyperthyroidism • occurs in approximate 15% of patients • more common among men and with advancing age (25 to 40% in individuals over the age of 60) • subclinical hyperthyroidism (low-TSH) is associated with > 3x increase and the risk of developing AF • atrial flutter, paroxysmal SVT, and VT are uncommon N Engl J Med 1994; 331:1249-1252 medslides.com

  7. Heart Failure • the hyperthyroid heart may be performing at its maximal capacity, with little cardiac reserve - even at resting conditions • “high-output heart failure” usually occurs in young individuals with severe and long-standing hyperthyroidism and respond well to treatment with diuretics • “hyperthyroid cardiomyopathy” may be due to the detrimental effect of sustained tachycardia on the heart; the systolic dysfunction is often but not always reversible once a euthyroid state is reestablished medslides.com

  8. Hypertension • systolic hypertension is found in 1/3 of patients, this is partly due to the inability of the vascular system to accommodate the increase in stroke volume • diastolic hypertension is rare in hyperthyroidism due to the fall in SVR • establishment ofa a euthyroid state leads to complete reversal of these changes medslides.com

  9. Diagnosis of Suspected Hyperthyroidism • serum TSH concentration permits the detection of subclinical and occult hyperthyroidism • measurement of free T4 is helpful • T3 should also be measured to detect patients with T3- toxicosis medslides.com

  10. Graves’ disease Hyperfunctioning adenoma Toxic or nodular goiter Subacute thyroiditis Chronic thyroiditis with transient thyrotoxicosis Thyrotoxicosis facticia Ectopic thyroid hormone production Stroma ovarri Metastatic follicular carcinoma Excess production of TSH Trophoblastic tumor Causes of Hyperthyroidism medslides.com

  11. Abnormal Thyroid Hormone Levels • nonthyroidal systemic illnesses may cause • low T3 state in up to 50% of hospitalized patients, or • low T3/T4 state with normal TSH levels in severely ill pts • chronic amiodarone therapy • > 50% of patients have elevated T4 levels (at an average of 44% of baseline) with normal T3 and TSH • 2-24% of treated patients may develop clinical hyperthyroidism with decrease TSH level medslides.com

  12. Treatment of Cardiovascular Disease Associated with Hyperthyroidism • conservative therapy in stable patients • intravenous beta-blockers in patients with unstable cardiac symptoms, and thyrotoxic storm • correction of the hyperthyroid state should be treated with propylthiouracil to inhibit synthesis of thyroid hormone medslides.com

  13. Treatment of Cardiovascular Disease Associated with Hyperthyroidism • congestive heart failure • diuretics helps to reverse volume overload • digoxin is less useful - relative resistance • atrial fibrillation • beta blocker to control ventricular rate • iv CCB should be avoided due to SVR and  BP • cardioversion should not be made before restoration of a euthyroid state; 2/3 of patients will revert spontaneously • embolic risk similar to other causes of AF Stroke 1988;19:15-18 medslides.com

  14. References • Hyperthyroidism as a high-tech output state. Am Heart J 1970; 79: 265-275. • Stroke in thyrotoxicosis with atrial fibrillation. Stroke 1988; 19:15-18. • Subclinical thyrotoxicosis. Endocrinol Metab Clin North Am 1998; 27: 37-49 • Thyrotoxicosis and the heart. Endocrinol Metab Clin North Am 1998; 27: 51-62 • Propranolol for thyroid storm. N Engl J Med 1997; 297: 671-672 • Effects of amiodarone on thyroid function. Ann Int Med 1997; 126: 63-73 • treatment of hyperthyroid disease. Ann Int Med 1994; 121: 281-288 medslides.com

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